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HIStalk Interviews Al Lewis, Workplace Wellness Skeptic

January 8, 2020 Interviews 9 Comments

Alfred Lewis, JD is an author of several healthcare outcomes books, operates the website, “They Said What? Because the Wellness Industry’s Pants Are On Fire,” and is founder and CEO of Quizzify of Waltham, MA.


Tell me about yourself and what you do.

I am CEO and quizmeister-in-chief of Quizzify, which is a an employee health literacy company. As we say, wiser employees make healthier decisions. However, I believe we are having this conversation because of my personal blog, which is called, “They Said What?” in which wellness vendors, diabetes vendors, and related vendors are critically analyzed to in fact show that they usually don’t achieve what they claim to achieve.

You’re offering $3 million to any company that can convince an impartial panel that their program can save employers money. Do you have concerns about having to pay up?

None whatsoever. The entry fee is $300,000, and believe me, it’s worth taking a one in a million shot with this impartial panel of five judges, of which I only get to appoint one and the burden of proof is on me. They don’t have a chance, which explains why nobody has tried to take me up on it.

Is it lack of knowledge or intentional deception that motivates wellness companies to sell services to employers without having sound science behind them?

Confucius put it very well. He said, and in those days it was all gender specific, that, “When a man makes a mistake and it’s pointed out to him and he doesn’t correct it, he is telling a lie.” So at this point, these folks know they are lying. They have made the gamble, and it’s a good gamble, that vastly more people are going to read their ads that are going to read my website. So what they do, and they’ve gotten very good at this in the last couple of years, is simply ignore my postings instead of responding to them so as not to create a news cycle and a whole discussion.

Is the available science good enough that they could do it right if they really wanted to?

I would say that for wellness generally, it is mathematically impossible to save money. There are not enough wellness-sensitive medical events. Even if you were to reduce 100% of them, you could not pay for most wellness programs. I’m not going to say it’s impossible, but it has clinically never even gotten close to that 100%. The typical reduction in risk is 0%, somewhere between minus 2% and plus 2%, while you would need a mathematically impossible 100% to 150% reduction to break even.

Most vendors are counting on the fact that most employers have absolutely no idea how many of their employees go to the hospital every year for diabetes. I could tell you if you like, unless you want to take a guess. Out of 1,000 people under the age of 65, how many go to the hospital with a primary diagnosis of diabetes in the insured population?

I’ll say two.

Actually, that’s very close. It’s more like one. Occasionally I run health and wellness trivia contests at conferences. How does the radiation in the CT scan compare to the radiation in an X-ray? But I also throw in that specific question. If you added all the diabetes events and all heart attacks together in a typical employer population, what would the rate be per thousand? In fact, it would be two, if you put both of those together. The guesses that I get are usually somewhere between 20 per thousand and 200 per thousand.

What about the perception of the incidence of chronic disease in general?

It’s not my take, it’s the world’s take. Because I do this show of hands thing, I do these trivia contests all the time. The employer benefits community thinks it is between about 20 and 200 of these events per 1,000 employees. Which of course makes no sense whatsoever. This is just what they say because they get bombarded with information talking about all the people who have diabetes and all the expensive chronic disease. Let’s take those two things one at a time.

A lot of people do have diabetes. They may not even know it. It’s not going to become an issue for them for many years after they find out. If in fact an employer intervenes, they may possibly be able to control it. But what they’re doing is saving Medicare money down the road because virtually nobody goes to the hospital with diabetes before the age of 65. Yet employers want to start paying for medication for these folks, so it’s a net increase in cost.

And then your other point of chronic disease. I’ve written extensively on this fallacy that 86% of cost is chronic disease. If you read it carefully, you’ll find that they are saying that that 50% of adults have chronic disease. Now if you’re defining chronic disease that broadly, you’re including a whole lot more things besides the things that a wellness vendor can get to. You’re including arthritis. You’re including hypertension. Who doesn’t have hypertension?

If you put all that together and say, “Let’s count every dollar that someone with hypertension spends on healthcare.” So someone with hypertension breaks their leg, you count that. You probably don’t even get to 86%, but most of that is also going to be in the over-65 population. In the under 65-population, the major drivers of costs are birth events and musculoskeletal.

The wellness vendors have done a great job of moving the goalposts. It used to be they would say, “You’re going to get a three-to-one financial return.” Then they started saying, “You’ll get a one-to-one return.” Now they’re saying, “There is really no financial return, but the employees will be healthier.”

If you actually look at the health of the employees … I’m not going to name names, except to say that there are a handful of vendors, generally the ones validated by the Validation Institute, that get more than a trivial improvement in health. There are other vendors — and I don’t mind naming names, Interactive Health and Wellsteps come to mind — where employees actually get worse as a result of these programs.

If that’s the case, won’t those companies eventually get fired for failing to deliver?

Some number of them are getting shown the door, but new employers are coming in. The problem is that the vendors have figured out how to measure outcomes fallaciously in such a way that most employers and most consultants aren’t going to catch them. They compare participants to non-participants, for example. It’s been proven up, down, sideways, backwards, forwards, and eight ways to Sunday that every iota, every dollar of savings in a participant versus a non-participant comparison is due to the mindset of the participants versus the non-participants and not to the program.

How do I know that? There are several data points. Studies have benchmarked those things and found exactly that. But the most dramatic one is a company called HealthFitness Corporation that did a wellness program for a company called Eastman Chemical. They separated the groups into participants and non-participants in Year Zero. But due to a whole bunch of incompetence and delays, they didn’t get the program started until Year Two. By the time they started the programs, the participants had already dramatically outperformed non-participants.

The funny part about that is that my nemesis, the Snidely Whiplash to my Dudley Do-Right or the Lex Luthor to my Superman, was stuck with this, so he moved the goalposts. He said, “Oh, we overlooked that. That was our bad. We weren’t competent enough to realize that the program had actually started in Year Zero, not in Year Two. Therefore, you don’t know whether it’s due to the participants or non-participants.”

That turned out to be a big enough lie. And I don’t mind saying, oh, I’ll say on the record, Ron Goetzel is a liar. He can go ahead and sue me. The difference between him and me is that if he calls me a liar, I’ll have him in court the next day.

They put out a graph that shows suddenly that the program started in Year Zero, not Year Two. The people who actually did the program got upset enough with that. If you go back and look at the website now, they have in fact replaced the lie with the truth, which is that the program started in Year Two after dramatic savings had already been found.

You’ve made the case that the simplest way to measure a workplace wellness program’s success is to ask the people who signed up if they participate regularly and see benefit from it. Do most programs fail even that basic test?

There is a tool put out by the Validation Institute that is the most elegant tool for measuring the cost-effectiveness of programs that I’ve ever seen. We are big supporters of it. You ask employees two questions. How much did you use something? You may not even have to ask them that because you already know. Then, did you find it useful? Then you multiply the number of times somebody used something times the usefulness they found. That gives you an engagement score as your Y axis. On the X axis is the cost of the program. You plot the engagement score against the cost of the program and you can tell in a single graph how cost-effective your programs are as viewed by employee use, employee engagement.

You’ve come down hard on Livongo. What concerns would you have as an employer who is considering buying their their program?

I would have two ethical concerns. One is that what they called a study that they point to is essentially a paid ad. The study was done by their employees and their suppliers’ employees. They don’t say anywhere, “We paid thousands of dollars to have this study published.” If they had disclosed that, that would be acceptable. Marginally acceptable. But to essentially take out an ad in this schlock journal disguised as a study, I have an ethical problem with that.

The other thing I have an ethical problem with is that that journal did do a modicum of peer review. Not remotely as much as I’ve done, but a modicum. And they said, “There is no causality here. It is only correlation. There is a correlation between having a Livongo program and having a reduction in costs.” Livongo put out a press release that said, “This study delivered a reduction in cost,” which is a lot different from a correlation. You cannot ethically take the word “correlation” and turn it into the word “delivered.” Those are my two ethical problems.

I have some arithmetic problems as well. The two things that you should measure if you’re trying to figure out if in fact you have reduced the severity and the incidents of diabetes are, number one, what happened to insulin use? Insulin use has actually been declining because the price has gone up so much, so it shouldn’t be a heavy lift to show a reduction in insulin use. Meaning you’re getting some diabetics off of insulin, which is a cost savings, and it also shows that the type 2 diabetics are improving.

Number two, you say, how many fewer diabetics went to the hospital for diabetes than they did previously? That’s a very standard plausibility test that the Validation Institute uses, that Health Affairs has used. It’s in my book, “Why Nobody Believes The Numbers,” which was a trade bestseller when it came out if anybody wants to look at it. It has never been challenged.

Either Livongo did not know enough to measure the two primary outcomes of a diabetes study — which are, did you reduce the use of insulin and did you reduce the hospitalization rate for diabetes – or  they measured them and they did not disclose them. Neither of those gives confidence in Livongo.

The third thing is that their first study said they got a 59% reduction in inpatient, which essentially means that they wiped out every single inpatient admission that did not involve birth events, trauma, cancer, or mental health. Every single one. Their second study made absolutely no reference to inpatient, but said that physician visits and physician expense went down by 26%. So essentially they had two studies, and when they put out the second one, they conveniently forgot about the first, which essentially said the opposite. That’s a red flag.

The other red flag is that every single other wellness vendor in the universe looks at physician visits and physician expense as a good thing. You’re getting people to go to the doctor more. It’s questionable whether that is a good thing, but that’s what everybody looks at. You’re getting people to go to the doctor more, so they’re doing more prevention, et cetera. The idea that you could be titrating all these diabetics’ meds, managing all these diabetics, and somehow have vastly lower physician expense is something they would have to do a great job of explaining to me.

That brings us to the final item, which is that some of what they do appears to be in conflict with other guidelines. This is also in my company Quizzify’s diabetes Q&A, which is reviewed by doctors at Harvard Medical School and carries the Harvard Medical School shield on it as a result. That is, that type 2 diabetics should not obsess with checking their blood sugar. That’s more of a type 1 thing, to check your blood sugar every few hours or every day or something.

It’s quite clear that there is no difference in outcomes between type 2 diabetics who do that and type 2 diabetics who check it vastly less regularly and just have a healthier lifestyle. They don’t have any kind of sentinel events, like a change in their meds or a big change in their weight or some kind of medical event of some type. You just don’t have to check it that often.

But Livongo brags about how many times they get their type 2 diabetics to check their blood sugar. Maybe it’s a coincidence or not, but they are allied with companies that provide medication and other supplies to diabetics. So I would have them explain why they are doing something different from what the literature says.

The manufacturer of Oxycontin pitched their product in referencing a friendly, somewhat obscure research letter that wasn’t peer reviewed. That’s what drug companies do – cite the positive papers in their advertising even if they are scientifically shaky. Is this a healthcare problem beyond just wellness programs, where we aren’t critical enough consumers of literature?

The Oxycontin thing was kind of funny. The doctor was not getting paid to say it and he was actually specifically referring to patients who are already in the ICU. They found something that happened to say what they wanted to say, and like you said, they ran with it.

This one is a little different, because they basically paid a bunch of their employees and they got their suppliers to write this article. Then they paid a journal to publish it. The payments to the journal have never been disclosed to investors. It does say who wrote the article. It does say that the employees and the suppliers wrote the article.

But here’s the thing. Most people, when they see the term “peer reviewed,” that checks the box for them. That says, “Oh, this is legitimate.” But I could give you 15 or 20 peer-reviewed articles in the wellness and the diabetes literature that are essentially incorrect on their face.

Anybody can challenge data. The issue is invalidating data. Can you look at data, and on its face, prove that it’s incorrect? With most wellness data, you can. In fact, I often say in wellness that you don’t have to challenge the data to invalidate it. You merely have to read the data and it will invalidate itself.

Many of those studies are peer reviewed, and many of never should have passed peer review. Oftentimes there are entire journals out there like the Wellness trade journal that have never asked me to peer review anything because they know true peer review would just shoot down everything that they put in it.

Employers talked a lot about coalitions and group purchasing to reduce their healthcare costs, but they haven’t accomplished much. Are wellness programs a half-hearted attempt to rein healthcare costs without addressing provider charges?

Let me take that question and put it into two parts. One is that wellness was very easy to put in place. You could say to your CFO, “Oh, look, we’re doing wellness. This will solve our problems.” Because for wellness, you didn’t have to negotiate with your suppliers or anything like that. You just layered in a new cost item and claimed that it would save money.

A guy by the name of Dave Contorno in our industry, a very capable guy, says the way to save money is to spend less of it, not to add on programs. Like Yogi Berra once said, “We don’t know where we’re going, but we’re making good time.” It was a panacea. There was even a guy — I don’t mind telling you his name, because he said it publicly — by the name of Bruce Sherman, who claimed in a conference that wellness could reduce industrial waste. When you get to that level, you’re just in fantasyland.

The second point that you made is, what should employers do? I would direct you to a book by a guy by the name of Dave Chase. It’s called “CEO’s Guide to Restoring the American Dream: How to deliver world class healthcare to your employees at half the cost.” He points out that, in fact, you can reduce costs by 20 to 40%. It’s been done. It’s not a question of finding solutions — the solutions have been put into place. It’s just a question of putting these proven solutions into place. Things like reference-based pricing and employee education, which is of course what we do. There are new levels of new types of pharmacy benefit managers that don’t have these massively complex contracts with all sorts of rebates that the employers never see, but rather just take wholesale prices and mark them up. All sorts of things have been done. All you have to do is do them and you will see. 

When I work with David Contorno or Dave Chase, I use a little formula with them. Which is, X plus Y equals 20%. X is the reduction in cost and Y is the increase in employee satisfaction with the healthcare program measure, however they want to measure it. Those two figures will add up to a 20% improvement. So if you really want to ratchet your costs, you can do that with no improvement in employee satisfaction. Or at the other extreme, if you feel that a really good program is great for attracting employees, you can keep the cost the same but then basically create low co-pays and  low monthly contributions and get your employees much more satisfied with the program.

HIStalk Interviews Joe Petro, CTO, Nuance

January 6, 2020 Interviews No Comments

Joe Petro, MSME is CTO and EVP of research and development with Nuance of Burlington, MA.


Tell me about yourself and the company.

I got into health information technology about 15 years ago. I started with Eclipsys, on the executive team running R&D. About three years after I was at Eclipsys, I got a call from Nuance. They had a smallish healthcare division and they were looking to go much deeper. I joined as healthcare senior vice-president of R&D. We’ve grown this business over time to about a billion dollars.

Nuance has two divisions. Two-thirds of the company is basically healthcare, while the remaining one-third is enterprise. About 18 months ago, I took over as a chief technology officer for everything. I do all of the products, the technology, and the research as well.

What progress has been made on ambient clinical intelligence and the exam room of the future as conceptually demonstrated at HIMSS19?

Ambient clinical intelligence is super exciting. Five or six years ago, Carl Dvorak at Epic was having a conversation with us and floated the notion of a room being able to listen. At the time, we didn’t have any necessarily tangible connection with how we were actually going to accomplish that. As conversational AI and other technologies developed, we started to get a firmer notion around what the exam room of the future could look like.

A lot has happened over the last 12 to 18 months. We have a number of clients now in beta, so we are learning from real feedback from real physicians. We have made a number of advances in terms of the state of the art and in terms of that summarized document that is produced by the conversation. From a tech point of view, that’s an intergalactic space travel problem in terms of how hard that problem actually is. We are jumping from a broad, basic, human-to-human interaction to a finely-tuned clinical document. From a tech point of view, we have advanced the state of the art.

We have also come up with the second generation of the ambient listening device that sits in the room. That second generation is being rolled out soon.

We definitely do not have a demand problem. Just about everybody in the industry has reached out to us, either as a potential partner or as a client. It’s a super exciting time.

A research article addressed the difficulty of turning an exam room conversation, especially in primary care where it might include social elements and cover multiple diagnoses, into clinical documentation. What are the technology challenges?

In the basic inside-the-tech, Russian doll part of it — getting inside and inside and inside – you are layering together accuracy levels on the entire problem. The first thing you have to do is diarize the speech, separating the multiple speech streams in the room. It might not just be the physician and the patient speaking — it might be the physician, nurse, patient, and the patient’s family.There’s a signal processing and a signal enhancement problem associated with that. That in and of itself has its own accuracy challenges. Then you have to turn that into text, and casual conversation is different from the more controlled clinical conversation.

We have 500,000 physicians on our Dragon Medical One product. That formal conversation has accuracy rates of something like 95, 96, or 97%. When it becomes more casual and conversational, it’s a different kind of a challenge because the text and the concepts aren’t necessarily well formed.

The next step is to extract facts and evidence, so you apply something like natural language processing, AI, and neural nets. You extract things like diagnoses and the active medication list. You try to associate things with the patient’s history versus the current issues that are going on with the patient. 

Finally, you jump to the summarized document. That’s a big jump, because if a patient is talking about the fact that they hurt their back changing a tire, that may or may not end up in the clinical documentation at all. Based on the data we collect, we decide which things to include in the documentation and which shouldn’t be there.

The flow I just went through involves, from a Nuance point of view, the last 20 years of technology that we’ve developed. Each one of the problems alone is hard, but all the problems together are even harder.

Is the technical challenge of multiple voices and accents less of an issue than when systems needed to be trained on individual voices and users had to speak closely into a microphone?

With the introduction of artificial intelligence, a lot of things have yielded. But it’s not just the AI on the software side of things. Inside that device that hangs on the wall is a linear microphone array. There is something on the order of 17 microphones in there, lined up and separated by a small distance. When you think about the capability of each one of those microphones, think about a cone that is emitting into space from each one. The software and the signal enhancement technology behind the scenes, which is AI based as well, figures out who is in the room and who is actually talking. Then with voice biometrics, we can identify that person and keep a lock on them even if they’re moving around inside the room.

That’s one of the breakthroughs that we’ve brought to this space. We have been in multiple industries for a long time. This has been going on in the automobile industry, as an example, for quite a long time. We actually just spun out our auto business and that has had speaker diarization in it for quite some time, where you’re identifying the person in the driver’s seat versus the passenger versus the variety of children and family members who might be in the back seat. That problem was cracked some time ago and we brought that battle-hardened technology over to the healthcare space.

Wouldn’t there be easily harvested clinical value in simply capturing the full room conversation and storing it as text to support searching, either within a specific patient or across all patients?

Yes, for sure. When I’m talking to the executives here or the executives at EMR companies or even physician or hospital execs, one of the things I always try to explain is that as we get deeper into this problem, opportunities are going to reveal themselves and present themselves to us for augmenting present-day solutions with things that we learn during the ambient clinical intelligence process. We have already had discussions about making the transcript available.

There are pluses and minuses to this. You always have compliance issues and whether physicians and hospitals want this thing hanging around as part of the record. But I think we’ll get through that and figure that out with everybody. But for sure there are things that we’re going to introduce, such as making that conversation available, making the diarized speech available, making the facts and evidence that are intermediate results available. We are having these conversations in an ongoing way with all the electronic medical record vendors, just to figure out what intermediate artifacts we might be able to produce along the way that have high value.

It’s one of the things that makes this exciting because it’s almost like gold mining. You are constantly discovering these things that have tangible value and you can introduce them as part of the product offering.

The excitement over extraction of concepts and discrete data from voice in the room overshadowed the ability to control systems hands free. Is it widely accepted that voice-powered software commands could improve usability?

It’s a little lumpy, to be honest with you. From a Dragon point of view we’ve had what we call Command and Control, Select and Say, voice macros, and these types of things for quite some time. Now we’re evolving this to what we call conversational AI, which allows you to do what you just described in a more conversational way. You can say something like, “Dragon, show me the abnormal lab values,” or “Dragon, let’s pull up the latest imaging study,” or “Dragon, let’s send something to the nursing pool.” It’s more conversational and it could potentially be interactive.

Whereas in the old days, and actually in the present day for the most part, with Command and Control, you’re using a voice command to trigger some kind of a keyboard accelerator that might be available through one of the EMRs. You’re trying to execute a rigid macro that checks off a bunch of boxes. The rigidity of all that, and the brittleness of that, is evolving to something that’s quite flexible. 

We’re at a tipping point now where, as you say, is there wide recognition that this could be really good? A certain segment of the population, like the advanced users of Dragon, have always been using this and think of it as rote. They’ve been using it, see the power in it, and realize how it can affect their lives.

I think what’s going to happen now is that we’re going to get past that early adopter phase that we’ve been stuck in for quite some time. There will be broader acceptance the more natural that experience becomes. It’s breathtaking how natural conversational AI can be now. Again, we’re bringing over technology from our auto business and our enterprise business that has been doing this for huge companies for a very long time. All that conversational AI expertise is coming over.

You’re going to see some really big advances here. I’m personally super excited about what’s going to happen over the next couple of years in terms of what we call virtual agents. That’s a very exciting territory.

Will consumer acceptance of voice assistants make it easier to get EHR users to use something similar?

It lowers that barrier, where someone might feel awkward interacting with artificial intelligence and doing it on a day-to-day basis in a natural way. The more that speech becomes ubiquitous as a primary modality that folks interact with, either artificial intelligence or some kind of behind-the-scenes systems, the more the barrier is lowered for us.

I was at a physician’s office the other day and someone had their phone turned up to their mouth and was dictating. The insertion of punctuation into dictation is so unnatural and awkward, but it’s amazing that the person was just sitting there doing the dictation. That type of thing creates relief on our side because it doesn’t feel so awkward for the physician to do it. It also doesn’t feel awkward for the patient to observe the physician doing it. It lowers those artificial barriers that used to be there. I think you’re right — that does create a certain luxury for us.

How do you see speech recognition and synthesized speech being used for population health management?

It can come from both sides. Voice-enabled systems allow folks who are interacting with those systems to to pull information out of them by telling the system what they want. You have a knowledge worker on one end and then the patient side, the reporting, and the things that we could capture from a social point of view that could end up in systems like this. You’re going to see a lot of territory covered in terms of what is actually available to patients.

We’re going to have to address PHI and all of that stuff in terms of what ends up in these systems, how it ends up, and how the patient opts in. But once we get through that phase of it, you will see a lot more entry points that are voice controlled. They will be on both sides of it. You’re going to get the speech side, which is pushing things in in a natural way or trying to extract something with a natural expression of a query. Then you’re going to have the interactions from the patient’s side, which are also voice enabled, but it’s all going to be conversational AI based. You’re going to be talking to a system that asks you questions.

An example of that might be if you ask the system to query something, and it’s an incomplete thought, the system can ask you using voice synthesis — what we call text-to-speech – for whatever it needs to complete the thought so that it can get the appropriate level of information. You’re going to see that all over the place. It’s a bunch of tech that sits around the periphery that will be involved as well.

What impact do you see with EHR vendors signing deals with cloud-based services from Amazon, Google, and Microsoft that give them access to development tools, and I’m thinking specifically of Amazon Transcribe Medical?

It’s another entrant. We keep track of everybody that’s out there. Google has their version of that, Microsoft has their version of that. It’s a good thing to see all the cloud players getting involved. It allows us to create clear differentiation between what we do and how we do it, the accuracy and the fidelity of the experience.

We think about the speech problem as being much bigger than just providing speech to text, and that’s what a lot of these SDKs do. In Dragon, there are literally hundreds of features that sit above the speech dial tone.

The more entrants, the better. That competition is a good thing, but it’s just another competitor type of a response from us.

What opportunities does AI create in going beyond transcription and voice commands to extracting information?

The Comprehend piece, the natural language processing piece — the ability to reach into a stream or a blob of text or documentation or whatever and extract facts and evidence — has been around for a long time. It’s not a new concept. But it allows you to make intelligence part of that natural interaction, which is so important.

For example, we’ve been generating queries to physicians in what we call Computerized Physician Documentation. That’s based on AI. It’s based on natural language processing and it’s also based on speech. It allows us to put intelligence into what we call the speech dial tone, so that as you are speaking, we are aware of the context of what is going on with the patient because we have access to that information through our EMR partners.

But we also know what you are saying. If you’re doing a progress note and you make a statement about some condition, we can connect the dots. If there is specificity missing, if a hierarchical condition category got triggered in the ambulatory setting, if there’s some piece of information missing that could lead to a different diagnosis, we can present that information to the physician in real time. This is making the experience both natural and very, very rich, because the more data we bring into it, the more it takes the burden off the physician.

Physicians are under massive cognitive overload every single day. If we can relieve that a little bit through these mechanisms, it will be a really good thing. Things like Comprehend Medical, the stuff that Microsoft has, Google, the stuff that we have — I think it will all move things in that direction.

Do you have any final thoughts?

We are really excited about the future. I’ve been doing this for a long time now, and I’ve never been more excited about what we’re doing. Ambient clinical intelligence definitely provides an opportunity for Nuance, working with EMR partners, to advance the state of the art in terms of the patient and the physician experience. We are all about the healthcare mission and we are all about relieving burden. What we’re doing here will improve life for all of us as patients, and the partnership with Microsoft and so forth definitely advances that. It will definitely accelerate our mission to get there as quickly as we possibly can. We are jazzed about it and we are really excited about the next few years.

HIStalk Interviews Laura O’Toole, President, Santa Rosa Consulting

December 18, 2019 Interviews 1 Comment

Laura O’Toole is president of Santa Rosa Consulting of Franklin, TN.


Tell me about yourself and the company.

I’ve been with Santa Rosa Consulting for 10 years and have played many roles here. I’m a passionate person. I pride myself on being a good mother and I live my life every day with gratitude and an appreciation for our industry because I’m a breast cancer survivor.

Santa Rosa is a professional services company that focuses on outcomes-based solutions for our clients. As of late, we are leading with more niche and meaningful services that we think our clients need to pivot to in continuing to be successful.

How did your experience as a patient with breast cancer change your perception of the healthcare system?

It has changed it a lot. It has certainly given me more appreciation for the importance of integration and communication among providers. That was a point that was very frustrating to me. Even as well as I can navigate the system, it also got me to see, upfront and center, how important it is to be an advocate for yourself. As a patient, you have to make a conscious choice to engage in your own care.

As somebody who has grown up in this industry and made it my whole career, it gave me a sense of empathy and almost a sadness for patients who don’t know as much as I do and the number of their questions that don’t get answered along the journey of being sick.

But mostly it gave me an appreciation for this industry and for what we all do. I do believe all of us — regardless if you’re a vendor, a professional services company, or whoever you are in this space that serves patients — want what’s best for patients. We as an industry have an obligation to do more to keep that patient at the center and to focus on the importance of clinical workflow.

It changed my life being sick, frankly. It made me look at everything differently. I live my life with a level of gratitude that I never had before. There’s still a lot to do in our space to make it better for patients.

How did you see the importance of technology as a patient versus what you expected?

Technology is the cornerstone of the building and at the center. Even as someone who operates every day in health IT, I never realized how important it is. If clinicians and providers could embrace technology as much as their IT counterparts do, we would start to see some real magic.

How has the demand for consulting services changed in the past few years?

The landscape has really changed. We have seen that as some firms are still around and some aren’t. Back in the day, everybody was focused on Meaningful Use because there was a lot of opportunity. I believe now that the healthcare professional services space needs to continue to put their clients at the center, but specifically to define value-add, niche, or bolt-on services.

So many of our clients now have implemented their core EHR. How do you take them to that next level? The consulting firms that can provide the most value to their clients are the ones that are looking out past where our client is today and listening to the client and what isn’t working for them.

We think the timing is right for test automation. Our clients simply cannot meet the escalating demand for the comprehensive testing that is required of the complex IT ecosystems that we’re seeing, along with the frequency of upgrades and releases from their EHR vendors. Clients don’t have the money or the resources to have armies of people, additional testers, and pulling their subject matter expects out of their day jobs away from being out in front with their business partners solving problems.

I believe that niche offerings like test automation — built from the ground up exclusively for healthcare and workflow centric — can give our clients more time, more energy, and more focus on their projects and patients. This is where the services for consulting companies need to go.

Integration as a service is critically important for our clients. Being able to fill a client’s needs just in time and to help them on the talent curve is also important.

The company does a lot of Meditech work and that company has made big changes to both its products and leadership team. How will their new professional services offering affect your business?

Certainly a large part of our business is around Meditech. We are a 6.1 Expanse partner. We have a detailed implementation methodology. I think we are the only firm that is confident enough in our delivery that we can provide that implementation on a fixed-fee basis. Meditech is transforming their business and their company. I believe they will be one of the three players left standing.

It’s interesting to me that they have focused on professional services. We believe it’s better to have an independent third party supporting our clients. We believe it drives better outcomes for our clients and that the client should always be at the center.

That said, we have great appreciation for what Meditech is trying to do. We will work alongside them, and with them, to continue to serve our clients and to do what’s right. I love the Expanse platform. It will take many of the Meditech clients that move to that platform to a whole other level of interoperability and care for their patients, so I commend them.

Are your clients asking for help with the industry’s move to the cloud?

Anything that we can do, or that vendors can do, to support interoperability for clients is the right thing to do. If you think back even if a few years ago, we had big health systems not wanting to share data and vendors not wanting to share information. But the constituents that need to share data are our patients and our clinicians. The more that we can evolve and support even bolt-on solutions or capabilities that provide interoperability is what is best. The cloud, and moving as much as we can to create a landscape that allows for more interoperability, is the right thing to do and what we all need to focus on. For our clients where that makes sense, that is our recommendation.

We also advise our clients that they need to look at other solutions and some bolt-on solutions that can take them up the delivery curve to best serve their patients and their physicians. It’s not always about the core vendor. Certainly that’s the cornerstone of the building, if you will, but there’s still a lot that can be done to make a difference and to get more niche services that can provide the optimum value.

How you determine the right time to develop a service line around a particular technology based on its maturity?

In professional services, it is “some days peanuts, some days shells.” You have to take the time to listen to your clients. We have built our company around several flagship accounts where we have done work from our inception as a company. We will continue to do that. We regularly talk with and use a core set of great talent within our client base to hear what their problems are, to try to get ahead of that curve.

There will be some that you will hit on, some that you will miss on. As I mentioned, test automation and the results and benefit for a client are just undivided. Clients like Novant Health, one of the leaders in the implementation of Epic, have realized dramatic improvements and time savings in their testing capabilities. They have been results driven and have the opportunity to reduce real risk in patient safety in clinical care and in revenue cycle integrity.

There’s a whole host of secondary benefits to that. Education and training. Everyone uses the word optimization. I don’t like that word, but taking their EHR up the value chain for their providers, for their clinicians, and improving data quality. If you focus on the core of what will make a health system successful and keep it around those offerings that can reduce time, save them money, and propel them into the future, you are doing the right thing for your clients.

You will always have some that that hit and some that don’t. You have to have a core base of flagship clients that know you, trust you, and know that you mean what you say and say what you mean. It becomes a personal commitment to serve them well. If you have that as the basis of who you are, you will do well, figure it out along the way, and as some offerings catch and some don’t, ride that wave and continue to do good work.

Do you see any little-recognized developments that could take the industry in a different direction?

I don’t see a tremendous amount on the horizon from a regulatory perspective as we did in the rear view mirror of the past. All of the clients that I talk to are trying to figure their integration and  governance strategy for telehealth. I think that will propel us. You’ll see a lot more in home health and outside the traditional box. Integration and integration as a service is an area we’ll focus on. 

You have to be able to plug and pull and have time available when a client needs it. They are just like us in going through ebbs and flows. There will be a dramatic need for high degrees of flexibility because our clients need to be able to provide quality care and some of them are struggling to get there without looking at the full landscape of everybody that is providing care in their ecosystem. Telehealth will be an interesting dynamic over the next several years.

Do you have any final thoughts?

I love our industry. All of us in healthcare want to provide value for our clients so that they can better serve their patients. Being a patient myself, I’ve gained such an appreciation for that and a gratitude for what providers and clinicians do every day to serve our clients. I look forward, as does Santa Rosa, to staying a part of that industry that supports care and makes a difference for people.

At the end of the day, we all have people who we love and care about that we want to see healthy. Healthcare is a beautiful place to be and I’m delighted to be a part of that industry and to serve it.

HIStalk Interviews Michael J. Alkire, President, Premier

December 16, 2019 Interviews No Comments

Michael J. Alkire, MBA is president of Premier of Charlotte, NC.


Tell me about yourself and the company.

I’ve been at Premier for about 16 years, filling a number of roles. My current role as president is focused on driving the two big strategies that we laid out at the beginning of the year. We are technology-enabling the supply chain for our healthcare systems. We are also building out enterprise analytics, embedding machine learning and artificial intelligence into an analytics platform that helps our healthcare systems reduce costs, improve quality, and migrate to new payment delivery models.

What is the ownership structure of the company now that it is publicly traded?

Our healthcare system member owners hold 46% of the Class B shares. As of our last 10-Q filing in September 2019, we have 155 member owners. The remainder of shares are held by the public.

What challenges do employers have in managing their healthcare costs?

The rising cost of healthcare is the primary reason that large employers are looking for alternatives to how healthcare is provided to their employees. 

Our journey for Contigo Health started about 18 months ago. A very large, self-insured employer came to us. They spend billions of dollars on healthcare and believe that 20% of that spend involves unnecessary variation and waste in the system. They would call out things like wanting a total knee or total hip in Orlando done the same as it is in Fargo. The way they described it is that there’s huge cost variation and huge clinical outcomes variation. They had an interest in building a high-value network of healthcare providers, both healthcare systems as well as other providers, to participate in this network.

They provided interesting statistics. From an oncology standpoint, 10% of their employees who are diagnosed with cancer don’t actually have cancer. Of those who are diagnosed with cancer, 30% are placed on the wrong regimen. Not only is the patient not receiving the right medical attention, the employer bears a huge cost. The patient may miss work due to being on the wrong medication and then getting established on the right regimen. They use that as an example of lack of standardization of care across the country.

They also talk about OB and C-section rates. Somewhere around 30% of all US births are done via C-section. In western Europe, the C-section rate is 22% or 23%. CDC says that C-section rates should be near 20%. This employer studied markets in which C-section rates were more than 50%. This creates significant cost as well as significantly more risk to the mother.

The prevalence of data that is available to these large employers is helping them understand where variation is occurring. They are looking for a partner that can help them manage this variation. I think they came to Premier because of our history of using discharge data from 45% of all US hospitals and our work with physicians and their quality reporting to Medicare. They liked the idea that we have the data. They also liked the idea that we have been working in collaboration with our healthcare systems for the better part of 15 years in improving the standard of care.

Is it an awkward conversation to tell health systems, which may be Premier’s members or owners, that your employer customer thinks they charge too much and don’t practice evidence-based medicine?

When this large player came to us and we built this collaborative that was the precursor to Contigo Health, we reached out to 35 healthcare systems that represented 440 hospitals. We said, “Very large employers are interested in building this high-value network, but we need your data, your claims data, and your electronic health record data.” We had clinical and safety data for many of them, but we needed to build data capability for this initiative.

At least 90% of the folks who participated in those first meetings provided us with their data or their interest in sharing their data with us. I think their reasons are twofold. One, they know that the market is moving in this direction, where the necessity for care to be standardized across the country is an imperative to drive down the cost of healthcare globally. Two, being part of a high-value network provides them leverage when they are negotiating with the payers in their markets. Saying that they adhere to and implement these standards and that they use the highest, best capable analytics to implement clinical protocols will differentiate them in their markets.

I don’t think that the idea is that employers will demand lower costs. They see so much variation in how care is being provided that their interest is reducing waste and standardizing the approach to providing care, as opposed to a negotiated perspective of wanting procedures done at a lower cost. The initial goal is to create a high-value network of a high standard of care.

Does this involve offering fixed prices for certain procedures, and similar to what Walmart is doing, sending employees out of their local geography to receive care from providers whose cost or quality may be better?

Payers are providing a lot of ancillary benefits to the employees of large employers, who aren’t taking advantage of them. Think about smoking cessation. We have the ability, given our Stanson Health acquisition, to write detailed analytics into the workflow. Large employers are interested using these workflow protocols to help ensure that employees are taking advantage of the ancillary benefits that they have access to. When an employee meets with the physician, it pops up on the screen that they work for Employer X, which has a smoking cessation program that they would like this patient to enroll in. There’s a free benefit that’s helping them do that. We will focus on these ancillary benefits as we get the Contigo Health programs started.

Then I think there will be two parallel paths. We will create this high-value network for things like maternal health, which will be nationally based and will involve certain protocols that these large employers would like these providers to follow. Second is exactly what you said. Large employers like Walmart call them centers of excellence, where they send employees out of geography for specific services. There will be a path for that in the short term.

But I will tell you that unless it’s something that’s very serious, very rare, or where the expertise just doesn’t exist in the local or regional markets, these large employers have an interest in getting care provided as close to the patients as possible. You will have these centers of excellence in the short term and mid term. They are nationally based today, but you’ll see more regionality of these centers of excellence, where you’ll have them in pockets along the various regional geographies of the US. Eventually I think they will become more localized to the extent that those geographies actually have the providers who can provide those services.

Premier’s health system customers should have been able to recognize and address their clinical variation given the reports you send them that highlight it. Why did employers have to apply the financial pressure to make them take action?

We work with some of the largest IDNs in the country, many of which span states and regions. They have their own focus on driving standardization of care across the entire healthcare system.

As healthcare systems are moving more towards taking downside risk, it’s imperative for them to standardize the way that care is being provided. It provides a benchmark for them to improve from. For quality outside of healthcare, such as in the automotive or high tech industries, you want to have that basis way to produce product, use that as the baseline and then always innovate off of that baseline. That’s what healthcare systems are attempting to do when they are trying to create that baseline. It’s two- sided risk.

Second is the movement to ACOs and capitation. A number of our healthcare systems that are creating partnerships with ACOs know that they have to be on the hook to provide standardized care across the communities that they serve.

The final driver will be differentiation. I spoke about this earlier in terms of their leverage with commercial health plans, but organizations that can prove that they are standardizing care and can prove that their outcomes are different than the big brands in their markets — or in some cases, bigger and smaller systems in the market — are the ones that are going to be the winners in the long term.

All of this is going to become transparent. That’s the fourth aspect, that healthcare systems are becoming aware that their outcomes are going to be transparently shared with the communities that they are serving.

Clinicians don’t always believe or follow evidence that is accepted elsewhere, or they think evidence needs to be tailored to local practices. How will you weigh the available evidence for a national group of health systems that haven’t followed it so far?

Stanson Health’s CEO is Scott Weingarten, MD. He was CEO of Zynx, which was all about creating standards of care, trying to standardize different protocols, and those kinds of things. They have had a very successful run. We were interested in Stanson because it takes those clinical decisions that come from the analytics and embeds them into the workflow.

For the first time, you will see a lot of this evidence-based clinical decision information show up in the workflow, when the physician is practicing or at the point of having conversations with their patients. They will see the clinical evidence at their fingertips.

The tool itself is unique. If organizations don’t want to use it from a proactive standpoint to provide alerting and other capabilities to the clinicians during the time of care, then a function on the back end can audit whether clinicians are following standard protocols that they have set up. Technology has allowed us to take this issue to the next level, both in being proactive at the point of care and to understand whether clinicians are following the standards of care.

Do you have any final thoughts?

Premier is working to fix US healthcare from the inside. We believe that healthcare needs to be consumer centered and provider led. Leveraging the providers, the data, and the analytics that we deliver to providers, along with the ability for them to collaborate, is the best way to solve our national healthcare issues.

HIStalk Interviews Michele Perry, CEO, Relatient

December 11, 2019 Interviews No Comments

Michele Perry, MBA is CEO of Relatient of Franklin, TN.


Tell me about yourself and the company.

Relatient is based in Franklin, Tennessee, and was started in 2014. Our name is a combination of “relate” and “patient,” relating to the patient. We are 100% focused on patient outreach and engagement, and it reflects in our name. We do this only for healthcare. We get calls all the time to see if we do this for prisons, courts, schools and everything else, but we are focused on patient engagement.

I joined in 2017. I replaced the original founding CEO. I’m a Saas software solutions veteran. I focus on high-growth companies.

I’m not a Nashville native, which you’ve probably already heard based on the lack of R’s in my vocabulary. I’m originally from Massachusetts and have spent time in New York, California, and Virginia. I was in Annapolis, Maryland for the 20 years before I took this job.

Are hospitals and practices wrong in thinking that all consumers really want is a patient portal?

Patient portals served an important purpose. They were part of the Meaningful Use requirement. But they are not addressing the needs of today’s consumers and patients. Find me a patient who thinks they are.

We compliment a lot of the work that has been done with patient portals and the investments that have been made in them. Lots of times we’ll drive people to things that are stored in a patient portal. But we’re all about using that phone and making it easy for patients.

In this day of the consumerization of healthcare, we all expect to be able to access things easily from our phone. Every day I’m making reservations, planning a flight, calling an Uber, checking my bank balance, and Venmo-ing money to my kids. You can do it with just a couple of clicks. Try to make a doctor’s appointment, check for your lab results, or register for that appointment while you actually have the medicine sitting in front of you at home. Try to do any of that stuff and it’s painful.

That’s what we’ve set out to fix. We make it easy for the patient, and if you make it easy for the patient, you make it easy for the practice. We see hospitals and clinics and everybody else wanting to engage with their patients.

What are the ones that are doing a good job doing differently from those that aren’t?

I’d love to say that it’s concentrated in different areas, but it’s not. We are seeing it across all specialties. Nebraska Cancer in the oncology area is using it to reduce no-shows by 47%. I was surprised – don’t cancer patients show up? The answer was that we need to alleviate the confusion around all the different providers and appointments people have during the cancer treatments.

We are co-presenting with Oklahoma Heart at HIMSS on driving patient engagement in a mobile-first market. We have FQHCs like Access Healthcare in Chicago, who wants to be able to message not just about your appointment, but to let you know that the food trucks that take SNAP are going to be there on the day that you are there for your appointment. Pediatrics organizations like Children’s of Colorado are doing interesting things with telehealth and remote access initiatives, reaching out into rural areas. Primary and women’s care, like Seven Hills or South Bend Clinic, are focused in gaps in care and things like that.

What percentage of hospitals and clinics are using electronic appointment reminders?

The first generation of those products was pretty basic, and it’s rare for us to run into somebody who hasn’t put in a first-generation solution. But now that they have it, they’re finding that they can do so much more with that communication. Do I need to fast before my appointment? Do I need to show up extra early for testing?

Some of our large hospitals have 120 kinds of appointment types, each of which require different messaging. They need support for multiple locations, especially now with telehealth and remote health, so they can say, “Your appointment is with Dr. Smith out of the Denver office, but you are going to be in the Grand Junction office.” The second generation of products needs these kinds of communications. But it’s really rare to find someone who hasn’t done a first-generation product, except for some small two- and three-doctor offices.

Why is patient self-scheduling uncommon?

Practices didn’t have it yet. They said, “Oh, we have a scheduler.” But people want to be able to schedule after hours, during lunch, or during conference calls. I want to quickly make that appointment off my phone or off my desktop. I want to be able to do that quickly. People hadn’t set those up.

We also found providers who wanted their front desk people to have ownership of that schedule. We’ve added to our product the ability to have a two-step acceptance. Let me make my appointment at 10:30 at night. When my kid’s not feeling well and I want to make an appointment, let me make that appointment. But let it actually have to be accepted by somebody in the office in the morning. They accept this one, accept that one, and then realize that they’re accepting all of them anyway, so they are comfortable skipping that step. But the ability to have ownership was important for a couple of our providers as we were bringing them on.

On the back end, does someone have to copy-paste from the self-scheduling application into the system that keeps the real schedule?

The way we do it is important. We actually write back into these schedules. People are sometimes kind of scared about it upfront, but then when they see that it works really well, then they give up. But yes, we don’t just send an email that someone has to then set up – we do all the write-backs right into the systems for appointment reminders, scheduling, e-registration, surveys, and all of the other components.

The culture of some hospitals and practices was built around a siege mentality, where patients aren’t allowed to communicate with a provider unless they make a billable appointment and come to the office. Is that changing?

Sometimes you can bill telehealth appointments, to have those paid for. People want to have access to their doctors, so they’re trying to make it easier to do these new types of appointments, because if I don’t make my physicians accessible to you, you’re going to go down the street to the urgent care or some other clinic. They would rather not have them go away to the Walmart clinic, the CVS clinic, or someplace else. They want you to come to their providers.

Your system offers broadcast messaging for unplanned changes to normal operating hours, like weather emergencies. Do practices who don’t have it just update their Facebook page and hope patients check there?

Some of the folks still change their websites or have a message on the answering machines. We have tremendous demand for demand messaging, or the broadcast messaging capability, when you have weather problems, like New England this week or during Hurricane Dorian. But it’s also used for non-weather things, like if a doctor will be out for the next two days on bereavement, or in OB-GYN for messages like, “This doctor was just called in for a delivery. Please call the office before coming to make sure they will be here for your appointment.” Specialists make appointments months ahead, so you have to keep up to make sure that you’re not blasting the whole patient base to get a message to the 20 patients who need it.

What about health campaigns such as disease-specific follow-up or seasonal items like vaccine availability?

There’s nothing we do that you couldn’t do manually, but it takes a lot more effort. Campaigns to close the gaps of care are important, especially in primary, women’s care, and pediatrics. Getting people back in to make sure their kids are getting the right vaccines at the right time.

We’ve learned the hard way how to actually do the notifications. Maybe 3,000 patients haven’t had this particular thing that needs to get done. If we just blast everybody, your call center gets overloaded the next Monday. We do a dribble campaign and send the messages in bunches so they don’t all go out at the same time. We pull the data from the EHR and practice management system, use the campaign to contact those people and get them to make appointments, and with patient self-scheduling, we can send them to the link so they don’t even have to call the office.

Consumers vastly prefer text message communication over all other forms for convenience, but it also offers better deliverability than email or phone calls and also gives patients a way to take action without writing something down.

What we have found, and what we recommend in our best practices, is a combination of all three. We do phone, email, and text, and we do them at a certain interval over time. We don’t want to stalk you, but we want to make sure you get the message. If you do just texts, your response rate will be lower. If you’ve heard it on an answering machine and you’ve seen it in the email, you might not have reacted to it, so it’s a combination of seeing those.

We send the final reminder at certain times of the day. Some at night, some in the morning, depending on time of your appointment. You might have accepted it and intended to go, but you drive to work and forget. But if I send you a text that morning for an appointment later that day, you’ll remember. I also can’t send them too late because you don’t want to be disturbing people at night and when they go to bed.

Do you have any final thoughts?

We’re still early on with patient engagement, how we’ll engage patients over time, and how we’ll do it within the constraints of HIPAA, GDPR, and other regulations. It will be exciting to see where this will go, with things like two-way chat. But as we do this, we’re committed to innovation. Not just product innovation, but throughout our company. We’re currently rated number one by KLAS for patient outreach, with a score of 95.6. We follow this score closely throughout the company. We believe it’s the best way to ensure that we are firing on all cylinders. We need to have great products delivered by great people to work with our customers to drive the ROI on our software.If we drive that ROI, we will help our practices have happy customers.

HIStalk Interviews Doug Cusick, CEO, TransformativeMed

December 9, 2019 Interviews No Comments

Doug Cusick, PharmD is president and CEO of TransformativeMed of Seattle, WA.


Tell me about yourself and the company.

I’m a clinician by background, although I’ve not practiced for many years. I’ve been in the electronic health industry for 35 years and I have the gray hair to prove it. I spent five of those years overseas, running a large healthcare and life sciences division for a large technology and services company.

TransformativeMed was a spinout from the University of Washington back in about 2012. It was co-founded by a practicing trauma surgeon, who continues to practice, and at that time the applications director at the University of Washington, who had overseen its Cerner implementation. The two of them together quickly saw a need to make the EHR usable, primarily for the doctors.

Does offering products that extend Cerner’s system limit the company’s opportunities?

The applications director was one of the inventors of MPages, which is used by organizations — including Cerner — to develop customizations to the Cerner Millennium software. The co-founders recognized that the EHR was just a platform, and in many cases, one that was challenging for clinicians to use. They went about inventing a series of applications that are embedded within Cerner and that have bi-directional information exchange. That allows specialty-specific workflows to be built.

By example, if you’re an endocrinologist, you need certain data at certain times in the decision-making process as part of the hospital’s overall care team. You want it in the format that is intuitive to how you practice. They developed 40 specialty-specific and subspecialty-specific clinical workflows.These are embedded in the clinical workflow, where all the action happens. Those users can manage their patient lists, the rounding and hand-off process, and care team coordination. They can also take advantage of disease-specific workflows, such as inpatient diabetes management and thrombolytics.

We continue to consume more and more of the breadth and the depth of what the clinicians need in order to make the electronic health record usable. We are moving pretty broadly across that realm.

What kind of relationship with Cerner do you need to make this work? How would that translate into working with Epic?

Our solutions are built on cooperating with the large electronic health vendors. It’s like the Salesforce model, with a great platform that is open for innovations. Cerner specifically is that type of platform. We rely on the data that is populated in the EHR. Our solutions allow that data to flow between the apps and the EHR, because it is embedded within the databases themselves.

In many cases, particularly with Cerner, the client representatives themselves come to us to help solve problems around clinician satisfaction, gaining efficiencies, and delivering on the billions of dollars that have been invested in the EHR.

It’s funny that in my 35 years in this industry, I can count on one hand how many doctors and IT people have ever said anything positive about any software solution. But in our case, what was so attractive for me coming on as CEO was that I get emails and phone calls every day from doctors and IT folks who love our embedded applications products that make their EHR usable, particularly from a specialty-specific perspective. It’s pretty amazing that for the first time in my career, we get so many kudos because doctors and IT folks love us.

How do you see the company growing? Do you hope to replicate your success in having helped other companies move up to the next level?

[Laughs] Absolutely yes, and most certainly. What was so attractive about me coming on board was that I had never seen anything like it. It isn’t disruptive to IT. Doctors and clinicians truly love us because we make their day better by delivering solutions that are intuitive to how they practice medicine. That we don’t need trainers on site speaks to the intuitiveness.

We recently went through a fairly substantial series A raise in Seattle. Before that, we were moving the company forward on customer revenue, and most of those sales had been done by word of mouth. For example, clinicians practicing at the University of Washington were moving on to other health systems and logging onto the EHR and saying, “This isn’t what I’m used to. I really need Cores,” which is the name of our product line.

When I came on board, we had a pretty nice array of clients and we’ve expanded that dramatically. I think we’re up to about 140 or so hospitals in the US. We’re selling our first international deal this week, so we’re pretty excited to expand internationally as well. Cerner has a large footprint.

We will be cautiously moving into Epic. We just closed our first contract with a health system that is moving to Epic. We couldn’t be more excited about gaining that experience, especially as interoperability and FHIR begin to take hold of the industry.

What business arrangement do you have with those EHR vendors?

We do not have a formal business relationship with them. We contract directly to the health systems. But with so many articles being published around physician burnout and lack of efficiencies and crises galore, the EHR vendors are seeing opportunity to deliver more innovation through their platform. The EHR is just data storage and the ability to move data around.

Health systems are recognizing that the EHR vendors aren’t going to deliver everything they possibly need. With the amount of true innovation that is going on across the industry, how can they add applications that make it more usable in a standardized fashion, but personalized for the clinicians who have to use it?

Particularly in this era of EHR optimization, we need to move way beyond the re-implementation of the EHR as the industry currently conceives it. EHRs need a massive overhaul to make them usable by the clinical community, and we have lots of studies to support that. CIOs are beginning to recognize, along with the clinical community, that they have a responsibility to help solve some of the problems.

It’s surprising that you can work with Epic without the company’s participation, and also that you can create add-on products without having problems when Cerner or Epic upgrade their underlying EHR.

MPages allows us to be directly embedded within the Cerner databases and all clients use it. Once we are given access to the system, it becomes our heavy lift and not an IT department burden, so CIOs love us. Plus, we are delivering huge benefits to the clinical community, namely the doctors who are finding that it is much more usable.

Epic is a different model and a more closed architecture. But we’re finding, particularly today in our first engagement, that Epic has been collaborative in terms of bringing our solutions within this health system. We’ll go live with them later in 2020. We couldn’t be more excited about the opportunity to move further into the EHR world. And not just here — the problems we face are being seen worldwide as more countries and systems purchase American EHRs.

EHRs weren’t necessarily designed for physician shift work and the resulting handoffs, such as hospitalists covering large numbers of patients for a fixed period, residents whose work hours are limited, and the use of multidisciplinary care teams. What does the market need beyond basic EHR functionality to support that model?

IT needs to become more interoperable. The 21st Century Cures Act is helping drive that interoperability forward, but health IT vendors as a whole are slow to comply.

I can use my phone to take a picture, edit it before texting it to my kids, share it on Facebook or Instagram, and my sister can download it and post it to her Nixplay electronic picture frame. This is real interoperability, and it should translate to healthcare because consumers expect it.

Doctors and other clinicians are spending so much time today away from the bedside and tied to a device – desktop or mobile – trying to get the data they need to make decisions. They need solutions that make it seamless and allow them to function as part of a care team. In the old days, you had just one doctor, like Marcus Welby, MD, but today that’s not the case. How do we continue to coordinate care across the health system to get the individual clinicians what they need immediately to make clinical decisions that positively affect the patient?

Our philosophy is about making that seamless communication and hand-off process as beautiful as possible so that clinicians can get back to the patient. They can deliver care as they’ve always wanted to. They are not tied to a computer to get the data they need in hunt-and-peck fashion. They go about doing their business and, in the process, become happier, and happy clinicians deliver better patient care.

Health systems, because they’ve invested so many billions, are now trying to figure out how to derive further value after these purchases. Companies like ours that are delivering innovation directly into the clinical workflow, where all the action happens, will be important. Because we’ve had such a substantial jump on it for the last seven years or so, we’re excited about the opportunity moving forward.

Beyond usability, EHR-related burnout seems related to the timing of system interruptions or guidance and the lack of workflow cohesiveness. Does that differ across specialties?

Absolutely. Consider the difference between what an endocrinologist may require when making a decision versus the oncologist. Although there are standards of practice, each specialty requires certain elements of data in a certain format that’s intuitive to how they practice medicine so that they can acquire that data with just one click, get everything they need, review the most appropriate and non-nuisance decision support, and then pass that on to the rest of the team.

That approach has garnered improvements in clinician satisfaction and efficiency. Instead of spending an hour and a half preparing for rounding, as some residents do, they don’t have to prepare. It’s right there for them, everything they need to do for rounding and hand-off. Those kinds of gains are making a huge difference, recognizing that some personalization needs to be done, but in a standard fashion.

Less than 1% of our solutions are ever customized because they are already intuitive to how the specialists practice medicine. That makes a huge difference, particularly with IT and the implementation process itself. Instead of taking 12, 15, or 18 months to implement a big EHR, we’re providing our applications from start to finish in less than 90 days. That’s a huge opportunity for doctors and executives to get those quick wins that deliver value immediately.

What prevents EHR vendors from using your ideas to develop competing functionality?

In the Salesforce model, these big vendors can only do so much, and they have a heavy lift across the entire system. As companies like ours begin to specialize and create niche markets, particularly for us around clinical workflows and disease-specific workflows, it’s easy for a health system just to drop it in and use it without the big lifts that they are traditionally used to with the big EHR vendors.

How will your business change as EHR vendors start using technologies from Amazon, Google, and Microsoft?

The difference is being truly embedded within the clinical workflows. The struggle in the industry is that a lot of great companies are doing a lot of great things, but they’re doing it from the outside, trying to get in. You have to toggle over to another system, or do something that disrupts the clinical workflow. We are clinicians and we are deeply embedded within the clinical workflow, where everything’s actionable. If you are using our secure messaging system, you get an alert that a particular patient’s creatinine level is high. It’s important to be able to take action from that message within the clinical workflow.

There’s much disruption and opportunity across the industry, everything from machine learning to artificial intelligence and certainly population health and analytics. Sometimes just getting the basics right around making it more usable in the clinical workflow for the clinicians is the huge opportunity. These players, Amazon included, are making huge strides in making the practice of healthcare delivery better. We welcome all of the opportunity, because it will change all of our lives, help us deliver better patient care, reduce cost, and produce better outcomes. We welcome the opportunity for companies like Amazon and Microsoft, which has now stepped back in in a dramatic fashion, because it means that healthcare will be better.

Do you have any final thoughts?

As we continue to see the industry mature, EHRs will become the platform where data is entered and stored. Companies like ours will make it innovative and useful to those who interact with it every day. This is the most change I’ve seen in 30 years, particularly as EHRs have become standard and problems had begun to arise that were never anticipated, problems that we have begun to fix across many health systems. I couldn’t be more excited to be in the industry. I still have the passion and the drive to deliver the change that we’re expecting, and it feels really good.

HIStalk Interviews Amanda Hansen, President, AdvancedMD

December 5, 2019 Interviews 3 Comments

Amanda Hansen is president of AdvancedMD of South Jordan, UT.


Tell me about yourself and the company.

I started in the position of president of AdvancedMD in June. It represents my 15th role within the organization over the past 13 years. AdvancedMD provides integrated workflow solutions and services to more than 35,000 physicians and providers in the ambulatory market.

How is that market changing?

We are in a replacement market. We sign a couple of hundred clients per month. The new clients we’re signing are on their second or their third EHR, so they are much more selective. Where historically with EHR it was about meeting regulation and Meaningful Use and driving towards that compliance, now it’s more about usability and workflow. Doctors don’t want a solution that is going to interrupt their workflow and add significant labor and administrative work on the back end.

The need for systems to be integrated and fully connected, that all-in-one, has definitely evolved over the past several years. Specialty-specific clinical records are more prevalent within certain subsets. You get a lot of benefit from having everything connected and working well together.

Is it fair for clinicians to say that the EHR causes burnout?

I do think it’s fair. It is necessary to have EHRs and the data structure and the storage of the information. Hopefully over time we’ll be driving more towards a patient-controlled health record in addition to the clinical records from the physician, and having those work in tandem.

But when you look at the demographic in healthcare, somewhere around 50 to 55% of physicians are over 50 years old. In that segment, it has driven some degree of burnout. The millennial generation, the generation that is rising now, grew up with all this technology at  their fingertips, so those types of physicians and providers are excited about the technology. I think it’s more of a generational issue than additional work that has driven burnout.

How are consumer expectations changing with regard to how technology can allow them to interact with their providers in ways that are convenient for them?

We spend a lot of time thinking about this and building strategies. The consumerism of healthcare is here to stay. I’m the perfect demographic to talk about it. I don’t have a primary care physician. My husband and I have three kids and we have an established pediatrician that we go to. But if I get sick, I go to urgent care. I want the same thing. I want an app that I can use. I want to do telehealth or do a telemedicine visit. I want that immediate gratification, that instantaneous response and result. In the healthcare IT space specifically, vendors have to put more resources on having those mobile applications.

Even at AdvancedMD, historically we’ve focused on patient engagement. But the patient engagement we focused on was more driven about how to help physicians engage with their patients, not to help patients engage with their physicians. We need to flip the switch. It has to be patient centralized, where everything drives from that patient and how they interact with their doctors.

With my pediatrician for my kids, we got a patient portal login. We never used it because it was really complicated. We couldn’t remember it. It was dual authentication, just very complicated. Whereas if I get a simple text message that says, go ahead and fill out this consent form and confirm your visit, I’m much more likely to do that than I am to remember some login. It puts pressure on the vendors to make sure that they’re delivering technology in a way that patients want to consume it.

How should interoperability work optimally when a patient’s records are scattered over multiple providers and there’s no PCP to collect and manage all their information in one place?

This is a huge opportunity. This is the secret sauce to making healthcare IT great, being able to have that interoperability and the connectivity. To make it successful, it has to shift from a clinical record from the physician to a clinical record from the physician that the patient can take with them always. This is something that I’m passionate about.

My dad was a type1 diabetic. He got diabetes when he was 20 months old. He passed away about two and a half years ago after two kidney transplants, two pancreas transplants, thousands of dialysis appointments, and a complete loss of vision. He was a modern day health miracle in many ways. He passed away when he was 60. It’s important to me because my mom would take him to doctor’s appointments and she would literally have to bring a binder of his health information with her everywhere they went. It had the prescription history, his conditions, his ailments, the procedures that had been done. It limited the ability of his physicians – specialists, primary care, mental health, behavioral health — to focus on his care at that moment because they were so focused on what had happened historically.

With FHIR and all the standards that are coming out in interoperability and accessibility of information, it really needs to be a record that is controlled by the patient. It doesn’t mean the patient is the only person inputting information we want. There’s a reason doctors go to medical school. We want it to have that flavor and we want it to be certified in the right way, but the patient should be able to take that information with them. What’s missing in healthcare IT is that patient. Companies are trying to address it, like Apple with the Apple Health Records app, and if you’re on an Epic system, you can get your medical record history. It’s something to assemble all of those records into one place that the patient can take with them

Why hasn’t the Health Record Bank concept taken hold?

There could potentially be a role for it. No one cares about a patient’s health as much as that patient. It is like your job, where nobody cares about your career or your progression at an organization more than you do. You have to own that.

Ideally, that the patient would have access to all of their own information and they could carry it with them and be the quarterback for themselves. Some people are in a situation where they can’t do that, and then their caretaker, spouse, family, or loved ones can help drive that. I really believe that it should be patient centralized, because we care about our own health more than any physician or provider is going to.

What is the mechanism of that patient carrying their data around?

That’s the mystery that that we all need to solve. It goes back to your earlier question, which is, can you have some sort of health data bank? We believe in big data. The challenge that we have had with big data so far is it has helped us to understand risk profiles of patients and to segment different patient bases, but it doesn’t create the action plan. If the information can be assimilated, whether it’s through a data bank or something else, that’s great. But the missing link has been what’s done with the information.

We know that 20% of our patient population has a high risk for adult onset diabetes, but outside of that, there’s not anything to link to what those next steps are. It’s tying that data into proactive tools, like our HealthWatcher solution that automates some of that process.

There are hundreds of EHR vendors and healthcare IT solutions. Unless we have some sort of universal health plan where there is only one vendor, then that can’t be the keeper of everything. We have to rely on something else, whether it’s the patient to control their own fate or if there’s some sort of health data bank. But we need to make sure that whatever information is assimilated, that there are action items and automated processes that happen as a result of the information. That’s the missing piece.

Are EHR vendors backing away from offering revenue cycle management services?

There is high demand for revenue cycle management, especially with the increasing complexity of getting reimbursed. Regulation is consistently changing and it makes it more and more challenging for doctors to get paid for the work that they do.

At AdvancedMD, we’ve seen a big influx in our revenue cycle management demand. Kareo recently divested their revenue cycle management business. I don’t believe that was for lack of demand. It seemed that it was more about the financial profile of the organization, where revenue cycle management is a more expensive business. It’s lower margin. With the exception of Kareo, the main vendors that we see day in and day out all have a revenue cycle management offering.

It has helped that providers and physicians want choice. If they want to do their billing themselves, they can use the software. If they want to have someone else do it, we have billing partners, and then we also have our own revenue cycle management division.

What was the strategy behind payments technology vendor Global Payments acquiring AdvancedMD in 2018?

Global Payments is focused on integrated payment solutions. The philosophy is that if they own software companies that have payments integrated within them, customers will be less likely to switch out their payment vendor for an alternative solution. They have, I think, 10 software companies in multiple verticals. Healthcare is a strong vertical, making up almost 20% of the opportunity in the US. We were their first effort in healthcare to have the integrated payment experience.

How do companies build a development schedule around technologies such as AI and voice-powered user interfaces that may be at various points on the hype cycle?

It’s always a balance. Technologists always want to work on the latest, greatest, really cool things. Sometimes those really cool things end up not being practical, or they aren’t something that’s even needed. A customer would rather you move a button or decrease the number of clicks to do a step in their workflow process. You see that more with startup organizations, where they are developing things that they think are really cool and revolutionary and then the adoption becomes much more of a challenge.

We experienced that historically with a couple of solutions that we put out. One of those was a benchmarking solution that we felt really excited about, paired with our analytics solution. What we quickly learned is that 70% of our client base is practices of fewer than five providers, independent practices, and they didn’t really care — even in a really cool way — to benchmark themselves against their competitors.

The most important thing that companies can do is to make sure that they keep the voice of the customer at the forefront. Not only do market research, but solicit those clients, internal and external, to help drive their roadmaps and make decisions on what to invest in and what to build.

What lessons have you learned in being promoted many times within one company instead of following the conventional wisdom that you have to move out to move up?

I’ve had a lot of friends come and go at this organization since I’ve been here. I can’t point to any of them and say that they are in a better position, or better off than I am, for having worked through the inner workings of an organization to drive my way to the position that I’m in today.

The biggest thing that I’ve learned is that moving ahead requires taking the jobs that no one wants to do. I’m sure that physicians, providers, and others in the healthcare space understand that sentiment as well. Sometimes it’s not the glamorous things. Sometimes it’s the ones that seem extremely challenging and difficult, but that propel you forward.

We have a great team assembled at AdvancedMD. I am extremely grateful and humbled for all of the people that I’ve been able to work with in my 13 1/2 years at this company. Nowadays, especially, you don’t see a lot of people who are fiercely loyal in sticking with an organization. It requires your own drive and will to do it. It also requires having mentors and advocates who look for opportunities for you. Lastly, it requires raising your hand to do the jobs that that may seem impossible at the time, but they’re not. Anything is possible.

Do you have any final thoughts?

We are excited and enthused about the opportunity to help propel the consumerization of healthcare forward, focusing on flipping the switch and with the patient being central to patient engagement rather than the physician. That’s through mobile applications and various programs to engage patients to play a more active role in their healthcare experience.

HIStalk Interviews Michelle O’Connor, President, Meditech

December 2, 2019 Interviews No Comments

Michelle O’Connor is president and chief operating officer of Meditech of Westwood, MA.


Tell me about yourself and the company.

I took over as president about six months ago. I was previously chief operating officer over operations and primarily development. I am now being reintroduced to a great leadership team that is responsible for our customer experience implementation and client services. We are re-engineering how we look at implementation to improve the physician experience and how we can improve customer experience as we continue to service them moving forward.

It is uncommon for companies to move developers into key executive roles, and Meditech is also different in that most of its executives have spent their entire working lives with Meditech. What is the company’s philosophy as the folks who founded the company and worked early in its 50-year history are handing over the reins to the next generation of leadership?

Part of the preparation for me taking over this role has been succession planning, which has been in the works at Meditech for many years. I’ve been in development, but previously I did work in implementation and worked on human resources with our staff management process re-engineering. I’ve done a lot of work with our staff, how we run the company internally and how we operate everything.

Working in development, I get introduced to the customer fairly regularly. Not necessarily in servicing and implementation, but I do work directly with them. That was especially true when we changed to an Agile development world, which I implemented seven or eight years ago when we started Expanse development. We engage our customers directly into the development process.

The plan for me to take over this role has been very well thought out. I’m prepared for what I need to do to take on more responsibility. That doesn’t mean that we don’t still have Hoda Sayed-Friel working more directly with our business partners and our professional services division and Helen Waters working with our marketing and our sales team. Those strengths help balance my role.

How does Meditech do business differently than competitors whose executives come and go from other health IT companies?

The value that Meditech brings to the table is that we look at what we need to do, we set a direction, and we move forward. Who would have thought that our senior VP of product development would have said in around 2010 when tablets came out that, “This is what we need to do in the future. We need to have mobile electronic health records.” We had just purchased LSS Data Systems. 

Because we are a technology company, we stay abreast of healthcare’s needs. We are able to pivot, move, and make decisions that allow us to do the right thing for the healthcare industry. We’ve been in the industry for 50 years. We have a touch on what customers need. By promoting from within, we allow ourselves to grow, evolve, and change to support it.

Meditech provides systems that go beyond core clinical or EHR functionality into modules that support nearly every aspect of a hospital’s operations in a long list of non-clinical departments. How hard is it to provide that breadth of systems?

I started with the revenue cycle product, which taught me the entire system and how things all come together. I look at non-healthcare technology companies and I can’t think of another industry that has to provide the level of service and the amount of functionality that we do. Meditech is one of the only vendors left that does financials. We are competitive with Cerner and Epic in the EHR, pharmacy, and lab space, but we provide financials and general ledger as well. It helps that we have been in business for 50 years.

It’s difficult for vendors to get into healthcare because our customers expect that level of integration. They expect that when you register in the lab system and populate a document that the pathologist reviews that we also drop a charge that goes over to revenue cycle so that your cost accounting system can deal with it and your general ledger can handle it. Then you send out a check for AP to do an overpayment to a patient. That’s totally expected of any of the vendors right now.

What are the biggest changes or trends you’re seeing across health systems?

Of course there is consolidation, but in terms of technology trends, I see providers who need to outsource their IT services through private clouds or what we’re going to be offering as the public cloud. It has become so complex for our organizations to support themselves. It’s a big change for them having public clouds handling the infrastructure and some of the help desk services. That’s one of the reasons we’re getting into the hosting business in offering Meditech as a Service or through Google.

We’re also doing it because of security concerns. Security is a huge risk. How many healthcare systems have been taken down for weeks and months from ransomware, and how did that disruption affect their overall business operations? A CIO recently told me that security is outside the EHR, but I think security is something that we as an EHR vendor have to do, to provide a system that can be highly secure. How can we do that more effectively and more cost-effectively?

We’re seeing a lot of announcements from health IT vendors who are partnering with Amazon, Google, and Microsoft, not just for hosting, but for using their embedded technologies to change the way they design and build their software. How will your relationship with Google change Meditech as a product and as a company?

It has already changed us, to be honest. In January, we’re releasing our first cloud-based product, High Availability Snapshot, where we are providing the ability for a customer to have access to the electronic health record through Google Cloud services. If they get hit with ransomware and their systems are down, they can go directly to the public cloud through a cellular connection and get a snapshot of that patient’s record. They can at least know what was done to the patient prior to their system going down while they recover from their disaster.

We are working on interoperability changes and API changes that will primarily use Google services. In addition, Meditech itself is lifting and shifting – I actually saw that term in a dictionary recently — lifting and shifting our EHR to run on a private cloud or on premise to the public cloud. As we’re doing that, we’re making significant changes to how Meditech systems are architected in order to run in the public cloud.

Our newest app is Expanse Now, which will be coming out early next year. It is voice enabled and it’s a Google services app as well. Creating new apps, building interoperability standards within the cloud services, and re-engineering our entire EHR to run in the cloud are the three primary things that we’re going to be using cloud services for.

How will these cloud services relationships change the health IT competitive landscape?

When we decided to write our product on a tablet and make it mobile, we made a concerted effort to build it based upon web infrastructure and not do direct apps, to allow us to have a cloud-based product working with on-prem. At that particular time, the clouds weren’t ready for us. Our goal was always to get Expanse into the public cloud. Honestly, it’s been a little quicker than I thought it was going to be.

A year ago, Meditech itself moved our entire operations to the cloud. Then we were going to move our EHR into the cloud. We accelerated that. Not only was it something we felt we could do, we found that with our infrastructure, we could do it much more quickly than we originally thought.

Expanse is getting the recognition that it deserves right now. The industry is seeing it as a great mobile platform to run electronic health records and to give our physicians mobility. Our nursing product recently gave them mobility as well. By doing it through the cloud, we’re giving our customers the ability to get there a lot quicker than they might have been able to if they were doing it on-prem.

There’s a lot more hardware and infrastructure needed to run these systems and costs are higher. By providing them through cloud services, we’re able to get them to the customer quickly without the high capital expenditure and to provide it more economically.

You’re sleeping behind enemy lines in being surrounded by a lot of Epic-using big academic medical centers. How would you, as a patient and a competitor, describe the state of interoperability in the Boston area?

You’re asking me a difficult question. I have elderly parents who have been going through the healthcare system pretty regularly over the past year. Interoperability in our industry is not good, the ability to share a record from a physician’s office to a hospital and to be transitioned to a tertiary care center or to a rehab center. We need to do better as an industry.

We believe that through our Traverse interoperability service, through using CommonWell, and by continuing to push upon using interoperability standards, that healthcare can get better if we all play together. We all work well together. We have seen a lot of the industry doing that. You see vendors coming together with CommonWell, Carequality, and things like that to push the standards. I know the government doesn’t think that we’ve been moving fast enough, but we all want to move data along more quickly to make sure that patients can be taken care of more effectively.

One thing you don’t know about me is that I really believe in what we do. Being in the industry for 31 years, we provide a tool that allows caregivers to deliver care to patients. We take that very seriously from a patient safety perspective and from a fiscally responsible perspective.That comes down to who we are as a company and who I am as a person. I truly believe that it doesn’t matter if you’re running Epic, Meditech, Cerner, or Allscripts — everybody has to be able to interoperate. Even if you have two different Epic systems, they still have to interoperate.

Are customers demanding better interoperability and system usability, or have their own internal policies and deployment choices made the EHR what it has become?

A lot of it goes back to the original question. It’s a lack of understanding of the complexity of the healthcare system and the data in which the systems are out there. Vendors are willing to share the data, especially defined data sets. It’s a matter of making sure that healthcare systems themselves understand that they have to share the data. But how difficult is it to share the data when it’s so vast and deep, and what is the actual data that needs to be shared? It’s not debits and credits. It’s not your ATM. It’s a lot more complex than that. If we all continue to work together, we’re going to get through this in the short term.

What population health management technologies are customers using or requesting?

We have a couple of perspectives on population health. There is managing patients that you’re seeing through through our registries within our ambulatory product. We have a robust system for managing the population of patients that you’re seeing. Then there’s the overarching population health, where you’re given the panel of patients that you’re responsible for managing.

We believe that we need to continue to provide the system in which you care for your patients, the system in which you are seeing what care gaps a patient might have, and things like that. But we’re not the insurance company that has the algorithms to figure out which patients are higher at risk. We are using a system called Arcadia to manage that by gathering all the claims, then providing back into the workflows of the caregivers and practice managers what needs to be done to take care of the patients.

Do you have any final thoughts?

After 50 years, Meditech has continued to evolve and change. We are the leading vendor that has been in this industry the longest. We’ve had a number of accolades. We had PCI and we had the first handheld nursing tool. We continue to use technology to move us forward. Expanse is live and people are seeing the difference in delivering care with the mobile platform that we’re providing. They continue to see Meditech provide technology to the delivery of care to provide better service than we’ve ever provided.

Our founder Neil Pappalardo always wraps up all of his conversations with, “The best is yet to come.” I truly do believe that.

HIStalk Interviews Bob Segert, CEO, Athenahealth

November 11, 2019 Interviews 8 Comments

Bob Segert is chairman and CEO of Athenahealth of Watertown, MA.


Tell me about yourself and the company.

I’ve been a serial CEO. I have been working in the private equity space for the last 11 or 12 years. This is the fourth company that I have had the privilege to run as CEO. I’ve been largely focused on software and services. This is my first foray into healthcare.

Athenahealth is going through an interesting and fruitful transformation from being publicly held to privately held. This is providing significant opportunity for us to rethink some of the old paradigms and the ways we thought about the business. This allows us to reposition ourselves to ignite against our new vision, which is to create a thriving ecosystem that delivers accessible, high quality, and sustainable healthcare for all.

What do you bring to the table as someone with no healthcare experience?

The real advantage I have is that I can ask all the silly questions and not feel like I should already know the answer. That allows me to get to first principles.

We are all users of healthcare, so we’re all somewhat familiar with some of it, but it’s cursory knowledge. You understand some of the steps. That at least allows you to focus in and have an objective view on the data that you hear.

The value that I bring to this enterprise is that I’ve been a longtime software and services exec and I’ve been in a lot of different industries across the United States and internationally. That allows me to think about this platform business and the apps that we have a different way.

I think about Athenahealth as being a technology company that provides solutions that help doctors be more efficient and effective in what they do. But the underlying core assets that we need to continue to improve and drive value with are, fundamentally, software and services assets. That’s where my strength and background has been in for the last 20-25 years.

What opportunities do you see with the Athenahealth network that connects hundreds of thousands of users on a single platform?

It’s the most powerful asset that Athena has. We believe in an open ecosystem. That’s why our new vision is about creating that thriving ecosystem.

Ecosystems must be dense, resilient, utilized, and open. Think about Athena in that context. We are the only platform out there that has that type of capability. We are fundamentally a SaaS-based application. All our customers are on the same code. We don’t have versions of the code. We update our software every night. Everyone gets it. You don’t have to reinstall it. If you want to get a new code, just refresh your browser and it’s there.

This allows us to powerfully change our rules and change our workflows to be more reactive to changes in the healthcare system and ways to make things better. We don’t have to wait for the next release a year from then. We don’t have to wait another three years for our customer base to adopt it.

The other thing that we’ve invested in, which is an amazing asset, is the data lake. We’ve abstracted all data out of our relational tablespaces that we have for each of our customers into a data lake. We have a full API gateway that is opened up to that. With permission, any person can get into that network of data and provide additional services, whether that’s the hospital system or ambulatory system on their own or whether that’s a third-party provider that has authorization from that practice to access their data. They can now access that seamlessly through the data lake.

Our real advantage comes from the scale of that network and the openness of that network. We have 160,000 providers that are part of our company today. We process over 10 billion transactions every year. It’s a massively scaled platform, open at its core, that fundamentally will continue to be a vanguard and leader in interoperability. Healthcare needs platforms that break down the silos, the information asymmetries, and the incentive asymmetries to enable a fragmented system to thrive.

How does Athenahealth work with vendors that don’t sell EHRs but offer add-on or complimentary products?

We have the Athena Marketplace, with almost 300 partners. Frankly, I think we have underutilized the benefit and the potential of that. I’d like to see 2,500 to 3,000 partners in our marketplace.

We want to make our network open and extensible. We will let anybody come and play in that network and add value to our customers. We think it also adds value to the healthcare system. We think it drives better outcomes, whether it be accessibility, quality, or sustainability.

We are very open to driving that open marketplace and we will continue to invest in that. That’s a key part of our strategy as we think about the business going forward.

We are also committed to driving interoperable solutions at an experiential level, at a physician level. One patient, one chart. The ability to schedule and refer across ambulatory and acute care settings. We want to be able to do that with every single EHR out there that’s willing to connect with us.

Our goal is not to hoard relationships or try to be a closed system. Our goal is to enable better healthcare outcomes. If we can do that, we will prosper, and the American public will benefit.

Do you see a role in helping those companies develop a business?

We have done that in several cases, where we have worked with small businesses that are exclusive partners to Athena to help them gain traction with our customer base. We’ve provided lead referrals. We’ve provided free office space in our main headquarters building in Watertown so people can develop their products and solutions. We’ve been a big proponent of trying to help our partners be successful.

I think we have a lot more that we can do. There are investments we want to make in marketing and onboarding and enablement that will allow us to treat that with a channel support-type mindset so that we can enable the success of those partners.

Of course, there are always opportunities for us to have a broader relationship with the companies that really take off and are doing well within our customer base, for us to have a broader relationship with them. That could be a joint venture, a minority interest investment, or even ultimately an acquisition by Athena.

What is your relationship with Walmart and their use of Athenahealth systems in their Walmart Health pilot in Georgia?

We are doing work with Walmart. We see that as a significant opportunity for us as we move forward. It’s a pilot program right now, but we see that hopefully being able to expand to many more sites over the coming months. We have a lot of other programs in the retail space that will be similar. We think it will be a big growth area for us going forward.

We are seeing demand there because of our SaaS-based platform. People who are trying to use cloud-based technology, SaaS-based technology, to enable outcomes naturally gravitate towards the type of platform that we have. It is dynamic, flexible, configurable, and adaptable.

Competing vendors seem to be addressing a mature EHR market by either expanding into areas that haven’t been big EHR users or cultivating relationships with pharma. Are either of these areas attractive?

We’re not focused on the pharma space. That’s not where our strategic intent lies. You’re not going to see us pivoting into pharma, either from a data standpoint or a broader services standpoint.

Where you will see us focused is on alternative sites of care. You’ll see us increasingly in employer clinics, retail clinics, the ER, and eventually in virtual medicine and telemedicine in the home. We want to be able to meet our patients where they are and help our physicians create a seamless, end-to-end experience across the care continuum as we expand our service offerings and our capabilities in those spaces.

But fundamentally, where you’ll see us double down is investing in our fundamental clinical workflows at the front door of medicine. Peds, OB-GYN, internists, primary care physicians — that’s where we are going to focus. We’re going to focus a lot of dollars on improving that EHR, improving those workflows, and then enabling the exposure of data to help them close care gaps in real time, when the patient is in front of the doctor. That is the key thing that we think we can drive in the industry that others have a hard time matching.

It was a seemingly odd mash-up of cultures to combine the old Athenahealth with the GE business to form the new Athenahealth. How would you characterize the company’s focus and culture now compared to what it was in those previous companies?

I would say it’s evolving. We are leveraging some of the best traits of both businesses.

In Virence, the old GE Centricity business, you had some long-tenured, expert capabilities — specialty workflow experts, anesthesiology, cardiology. You have hospital-related capabilities and RCM. GE had discipline, while Athena was traditionally more freewheeling, with an entrepreneurial, founder-led culture and all those elements that has made Athena such an amazing place to work.

You take that additional expertise and specialty workflow capability and pair that with that front door capabilities that Athena had, where because of its SaaS-based platform, it could succeed with one- and two- doctor practices, because that the delivery model makes so much sense for them, whereas premise-based software doesn’t. It’s a nice mash-up between the two.

We are right in the middle of it since it has been around nine months since the transaction closed. The cultures are coming together nicely and it’s going to continue to evolve over time. You don’t move cultures quickly — cultures evolve. We’re committed to taking the best of both and bringing them together to be even a more dynamic and exciting place to work.

Athenahealth seemed to struggle in its final publicly traded days with a post-Meaningful Use mature market. How does that affect your business strategy?

There’s no doubt that Meaningful Use, the emergence of EHRs, and the incentive to adopt EHRs floated all boats. A lot of companies sprung up because of that. As the Meaningful Use hurdles get higher and higher each year and certification become more and more difficult, I think you’re going to see increasing pressure on some of the smaller EHRs that may not have the engineering wherewithal and financial background to be able to survive.

It is a replacement market. It’s going to be a consolidating market. You’ll see some of the smaller players thrive less than they did in the past. Some specialized small players will continue to do extremely well and grow based upon a focused strategy. You’re going to see some of the bigger players like Athena working to differentiate ourselves in the marketplace, trying to gain relative share as these opportunities come up for replacement.

My view, and what I’ve seen since being inside the tent, is that we have amazing products that people really, really love. We’re not perfect, but people love these products. When we get into a demo environment, when we get a chance to get in with the physicians and show them what Athena can do, we win more times than we lose.

Our big challenge right now is how to get market awareness of the brand, what we’re doing and the favorability around the brand, and to get more at-bats. We know when we get in the batter’s box, we tend to get a base hit or more.

Is it difficult to get the attention of those small practices cost-effectively to earn a sale?

I don’t know if difficult is the right word. Each market segment has a different set of tactics that you need to employ. Small groups, those practices with six doctors or fewer, make up a different market mix. It’s a lot more online advertising. It’s business development resources that are calling and trying to reach doctors and try to set up meetings.

It’s very fast deal cycle. You set up a meeting, have a phone call, set up a meeting two weeks later, and go do a demo. Two weeks after that, you have a signed contract. You literally need two weeks to 30 days to sign a contract. It’s more of a flow business. You must have the resources upfront to canvas the marketplace to make those phone calls. That must be supported with good marketing campaigns that are focused, with real content and intellectual property that gets the doctors to step up and notice.

In our major cities, we just launched the “State of the Smart” campaign. You’ll see a lot of out of home advertising. We just had a full page in the Boston Globe on Sunday. We’ll have another one coming up. You’ll see a lot more Internet-based advertising and print advertising as we continue to position our brand out in the marketplace.

Enterprise is a little bit different. Sales cycles are longer and it’s more of a direct sales relationship sale. But we have a strong engine. I would say almost 40% of our bookings are coming in the small group space. We see that as being increasingly an area of strength for us as we move forward.

Who are your most significant competitors, taking into account the spread of Cerner and Epic into smaller practices and Allscripts saying it will develop a new EHR?

It’s a very competitive market. We compete with all the major players. We compete with all the specialty EHRs when it comes to some specialty practices. We compete on a broader outsourcing model with the companies that are providing broader RCM solutions. It’s a dynamic marketplace for sure.

Everyone is focused on trying to create value for customers. We’re no different. We believe that our core advantage sits around our expertise, the type of people that we have. It sits around our platform and the open interconnectedness into it. It sits around our ability to drive value from data analytics and benchmarking from the real-time execution of our processes. That enables us to differentiate ourselves in the marketplace vis-a-vis some of those other competitors.

Hospital consolidation will continue, there’s no doubt. Hospital bed stays are going down. More and more procedures are moving into the ambulatory care setting. Clinical advances, along with patient experience and preferences, are driving that. We are going to continue to see a robust and valid market in our core segment of ambulatory care. Even if there is some additional hospital consolidation, it’s not going to take the lion’s share of the market. There’s plenty of room for us to continue to grow and thrive.

Are you still planning to release an inpatient hospital system?

We had developed an inpatient EHR platform and sold it to several customers. We will continue to maintain that platform, the rules engine, and certification. We are not actively selling that in the marketplace today. We are redirecting our full focus into core clinical workflows, rev cycle, and the ambulatory care market. But just to be really clear, we will continue to support that hospital product.

We are also strong in hospitals with our Centricity assets. If you look at Virence and the Centricity Business platform, it has a world-class central billing office capability that cuts across both the acute and ambulatory care settings. It is focused on large IDNs and research hospitals. It is one of the gold standard rev cycle products out there in the market today. We are fully committed to Centricity Business. We will continue to invest in that and we see that as being a long-term part of the Athena portfolio going forward.

What about Epocrates?

Epocrates is a part of our business. It’s a relatively small portion of the company today. We see additional opportunity in Epocrates. We believe that there’s more that can be done, more that can be leveraged as we think about how to extend the value of that platform to physicians.

We know that the people who use Epocrates love Epocrates. It’s got a very good brand reputation. We see people using the product and it influences their drug prescribing decisions. It has value in the market. We see that as an asset that can be further invested in and leveraged. Epocrates is part of our family. It’s a smaller part of our family, but we believe there are opportunities there.

Private equity acquisitions often involve cutting costs and selling off non-core businesses to boost profit, then flipping the company or going public three or four years later. How do you see Athenahealth’s future given your background working with companies that grew in different ways?

The right mindset to have with private equity is that they are equity investors. Whether it’s private or whether it’s public equity, equity value and firm value magnifies itself with growth. Every great private equity investor is trying to drive growth. Our investors are no different. This is not about us trying to maximize and take every cost dollar out of the system we can.

We have seen things that we think can be done better. We can be more efficient. We can reprioritize some of our assets and investments outside of areas where we were investing and reprioritize those in other areas. Private equity has a specific focus on value levers and how you drive value creation.

That’s the way you should think about our owners, as being people who want to invest in the business. We made a big, one-time investment in technical debt to improve the platform so that we have a more solid foundation to continue to innovate on. They are very focused on us driving growth. They are very focused on us being innovative.

They have been great partners in the process, and they’re all about creating a great company. They are not about squeezing every last nickel out of the business, because that’s not the way you create long-term value. It needs to be a sustainable enterprise.

My experience with private equity has not been about crash and burn. It’s been about focus, re-prioritizing investment on the things that drive the highest level of growth, and creating the most value for customers. If you create the most value for your customers, then you get to take some of that value yourself.

Do you have any final thoughts?

Athenahealth is an amazing company. It has an amazing heritage. It’s a business that has the right to succeed and the right to thrive. We have a set of unparalleled assets in our employees, our customers, and importantly, the platform and the ecosystem we’ve built. We now have a leadership team in place, a team that’s behind us, and investors who are focused that will allow us to make the smart investments that we need to make to reposition the business for long-term growth and prosperity. That will benefit all the physicians in the United States and the entire system as we create a thriving ecosystem that delivers accessible, high quality, and sustainable healthcare for all.

HIStalk Interviews David Lareau, CEO, Medicomp

November 6, 2019 Interviews 2 Comments

David Lareau is CEO of Medicomp Systems of Chantilly, VA.


Tell me about yourself and the company.

Medicomp provides a clinical engine and tools to use it that provide physicians, nurses, and other clinicians what they need at the point of care so they can do their jobs. We give them what they need when they need it, stay out of their way, and let them focus on the patient. I discovered Medicomp in 1992, joined the company in 1995, and have been CEO for about 10 years. We are continuing to build our content and tools to support point-of-care use for better patient care.

How would you characterize the EHR industry and how it has changed?

Over the last few years, I would say the last 10 years, the focus has been on getting the money. Getting the $30 billion to $40 billion that the government gave out to promote and make electronic records ubiquitous in the industry. That’s been done, but I don’t know that it has moved the needle at all in providing better patient care.

Now the industry is being forced to turn away from the number of transactions processed or encounters documented to, how well are we taking care of these patients? How do we report that? How do we measure it? How do we make it happen? How do we prove that we did it? It’s a major change to try to make these systems usable for clinicians at the point of care.

Are EHR vendors committed and capable of making usability what users want it to be?

I’m not sure they are. As part of my evidence for that, people seem to be thinking they can rely on artificial intelligence, NLP, and machine learning to solve the problem of usability. Or the use of scribes. That indicates to me that they recognize that they can’t do what it takes to make these systems, the way they’re currently constructed, usable for physicians at the point of care to meet all the requirements that they need to. They need to be efficient, effective, they need to meet these quality metrics, and they need to do it without getting in the physician’s way or slowing them down.

They seem to be turning to, “OK, ambient AI. Say anything you want and the machine will figure it out.” The problem with that is that the machines are taught by programmers, not necessarily by clinicians. So I don’t see where the ball has been moved toward clinical usability much at all in the last 10 years.

Is it fair or unfair to say that EHRs cause burnout?

It’s fair to say that EHRs cause burnout, because EHRs, as currently constructed and implemented, weren’t designed with the patient or provider in mind. They were designed to maximize reimbursement and track transactions. Clinicians they have this reputation as being difficult to work with because they are the most highly trained knowledge users in the world and the systems they are using actually dumb them down. They get no benefit from it. They pour stuff in there and they get nothing out of it that helps them, because they already know what to do. Just get out of my way and let me do it.

What value can be added to a vendor’s EHR to make it more useful and satisfying to clinicians without having the EHR vendor themselves making changes?

Every EHR should have a problem list. If there’s something in the problem list, you ought to be able to just click on that problem and see everything in the patient’s chart that’s relevant for that problem. For diabetes, you ought to be able to see on one screen the lab results, medications, symptoms, relevant family history, relevant past procedures, et cetera.

We provide a huge clinical engine that has about 120,000,000 links between problems and the other clinical concepts related to that problem. That helps people get clean data in, use it, and see it at the point of care, rather than having to go to six different places in the EHR to look at labs, meds, and procedures. It needs to be pulled together. Physicians, because of their training and experience, already know what they need to see. They’re highly trained. They know it. Just give it to them.

We’ve been working with clinicians for 41 years to say, if you’re thinking about diabetes, what do you need to see? If you’re thinking about chronic renal failure, or thinking about this other issue, what do you need to see? They know it. Just give it to them and they can focus on the patient in front of them at that moment without having to navigate through the EHR to find every little piece of information.

How has private equity and other forms of investment changed healthcare lately?

You had a nice article on Jonathan Bush where he said, boy, once you let them in the tent, they own the tent. There’s really no room for anybody else. They have a three- to five-year time horizon to get in there, get things lean, flip it, and get out. Typically. Typically. Now, a lot of them say they’re long-term investors.

We’ve been doing this 41 years. We’ve decided to keep it, and we will continue to keep it, private and closely held so that we can continue to focus on doing what we’re doing and not be distracted by the flavor of the month. “Why aren’t you guys doing NLP? Why aren’t you guys doing AI?” We have a form of AI. Our engine was built using doctors to say what’s relevant, but we don’t talk about it as machine learning. It was actually taught by our clinicians.

If we accepted private equity money or outside investors at this point, we would lose our focus on the long-term vision, which is providing tools to let clinicians provide better care for patients at the point of care. That’s really what we’re trying to do here. Everybody has their own idea of the latest thing they should focus on. We stick to our knitting.

Is it hard not to get wrapped up in the AI buzzword that everyone suddenly claims to be using in their old products?

It’s tough. What is competition? Competition is anything that causes people to not engage with you at this point in time.

People have been telling me for three to five years that, “In three to five years, AI and machine learning will be able to do what you do.” That’s competition for us, in that it causes somebody to say, OK, we will wait and see what happens with that. People are now getting used to the fact that even if you use artificial intelligence and machine learning that’s programmatically-based rather than clinically-based, if you put garbage into these systems, you get garbage out. What error rate are you willing to accept?

We don’t try to compete with AI or machine learning. I don’t want to sound like a troglodyte. It’s valuable in identifying associations from large populations of data, saying, “We need to do more of this. We need to do more of that. This is happening in our population.” But for an individual patient, at any point in time at the point of care, I don’t think it’s going to be ready any time soon.

What are the secrets of working with EHR vendors instead of trying to compete against them?

You have to provide something of value to them and to their users. We provide a clinical data capability that they don’t have otherwise. 

One of the secrets is when they say, “We have to have certain technologies. We need Angular. We need React. You have to do Docker containers. You have to host it in the cloud. It must be able to be  web-based. We don’t want to use your UI, we just want to call out to it and have it linked,” you have to  make sure that whatever tools you create allow them to stay in place to do all the things that they do well. Patient registration — we don’t do that. Storing of data — we have data services that pass it back and forth.

You’ve got to be willing to not enforce your vision of what their application should be. You’ve got to make your tool customizable enough and flexible enough and you’ve got to constantly redevelop your technology so that it meets the latest requirements for integration with these systems.

With these systems, the concrete is poured. They’ve got a bridge in and the concrete is poured. They want to improve their roadway? Yes, we can put down parts of a roadway, but we can’t rebuild the bridge, and nobody wants us to. So you’ve got to be willing to be part of their implementation. And in our case, our clinical stuff becomes a core piece of what they do, but it doesn’t look like it is to their customers. It just does what it needs to do and sits there. You’ve got to make it work in their environment.

Health IT vendors are making splashy announcements about embracing Amazon Web Services, Google Cloud, or Microsoft Azure and using their tools for AI and speech recognition. How will that change your business?

We’ve already begun part of that. We already have people using AWS and Microsoft Azure to host our stuff, or their applications with our stuff in it.

We will probably be asked very shortly to provide some sort of a clinical relevancy service to some of these people who are making announcements so they can find anything they want with just one or two words. For clinicians, finding anything you want means finding the things that are relevant to that, given the fact that somebody has asthma.

Over time, probably in the next two or three years, we will probably have to split our stuff into separate consumable services, one of which we’re already doing with our HCC and Medicare Advantage service, so that people who aren’t even using our concepts, engine, or terminology can do risk adjustment reviews if you just give a problem list based on SNOMED or ICD-10.

Microservices was a big buzzword a few years ago. We’re probably going to have to be willing to work with not just vendors, but suppliers of technology to those vendors, by allowing people to consume services from our engine, but not necessarily the whole thing.

Google has expressed interest in creating an EHR search engine, but it seems like it would find “patient denies chest pain” just as readily as “patient complains of chest pain.” How important is the contextual element of the search?

There is no question that natural language processing, based on noun phrases alone, is not going to work in medicine. You need context, you need to know relevancy. Is pain relevant for somebody with asthma? Yes, chest pain. What about wheezing? Did it start suddenly or not? The more that people drill down into this, the more they realize that you really need the clinical context within which the phrase you’re looking for exists.That’s a big part of what we provide.

What do you expect to see at HIMSS20?

A lot of the vendors complain that the CIOs, CMOs, and CMIOs don’t go to HIMSS. I think that’s true more and more. If they already have a platform — Epic, Cerner, Meditech, Allscripts, some of the big guys — there’s nothing they can do about it. They’ve got it. They might go to HIMSS looking for the ancillary vendors to add on certain products. We’re still seeing those people come through.

Ten years ago, health systems would send like 15 people, and say to the 15 people, “Fan out. You check this out, you check this out, you check this out.” You’d see them meeting at breakfast and planning their day because they were going to switch vendors. They were looking for a vendor. You don’t see that much any more. Because we’re not there to replace vendors, we’re there to have our stuff in as additive value, the fact that those people aren’t there doesn’t affect us so much any more.

Going into HIMSS last year, I was thinking about downsizing the booth. But by being there and by making a stronger statement about what we do – “We fix EHRs” — people said, “Finally, somebody says what they do. No buzzwords.” We met two major new accounts and opportunities that we have license agreements with. I decided for the first time to splurge and get a booth on the main aisle, because if you’ve got a good message and you know who your target market is, it’s still worthwhile for people like us. But boy, there’s a lot of noise. 

Half the team you bring is there just to figure out, “Somebody just stopped by the booth. Are they serious, or are they not?” We’ve been going to HIMSS since 1996, so we’ve gotten pretty good at that.

It’s worthwhile for us still because we’re solving a problem that everybody has, and they know they have, which is clinical usability. We’ve managed to hone our message on that in the last few years, so it’s effective for us. But if I was going in there for the first time, it would be like a deer getting caught in the headlights.

How do you see the future of the company?

We’ll continue to do what we do. We’ve been doing it since 1978, 41 years. We’re really starting now to benefit from people realizing, “We’re not just tracking transactions any more. We’ve got to manage the patients better. It takes really good data to do that. We’ve got to make it usable at the point of care. What are we going to do? What are we going to do?”

This, I think, is our time. We’ve got to stay focused on what we do. Going after outside investors, changing ownership, changing leadership would just distract us from our mission. One of my main challenges is identifying and nurturing the next generation of leadership here, because we’re going to continue to do what we’re doing. I look at the senior people at companies to see, how long have they been there? How many generations of those people have they been through in the last 10 years? If it’s more than two, that’s a bad sign for continuity. The only way we can continue to do what we’re doing is by continuing to do what we’re doing.

HIStalk Interviews Scott Shreeve, MD, CEO, Crossover Health

October 30, 2019 Interviews No Comments

Scott Shreeve, MD is CEO of Crossover Health of San Clemente, CA.


Tell me about yourself and the company.

I am an emergency medicine physician. I was one of the co-founders of Medsphere, the first open source enterprise electronic health record. It was built and based on the Veteran’s Administration software system that was in the public domain. We had a good experience commercializing that software for hospitals and health systems that couldn’t afford the Epics and Cerners of the world. We had some nice success and early wins. I left the company under some challenging circumstances, but I’m thrilled to see it go on to be successful.

After I left Medsphere, I became interested in healthcare delivery and primary care. I was doing a lot of reading about re-architecting and designing new types of health services. I had read “Crossing the Chasm” and “The Innovator’s Prescription.” Primary care has always been such an important part of the foundation of a good, strong, healthy healthcare system, and if we could design that primary care foundation in a better way, with new payment models and a new care experience, that could be the basis of some great innovation.

After speaking, consulting, writing, and blogging about those topics for several years, I decided to take the plunge in 2010 to start Crossover Health. It began as a direct primary care practice. We had some initial success after opening up our first store in Aliso Viejo, California, but quickly learned that going directly to the consumer was quite challenging. We pivoted our innovative primary care model to address the needs of self-insured employers. Crossover became the medical group that provides services to companies like Apple, Facebook, Microsoft, Comcast, and others. We’ve been on quite a run since then.

Crossover Health describes itself as a digital-first national medical group. How does that work in terms of access, provider licensure, and use of analytics?

Crossover is focused on Fortune 50 companies and Fortune 500 companies that are looking to bend the cost trends in healthcare, that want a different experience, and that want to get more involved in healthcare delivery. They hire us to do that. We’ll come onto their campus or near their campus to build these health services.

What we find, though, is that most of the employers we work with have scattered pockets of employees all over the country. We were addressing only 10% to 40% of their populations by building near their headquarters. That was great for the patients who had access, but it didn’t address the needs or solve the problems of all of their employees. What they’ve asked us to do, and what we were doing on our own, is to extend our care model by adding digital-first as a strategy to capture the rest of the population.

That move is critically important. Telemedicine has been around for years. A remote employee in Georgia might work for Facebook in Menlo Park, but they can pick up their phone to immediately access their dedicated care team for the designated Facebook population and get the care they need right off the bat. We can either address is then or have them follow up locally where they live in Georgia with a curated network of specialists.

We have built a consistent care team that is licensed in all the different states. It is available to the people throughout the country who are covered by the benefits of that particular employer. Because we’re not physically in Georgia, we then have to steer, navigate, and coordinate the care for them when they access care that they may need locally. 

It’s an interesting solution. We either come on your campus or near your campus and provide a set of services, but now we are meeting the patients where they are, and that is digital-first. People are comfortable coming online. It’s  how they work in the rest of their life. Now we’re allowing them to work with their dedicated care team in the same way.

Surveys have shown that Millennials love technology and the immediate gratification it can provide, but don’t have much interest in cultivating an ongoing relationship with a primary care provider. How do you work with those employees?

I love the quote that “nature finds a way.” Everyone finds a way to get care. Millennials are comfortable getting online and asking things. If there’s not a coordinated, organized way in which that happens, they will meet their needs their own way.

What’s fascinating to me is that when you give them the opportunity to interact with a primary care physician and a consistent care team, they love it. It’s simple to them. They want to establish a relationship, but it has to be convenient, accessible, and in the way that they normally live their lives.

Our technology isn’t an electronic health record designed for billing. It’s a more like Slack, asynchronous communication with a consistent care team, where we can have that constant communication as needed. Then guide them in their local geography.

We’re finding that Millennials really do care about their health, but they don’t care for the traditional system that doesn’t provide access and tools. If you can meet them where they are, it’s very effective, very powerful. They are used to picking up their phone, logging into an app, texting their provider with a question, getting a response, and then digging in deeper if needed or being guided and steered to a local, curated specialty group. They are very comfortable with that. That’s not foreign to them, that’s expected. We are having a lot of success with that population.

Each employer has their own fingerprint and demographics. Some have older employees, such as in manufacturing and retail. We’re finding that those people very much want a relationship as well, and they are becoming comfortable with the tools. It’s almost like you are looking at different ends of the spectrum. You have the Millennials, who are very comfortable with the tools, and by the way, the relationship is great. On the other end, you have “I really care about the relationship,” and by the way, the tools are great. It seems like we’re crossing the generations through this type of a care model.

What are the contrasts you’ve seen as a former EHR vendor who now has the luxury as a provider to build the exact systems you need?

We’ve always had an electronic health record undergirding the foundation. But we built our own patient technology. Our patients never see the electronic health record. They see our tools, our patient engagement platform. With Jay Parkinson coming on board and all the work that he’s done at Sherpaa, we are building more tools and capabilities for our team members, our provider groups, to interact in this more asynchronous, structured question way.

Most of the care that we provide is through asynchronous means. Someone says I’m not feeling well, so we get orientation of what that is through this asynchronous communication. Once we’ve narrowed it down to a diagnostic category, we’ll send a structured question set, say, for stomach pain. Patients will take their time to answer that back. Based on that feedback, we’ll take the next step. We may need to see them in person and we ask if we can schedule that right now, or it could be that we suggest waiting for it to declare itself over some period of time.

We look at the electronic health record as the Slack channel. Each episode of care that we open up is its own project. We have tools that are effective at managing projects. Over time, we see replacing bits and parts of the EHR infrastructure with this patient engagement tool set because we are so focused on that. That’s where we see the evolution with Jay and with Sherpaa coming on board. Jay has taken on the roles of our chief designer and is building and extending what he did at Sherpaa, on a platform that has both a digital and now a physical presence. That combination is where he gets to play and innovate now.

Why is there a disconnect between widespread availability of virtual visits and the low percentage of Americans who have used them?

We are finding that it is not in the human experience, certainly not in the cultural experience in America, to get on the phone for 10 minutes with a random physician that you have no relationship with. We see 2% to 5% utilization. There are clearly situations where that is fine and where it works for the 30 set conditions that you can manage. What we’re really talking about here with our model is full-blown primary care that has, as its basis and foundation, a physical visit that’s done a little bit differently. Better, we think. But now purpose-building in the virtual connection as well and delivering it in the same way.

It’s a known care team that now has new capabilities. It can extend to individual patients and interact with them in the way that they do in every other aspect of their lives.

Traditional telemedicine — when it is disconnected, when it’s a random physician that you don’t have a relationship with, and when it’s not endorsed from your provider — is only going to have a certain percentage of pickup. Our thesis has been that you can develop trust in a medical group that is endorsed by your employer; that you have met, touched, and felt; and that now has the ability to extend the technology to you. That is really powerful. The person is at home and can access us. They know us. We get back to them. We’re on call 24/7. They have this connected experience wherever they are in the country. That’s the difference that we are banking and betting on.

How do health systems that make big money selling those questionably necessary visits react when you sign on with a big local employer?

Comcast / NBCUniversal is a huge player in all these different markets. Every health system wants to cater to their business. Our other employers are similar.

A lot of the health systems don’t really know what to make of us. If your business is built on sick care and you’re dependent on me feeding your MRI machine, that business model is doomed. The health systems that we do have a chance to work with are really innovative. They are very much based on value-based healthcare. They are realizing that while having a incredibly full hospital has historically been a big part of their business, I don’t really want that for the overall health of populations and value-based contracting.

We’re somewhat of a nebulous group to interact with. Some know that it’s a great model and a great primary care foundation, but it’s also challenging for them to understand how to work with us. Some innovative health systems know they haven’t been able to change the fundamentals of primary care in their own markets, so let’s do something totally disruptive outside of our system, but in partnership with a primary care group that is value-based and will send us the right referrals. It might initially look like that affects our immediate, short-term bottom line, but over time, given the new financial models that they’re moving towards, this is exactly what needs to happen, and they are embracing and endorsing it.

How much of Crossover Health’s identity do health systems use when announcing those services?

Most health systems have a lot of equity built into their brand from the trust and years and decades of work in that community. We have the option, and we do this with our employers as well, to white label our services, so it is very strong on that particular health system or employer’s brand. We can go all the way to the other end toward Crossover, because there are advantages to being totally separate, new, and different. In different settings, the privacy and the security and having a separate entity provided is useful.

We find that most strike a middle ground, where they want to have their name. but also our name together. It becomes a “powered by” situation. We leverage the good name and goodwill of that institution or brand from the employer, the health system, and then you can also show and highlight that you have this innovative collaborative partnership as well. That’s where we see most people land.

You’ve been out of health IT for a long time, but how do you see that landscape developing, especially with regard to what investors are funding?

This is like a view from 10 years ago since I left the industry when I was following it closely, but a couple of comments, maybe. One is that I’m surprised, but also not surprised, that Epic essentially has eaten the entire medical space. I think Judy’s concept of having a fully-integrated, comprehensive suite and then being able to get ahead of that is amazing. The value of the integration has been greater than any limitations of their underlying technology or otherwise. That’s been impressive to see from the outside.

Conversely, these monolithic kinds of system are incredibly hard to work with from the outside. It’s not that they are so technically hard to work with, it’s that they flat out don’t want to work or integrate with other people outside. That’s the negative side of how big they have scaled.

It’s interesting to see where Cerner has continued to evolve, along with Allscripts and others. I’m still a huge advocate of open source technology and love to see that Medsphere and others are out there still doing it.

Where my perspective has changed is that I see healthcare IT as simply a tool. Whether I have this tool or that tool, it is a tool that enables the information, the sharing of information.

The problem I see with health IT as it is today is that if architecture is destiny, then the way that these systems have been architected is highly concentrated around billing and other things. They have added other clinical components that are important, but that overemphasis and tying it to a fee-for-service system, which I also feel is doomed, impinges on the potential impact of where healthcare IT can go. What we are working toward and building is trying to get things that are more consumer-centric, where consumers can be more involved with their care, the record is really theirs, it is shared with their provider groups, and they have modern tools for interacting with their care teams.

Where IT has always been strong and remains strong is that you can aggregate the data, analyze it, and provide advisory services back to the people who need it, both providers and patients. I am pleased to see where that’s gone and where it hopes to go with machine learning, artificial intelligence, and other ways to introspect the data that has been gathered. That is really promising.

One of our big collaborators is Health Catalyst. Some of these big-iron tools that do deep-dive data analysis for big health systems are getting to the point where smaller providers like us can access them and put them to work. So much of our care is not about reacting to what’s on our schedule that day, but proactively reaching into the population to find those people who we need to be seeing that day. Then using digital-first tools and otherwise to get the people who maybe are less acute, but still have needs. Can we address those another way so that we can reserve the in-person visits or our concentrated efforts on those people who need us most?

How can technology overcome the fact that health system consolidation and the involvement of huge for-profit companies have left patients dealing with ever-bigger and potentially more bureaucratic organizations in their moments of need?

Privacy and the value of healthcare data is incredibly important. How you manage it, and the trust and confidence that people have to have and who’s storing the data, is critical. We work with some of the biggest technology companies with amazing amounts of data on different customers and the lives of all the people who use their platforms. We’ve learned a lot from watching how they do that.

There needs to be a role for a new type of health service that you join that keeps you healthy, that is independent of CVS, Walmart, and the insurance companies. People could join an organization that is purpose-built to manage their health information at their request. Who will be the first health banking service that is a trusted, independent third party that can aggregate your data and that you can assign in a permissioned way to allocate access to your data at certain points in time? Whoever creates that is going to be powerful.

The future health economy will be built on the currency of trust. One of the things that we sell quite a bit to our clients and employers is that Crossover is an independent, tech-enabled, data-enabled, national medical group that is independent of payers and health systems. We are a potential candidate to become that trusted intermediator of your health data. To bank your health data in a way that you trust and to allocate and invest your health information based the permission and rights you have. We are excited to see where that goes.

HIStalk Interviews Kavita Bhavan, MD, Chief Innovation Officer, Parkland Health & Hospital System

October 16, 2019 Interviews 2 Comments

Kavita Bhavan, MD, MHS is associate professor of infectious diseases at the University of Texas Southwestern Medical Center and chief innovation officer at Parkland Health & Hospital System in Dallas, TX.

This interview was conducted by Vikas Chowdhry, MS, MBA, chief analytics and information officer of Parkland Center for Clinical Innovations in Dallas, TX.


Describe how your career led you to become a chief innovation officer.

I started out as a graduate student in public health at Johns Hopkins and then pursued my MD at Penn State. After completing my residency training in Internal Medicine at Ochsner, I chose infectious diseases, at Washington University, as a subspecialty because it is an area where public health and medicine naturally interface. I joined the faculty at UTSW in 2009, working in an HIV clinic at Parkland.

Shortly after joining the faculty here, I was asked to work in a smaller capacity with a great team of pharmacists on ways in which we could improve delivery of care for uninsured patients that require long courses of IV antibiotics in the outpatient setting. The existing disparity between this group of patients and those with adequate insurance was that they could not access standard forms of outpatient therapy, such as infusion centers, home health services, or skilled nursing facilities.

Prolonged inpatient care is difficult for an individual patient since it limits their ability to return to work or care for family at home. It also impacts the safety net system, where many patients may be waiting to be admitted in the ER. We innovate in this kind of an environment out of necessity and can only succeed when we are given space to rethink care delivery with support from leadership and key input from frontline providers.

What does innovation in healthcare space mean to you?

Innovation in healthcare can present itself in a various forms. While many people associate technology with innovation, I’ve been increasingly interested in thinking about another aspect — low-tech, low-cost approaches to patient-centered innovation to address disparities and improve health equity. The most natural place to start seems to be effectively engaging patients in care processes to reconfigure existing resources to improve high-value care.

What does that mean? In healthcare, we often talk about empowering nurses, social workers, and physicians to practice at the top of their license. What does top of the license for patients look like? Innovation in healthcare includes co-designing care with patients to improve access and address other existing problems. Better clinical outcomes can be achieved with such co-production of care.

There is a shift that occurs when a patient is providing care for themselves at home, as in our home IV antibiotic program. They move from being a passive recipient of care in the hospital to being an active participant in their care at home. We have observed better clinical outcomes over the years while also seeing enhanced engagement and management of one’s health, including other chronic diseases such as diabetes.

Innovation is usually thought of as synonymous with technology. While technology is important, we need to make room for another model of innovation that is even cheaper and easier – recognizing human potential.

How does engagement that goes deeper than “use this app to check your lab results” or “use this device to report your steps” work in practice?

Our self-administered outpatient antimicrobial program at Parkland has become a new standard of care for our patient population and is an example of effective patient engagement. Typically, patients with infections that require long-term antibiotics receive intensive diagnostic and therapeutic services in the first several hospital days. Afterward, they remain in the hospital only to receive antimicrobial infusions.

Insured patients may be discharged early to complete their antimicrobial courses at home with contracted nursing assistance or in lower-cost nursing facilities, but uninsured patients usually remain in the hospital because they cannot afford a healthcare-administered outpatient parenteral antimicrobial therapy (H-OPAT, overseen by the healthcare system).

Those uninsured patients have limited options and may be confined to the hospital, which prevents them from resuming work or other activities of daily living or caring for family members at home. In the safety net hospital setting, this can be a challenge in terms of capacity and the ability to care for other patients, in the ER for example, as a sub-optimal use of resources such as beds.

We approached this problem by piloting our program with a few patients in 2009 with the goal to teach and train the method of self-administrated IV antibiotic therapy by gravity at home. We started the program with minimal resources as patients did not have a home visit or access to home health nurse, infusion center, or devices such as pumps / elastomeric balls (S-OPAT, overseen by the patient themselves).

We began with four patients as a proof of concept and have now cared for more than 4,000 patients through this program. Along the way, our multidisciplinary team listened and learned from our patients what works and what doesn’t work to further refine the process.

We translated education material to appropriate levels of health literacy for our population, achieving a fourth-grade literacy level in English and Spanish and including pictures. After a few years, we moved to an audiovisual process where patients can scan a QR code on the back of an IV bag and be sent to a teaching video on their smart phone where they can watch the process and review all of the steps for infusion at their own pace. This has been effective not only for patients who speak other languages, but also for those who prefer visual learning.

We developed a competency checklist, and using the teach-back method, had patients demonstrate all of the steps of infusion and PICC line care needed to ensure safe discharge from hospital to home.

After the first four years of operation, we tracked clinical outcomes for our S-OPAT patients compared to patients with insurance who left our hospital for healthcare-associated OPAT such as home health or skilled nursing facilities. We were surprised to find that our S-OPAT patients had a 47% lower 30-day readmission rate along with higher patient satisfaction.

How is that possible? When we talked to our patients on return visits, we found they mastered all of the steps and took ownership of the process. It was clear they were more invested with effective engagement. One patient actually said she thought she did better because “it is my own body” versus a nurse coming out to the home to perform a job. We began to appreciate the positive impact of patient engagement with meaningful results.

How do you scale the program?

One of the interesting aspects of this program was that after learning about the success of self-administration, other patients who were insured with access to healthcare-administered therapy wanted to participate in our self-administration process. I have since learned from others that this may fit a model of disruptive innovation. You create something that is useful for a small section, usually a bottom tier of your consumers, that eventually becomes attractive to the broader market. However, unlike a consumer market, adoption by the broader market is determined by a lot of other factors, including existing health policy, reimbursements, etc.

There has been other interest in promoting patient engagement as seen by the recent CMS position on encouraging at-home dialysis. The proposed ESRD Treatment Choices model will give patients an ability to choose at-home dialysis, which may potentially improve satisfaction, lower costs, and improve outcomes.

Could your work have been done at other institutions?

UTSW and Parkland’s partnership is unique because we are committed to caring for a large population of uninsured or underinsured patients with health disparities. Innovation centers attached to larger health systems may have greater investment in technology-based innovation. Our approach has been more patient centered. Our CEO, Fred Cerise, MD, MPH, described another way of looking at innovation that does not need to be driven by profit in his Harvard Business Review article a few years ago

We are likely in the minority coming from a safety net hospital in the larger healthcare innovation space, but there is a need to grow across the country since safety net settings innovate out of necessity.

What’s the most impactful book you have read in the last 12 months?

“The Moment of Lift” by Melinda Gates. She articulates the value of inclusiveness and educating and empowering women to fully recognize our collective potential as a society. There are examples of how impactful this can be around the world and here in the United States.

How do you remain optimistic as a physician when working with a population whose inequities and social disparities are root causes that you can’t address?

The problems are far reaching and there is no simple solution. We are increasingly aware that social determinants affect health and outcomes. Just because we cannot do everything to solve these problems does not mean we cannot do something, to do some small part to help address a given problem to improve the status quo.

I’m lucky to work in an environment where I and many others have the opportunity to make some small difference as we strive to improve patient care.

HIStalk Interviews Karly Rowe, VP, Experian Health

September 30, 2019 Interviews No Comments

Karly Rowe, MBA is VP of new product development, care and identity products, at Experian Health of Franklin, TN.


Tell me about yourself and the company.

I’ve been with Experian for eight years. I oversee all of our new product development, the processes, the teams, as well as our identity and care management portfolio. Our Experian Health business is represented by the areas of revenue cycle management, identity management, care management, and analytics. We started in the market serving a group of providers.

What are the chances of the US implementing a unique patient identifier?

Now more than ever, there’s an openness to consider a national patient identifier, especially as topics of interoperability are getting more and more advanced through things like TEFCA. There’s a new acknowledgement within the public sector, the private sector, and the healthcare industry as a whole that a lot of the things that we want to achieve — in terms of true interoperability and improvement of care for patients and care coordination – all foundationally stem from having a national patient identifier in place.

I don’t have a crystal ball to predict whether that time will be tomorrow, next week, or a year or two years from now. But I do think that there’s been a significant shift and an openness, to where we are closer now than we ever have been to getting to a point to embrace the national patient identifier.

How would that change the company’s business?

I don’t see a large pivot. Our position is that there isn’t one key-holder to this identifier. It’s more likely and more beneficial that it’s a handful of vendors, of organizations, working together to provide it. 

We collaborate with vendors across many other lines of business. Our core business is as a credit bureau. If you look at that model, Equifax, TransUnion, and Experian work together, collaborate, and share information as it pertains to individual’s credit to ensure that the information is the most accurate when going out to consumers.

For us in a healthcare setting, do we provide identity services? For sure. Would we be open and accepting to collaborate with other key leaders within the industry to make this something that could truly help transform the healthcare industry? 100%. There’s precedent that has been set across multiple aspects of our business. That credit example is just one of many.

Online services often ask people to verify their identity by choosing their previous address or a car they used to drive from a list of choices, something that they know that others would not. How is that being used in healthcare versus just taking a patient’s driver license or insurance card?

That’s a service that Experian Health has been providing to the healthcare industry for several years. We work with a lot of the patient portal systems and are integrated directly with them. We can help provide the confidence to our healthcare clients that the patient is who they say they are, before you then open up access to all of their personal health information that’s highly sensitive. 

That’s something that we have carried over. Banks and financial institutions probably paved the way and were pioneers of setting that precedent. Healthcare is adopting that, as patient information is no longer on paper and it’s all electronic records. Access to that information needs to be protected and treated with the highest degree of security and sensitivity.

Surveys have shown that consumers, wisely or not, are willing to share their private information with companies that give them something in return. How will that play out in healthcare?

Even speaking for myself as a consumer, there’s a general frustration that we all feel when we say, “I can’t access all of my health information, my historical information, anywhere.” Unlike when I go online to look at my credit card statement and I can see all the transactions and I can look across multiple credit cards. The history, credits, and debits are all there.

It is absurd in healthcare that from a consumer perspective, if I wanted to do that today, I would have to individually reach out to find every doctor, every pharmacy, every lab test that I ever got, and manually go ask for that information. There’s a convenience where I would love to know that the care that I’m getting, the decisions that the doctor who’s standing in front of me is about to make on my health, are the best decisions.

The way for that doctor to make the best decisions is for me to provide the consent to say, you have access to that information, and there’s a way to pull that all together. The only way that that really happens is if you have an understanding of who I am as a patient across all of the different encounters that I’ve had. That stems by speaking the same common language, and the problem that we have today in healthcare is that we’re all speaking different languages. Everybody’s got a different way of identifying a patient and none of them interact. It’s like one health system speaking French, one speaking German, and another speaking Italian, all trying to talk to each other about a patient. It’s impossible.

Are health systems interested in using outside consumer information for patient engagement, marketing, or other communication that doesn’t involve only what the EHR contains?

Some are, but there are clear lines of distinction. This is where the patient plays a role in what information is being shared and for what purposes. There’s that clinical aspect of saying, I just want to be able to provide the history of my health so that that doctor has seen every lab result, every test, every procedure in their hands.

There is another element where, like in many other facets of our lives, we like the customization of the ads that are being sent to us, the coupons that are targeted to services that we enjoy, or the commercials. That transcends every other part of our life. In healthcare, there is an interest in saying, “Maybe there are pieces of who I am as an individual and the likes that I have. I’m OK with you having so that you can tailor my experience when I’m a patient visiting your portal or when I’m interacting with you as a healthcare system.”

That starts to get into things that could improve the patient experience and their overall engagement. A lot of topics stem around overall care management, care coordination, and how that patient is being treated and receiving care. There are broader socioeconomic data factors that can assist in that. But I draw a line of distinction between those. For a lot of consumers and patients, clinical information is different and feels different than your lifestyle, behavioral, and socioeconomic type information. Patients may want to choose to share those things differently for different purposes.

Some of the first uses of commercial consumer information I saw in health systems were as simple as verifying a patient’s identity via the address they provided or to determine their propensity to pay. Is it a big leap from there to using social determinants of health?

We talked about having a patient identifier. Studies done by ONC on patient matching show that having reference data, knowing more about a patient than what’s present within a healthcare system, can help you get a better match. It’s the same in social determinants of health. They say 80% of health outcomes are attributed to non-clinical factors. That means the socioeconomic factors that surround someone.

If you take a step back and say, what am I willing to give to get, it is like what you said about consumers. If a consumer knows that they could receive better care or have better care decisions made for them if they allow the caregivers or the healthcare organization to have a more complete picture of who they are as an individual, I don’t know who wouldn’t sign up for that.

Protections need to be in place to make sure that there isn’t abuse. Organizations like ours take it very seriously — the types of data, how that data is being used, and adhering to all of the regulations that are set forth. One of the things that we stand by very strongly is that we’re an original source compiler, which means all the data that comes into us, we have direct relationships with all those data furnishers. That allows us to ensure the integrity of that data, how it is intended to be used, and the regulations that are involved.

Others are buying data from somebody who buys data from somebody who buys data. The further downstream you get and all those different extensions, the higher the risk goes in terms of that data being used for the wrong purposes and for purposes that wouldn’t make a patient feel good.

What trends are you seeing in the increasing number of uninsured patients and high-deductible health plans that leave them paying more?

Patients have two pain issues – paying a larger percentage of the total and wanting visibility earlier. Sometimes it’s not the total of my bill that bothers me, but rather that I don’t have visibility before I get that bill in the mail. We do a lot of work with many of our clients to put patient estimates in the hands of consumers so that they are not surprised by what a particular procedure will cost or what their bill will look like. That goes a long way in helping them have a dialogue and a conversation with their healthcare provider to understand whether they have options or flexibility. 

That becomes critical, because it ties directly to the overall amount that the patient will ultimately be burdened with. There may be things that are optional within a patient’s care plan, there may be things that aren’t, or maybe there’s a drug that’s getting prescribed where there’s the option for a generic. Having that patient visibility into the cost up front allows that dialogue to happen, and maybe downstream to reduce that total burden and allow the patient to play an active role.

What is the expected outcome of Experian Health acquiring patient scheduling vendor MyHealthDirect?

What MyHealthDirect does is synergistic with what we do. We provide a lot of services that fall into the patient access realm. Bringing in the scheduling component to our suite of solutions, providing that ability to schedule a service, combining that with our matching and the correct identification of that patient, and then being able to facilitate the registration process, which starts to include running eligibility, looking at coverage, and providing those estimates. It’s really just continuing our breadth and advancing the more holistic solution of the patient access services that we can provide to our client base. 

All of this ties around our broader vision of of helping improve the care coordination for patients on behalf of our clients. It’s a natural fit and tie-in with many of the services that we provide today, but it also allows us go back to our clients with a solution that helps them manage that upfront interaction with a patient from the point of scheduling an appointment.

Do  you have any final thoughts?

We at Experian Health are excited about how we can help transform the healthcare industry, providing services and offerings to the market that are unique to our business. How we combine those, how we help solve challenging problems. One of the reasons I got into our healthcare space is that we have unique data and unique capabilities that, when hearing the challenges that our clients are facing, allow us to provide a differentiated solution. We’re excited about where we can help take the industry as we go forward.

HIStalk Interviews Jeremy Pierotti, CEO, Datica

September 16, 2019 Interviews 2 Comments

Jeremy Pierotti is co-founder and CEO of Datica of Minneapolis, MN.


Tell me about yourself and the company.

I’ve been working in healthcare IT for about 20 years. I started off working at Allina Health in Minneapolis and ended up doing consulting. Then I co-founded Sansoro Health. Sansoro and Datica merged in June 2019, with the go-forward company name being Datica. We help healthcare move to the cloud by addressing compliance and data integration challenges.

What can the merged companies do more effectively than they could have done as separate organizations?

We knew that healthcare is moving to the cloud at an accelerating pace. As Travis Good and I started talking, we recognized that we had a complementary set of products, technologies, and team talent, and that if we put the companies together, we could help digital health engineering teams address the two challenges that they have to solve. Those are cloud compliance — which increasingly means meeting the HITRUST CSF requirements — and data integration, being able to exchange data bi-directionally between lots of different digital health applications. Electronic health records, but also all the different supporting systems that every health system runs.

How far along is healthcare in its seemingly inevitable move to the cloud?

It is toward the beginning of its journey, and it’s going to move fairly quickly. We’ve read lots of reports that show anywhere from 10 to 20% CAGR growth over the next five to seven years, and we’re experiencing that ourselves.

Like every other industry, healthcare is recognizing that what the cloud brings is not just running your software on somebody else’s computer in a data center that they manage, but providing access to a whole new set of tools for data analytics, supporting mobility, and integrating lots of types of data from lots of sources. You just can’t develop software with those features using an on-premise architecture. You are increasingly seeing large companies develop their new applications on a public cloud framework because it gives them the flexibility and the power of the toolset to leverage the capabilities of engineers and development teams all across the world.

How does the work of Cerner, Epic, and Meditech fit into a strategy of making their data available for use by cloud-based services?

They are moving deliberately and cautiously, understanding that they can’t make dramatic changes overnight. Their customers are big, complicated provider organizations for whom stability is enormously important. They are all looking for the right balance of making new capabilities available and taking advantage of cloud functionality that will give customers the features that they want, while at the same time, keeping their core systems stable. That means something a little bit different to each of those vendors, but they are all trying to find and strike that balance.

Would a move to the cloud change the exclusive relationship between a health system and their primary EHR vendor?

In the short term, I don’t think it changes anything significantly. I certainly don’t think it makes it more exclusive. In the long term, I think it makes it less exclusive.

I was listening to a podcast from Andreessen Horowitz, where Mark Andreessen was talking about how in Silicon Valley, you have this rich ecosystem of API-driven data exchange and whole companies that have been developed just to facilitate the development and management of APIs within industries. What we see in other industries will come to healthcare, too. When you have increasing adoption of cloud-based application development, you end up stitching those pieces together with API-driven data exchange. We’re seeing that same thing in healthcare as you look at the emergence of FHIR and other API toolsets for patient data exchange.

A move to the cloud by Cerner, for example, is not going to tie the hands of Cerner’s clients and make them any more dependent on Cerner. It is just part of the the slow, steady move toward health systems being able to choose from a variety of tools and integrate the tools that work for them best.

What is creating the demand for cloud-based services?

My colleague and our chief medical officer, Dave Levin — who used to be CMIO of at the Cleveland Clinic – says he spends all day working in healthcare and then he goes home to the 21st century. The reality is that it’s consumers. It’s our everyday experience with smart phones, tablets, and advanced software that we run on whatever device we choose and that allows us to move from one device to another almost seamlessly.

Those experiences that we who work in healthcare have every day in every other part of our lives make us realize that we need that same type of functionality when we’re delivering healthcare services to patients. When we’re managing populations of patients or health plan members, we need those same capabilities, those same toolsets.

To take the simplest of examples, there’s no reason that if I’ve been to the same doctor’s office six times in the last year, that I should have to fill out the same piece of paper on the same clipboard the seventh time. When when I walk into all sorts of other businesses, they know who I am. They have read my license plate or I’ve agreed to have my smartphone notify them when I walk in, so they know from the beacon  at the front door that I’ve arrived and they’re ready for me. It’s those kinds of experiences — the scalability, the mobility — that is driving healthcare organizations to create software with those same capabilities.

Will it be hard for healthcare IT vendors to move their systems to the cloud?

Vendors are looking to do that module by module. I don’t have deep insight into the Cerner-AWS announcement that came last month, but the way I understand it, Cerner is not saying that all of a sudden they’re going to move all of their clients who use Cerner Millennium onto AWS servers or AWS services. But they will be increasingly developing new software capabilities on the public cloud. On AWS specifically, for Cerner.

Going back to what I said earlier about the need for stability and reliability by providers and payers, but especially providers, our expectation is that you’ll see vendors developing their new software, their new modules, in the public cloud, taking advantage of those capabilities. They will work deliberately over time to figure out what makes sense in terms of potentially migrating their legacy products to a cloud infrastructure. I’m not sure I have any unique or special insight into that, but that’s the trend I’m seeing, health IT companies developing their new stuff in the cloud and migrating their customers who want those new features to that new platform.

Health IT vendors seem obligated to name-drop AI and analytics in their cloud announcements. What kind of learning curve will they and their cloud services vendor encounter as they modernize healthcare applications?

I wish I knew the answer to that. There clearly are some tremendously exciting applications of artificial intelligence and machine learning in healthcare. I’ve also read many pieces recently about the need to approach it carefully. Any time you’re going to train a machine to learn something, you need to make sure that you’re training it in the right way, otherwise you can create more problems than you’re solving.

But the cloud is a big part of that, because there are so many AI and ML services that are available through a public cloud infrastructure. AWS announced Comprehend, their natural language processing service, a couple of years ago. It allows users to train it and it comes at a competitive price point. That’s an example of how cloud service providers and application developers in AI and NL are looking to leverage the cloud — making those services available, allowing lots and lots and lots of engineers and creators to experiment with those services, test them, and determine what can have a real, positive impact on patient outcomes.

Big provider organizations are announcing their own cloud partnerships, such as Mayo Clinic and Google Cloud. How will those organizations work directly with cloud providers?

It speaks to the amount of data that providers are accumulating. They need to find ways to support the efficient storage and analysis of that data so that they can learn from it as quickly as possible and apply that to better operations and better patient care. It’s not surprising to me at all and I think we will see more of it. It’s understandable, because in other industries, you have big players, big companies that are on a daily basis using cloud platforms and the analytics capabilities of cloud platforms. To improve their products, to improve their customer service, and to improve their deployment of personnel.

Healthcare has the same needs and the same demands of end users to capture those capabilities without having to invest in standing up a new data center full of physical hosts and a big huge team of devops engineers, DBAs, and others to manage all of that traditional infrastructure. You’ve got all of that data and you need somewhere to quickly and efficiently store it and analyze it.

What impact do you expect to see from the federal government’s implementation of the interoperability and data blocking implications of the 21st Century Cures Act?

We’re waiting just like everybody. Our sense is that when the final rule is released, it will raise the floor, but it won’t necessarily raise the ceiling. We are looking to continue to push the ceiling with innovative solutions for integration.

We recognize that even when ONC and CMS release those new rules, it’s likely to be several years before they’re enforced. It’s going to take the vendors time to develop the technology and capabilities that those rules may require. We’re not waiting. We are working every day with health systems and innovative health IT companies to figure out how they can make the most of the data exchange capabilities that exist today.

The bottom line is that we’re eager to see what comes out. Industry discussion of those rules has been robust and the public itself is highly interested in it. Every person has a personal investment in being able to get access to and make portable their health information. So it’s fascinating, but we recognize that it will be years before anything is actually required and implemented. Our goal is to help our customers, providers, and payers take advantage of what they’re capable of right now.

Is the federal government at risk of oversimplifying the interoperability challenge in declaring mission accomplished just because the use of APIs and FHIR has widened?

As I listened to the debate over the last several months, and certainly after the draft rule was released, I was struck by how thoughtful and mature the discussion was across the board on these rules. There is a broad recognition within health IT that if this were easy, we would have solved it.

I’m not saying that it’s challenging mostly from a technology standpoint. It’s challenging mostly because there are lots of competing interests that have to be resolved, and they’re not necessarily easy to resolve. There are ways to do it, and our company and I personally have our own views on how to address some of those challenges. But it’s been a robust, mature discussion about how we balance the interests of different players, always keeping in mind that the goal here is the delivery of better patient care at lower cost and having better outcomes.

Do you have any final thoughts?

My colleagues and I are excited about the pace of innovation in health IT. If we weren’t, we would go find something else to do, since goodness knows the world has plenty of other problems to solve. I look forward going to work every day because of the opportunity to partner with people who feel emotionally compelled to bring positive change to something that impacts every single person — the delivery of quality healthcare.

HIStalk Interviews Steve Shihadeh, Founder, Get-to-Market Health

September 11, 2019 Interviews No Comments

Steve Shihadeh is founder of Get-to-Market Health of Malvern, PA.


Tell me about yourself and the company.

I’m the founder of Get-to-Market Health, a consultancy that helps healthcare technology companies accelerate their growth and revenue. I got my start in healthcare IT as a sales trainee with Shared Medical Systems, and through a series of growth experiences, ended up being their leader for commercial activities. I then had that same role at Siemens Medical after they acquired SMS, at Microsoft Health Solutions Group, and then finally at Caradigm, a population health company.

About two years ago, I formed Get-to-Market Health. I have a passion about the business and what technology can do. I also have a strong belief that high-quality commercial activities are an important part of any successful healthcare technology business.

What advice do you give a startup or a company that is getting into healthcare for the first time?

A big part of what we do is help people understand the market, but equally, help them understand how the market looks at them. Healthcare buyers are different. We will often have clients who want to enter a new space and it’s just not the right fit, or they need to make some adjustments. Lead generation, building a pipeline, qualifying — all those things are important, but the most important thing is figuring out where their product fits.

What help do companies need in deciding what product to bring to market or how to get it in front of the right people?

The healthcare market is incredibly complicated, in a good way. It’s not just hospitals and doctors any more. Trying to figure out who the real buyer is, who has the authority to buy, who has the budget to buy, and how to present a product in its best light is an important issue for any company, but especially smaller companies that are trying to grow.

How should companies approach a market in which Cerner and Epic have become dominant and may become even more so as providers consolidate to create a customer base that has fewer, larger players?

It’s funny how the market has swung. It used to be that everything was interfaced and people bought best-of-breed. Now the pendulum has swung the other way, where a few large companies dominate the space. But I don’t think you can keep innovation or innovators down. 

A lot of the work we do is coaching and helping innovators figure out whether they should have a relationship with one of those big companies. If they are going to compete, how? And if they are going to get out of the way of the big vendors, how do they do that and still be successful? It’s a tricky landscape.

I think of the relationship between newspapers and companies like Facebook or Google that send them much of their traffic, but also take a lot of their revenue. How can companies figure out how to cooperate with those big EHR vendors while remaining aware that they also compete with them?

We see that every day. There is coopetition, where companies are OK that you compete or you partner. But I think vendors and also providers are trying to watch the way the landscape is moving because hospitals and health systems have that same issue around digital traffic as well. It’s a pretty interesting time to be in this space.

Will big health systems succeed in their for-profit efforts to create IT companies, invest in startups, or run accelerators and incubators?

That’s the multi-million dollar question. The organizations you’ve written about, which I know well, have invested hundreds of millions of dollars to incubate businesses. They are  becoming the investor. 

I understand the argument. To have a strategic investor behind a product like that is a big deal and will clearly help with other providers deciding to do business with them. 

It’s early to declare success. You can certainly point to some great examples – UPMC, Providence, and Northwell  have made some  good investments. It’s a clear trend because they aren’t able to make the margin they want on the core business and they have valuable intellectual property that they want to leverage.

How do companies that bring in new investment money meet the accompanying heightened expectations for growth?

It may be a little overused term, but it’s clearly an inflection point. The investor is betting on a multiple and a growth that wasn’t there before the investor showed up. Often the company that has taken an investment hasn’t really thought through how they’re going to make that growth happen. It is a point in time where the business evolves. Sometimes the players stay the same but just change what they’re doing, sometimes there are new players, sometimes there are new markets. But generally when an investor writes a big check, something’s going to happen.

What catch-up work do small companies need to do once they’ve hit a higher revenue level and have to start behaving like a bigger company?

We generally get called in when there’s a realization by the leadership team or the investor that they want to do more in terms of marketplace growth. What got them to that point isn’t going to get them ahead, so they want to try something different. It could be new markets. We have one client that is bringing in an AI machine learning platform from Europe to the US. People are taking products up into the enterprise space where they just used to work in community hospitals. It’s a realization that they want to do something different and they’d like an outside point of view as they do that.

How does a company formalize its sales process?

That stereotypical sales guy or sales gal from the past still exists, I guess, but they are a dying breed. One of the biggest changes I’ve seen in my career is how much more capable providers are getting as organizations and as buyers. They are pushing and demanding more from their salespeople than just buying lunch and overseeing a good demo. It’s clearly gotten better. Often we get called in to help them improve the deliverable that their sales team provides to the buyer.

How much of a company’s success is based on the skill, personality, or perseverance of a superstar salesperson whose traits can’t be easily replicated or obtained elsewhere?

It’s an interesting point. I suspect that the head of engineering has a few people he or she really relies on. The head of services has a few key people they rely on. I can’t argue against salespeople who are stars.

However, it’s more of the whole commercial mechanism —  how the company presents the product to the marketplace, how it prices it, how it creates product awareness, how it names and positions the product, and how it approaches buyers. You have to approach the CIO IT shop with your act together. You have to be able to answer the security questionnaire. You have to answer how it integrates with the EMR platform. You have to be pretty buttoned up in order to be successful today. It takes more than just a great salesperson. Although they are good to have and everybody wants them, it’s far bigger than that.

How do you advise companies to fit user surveys from companies like KLAS and Black Book into their marketing plan?

Really small companies don’t have to worry about KLAS, but they have other activities. Big companies have to invest in KLAS, Black Book, and various awards. Folks on the buying side really do use it. You may not be number one, but you had better not be off the list. It’s an acquired skill to be great at both delivering customer satisfaction and managing your relationships with those companies.

Do vendors call you because they haven’t done a good job at developing relationships with their existing customers?

One of the cool things we’ve been doing a fair amount of lately is running focus groups with clients and potential clients, to help them understand how they are perceived and how their product comes through. It gives them a safe zone to test ideas and get honest feedback. We facilitate that and help them hear what the potential buyers say.

Cerner hired KLAS to convene some of its big customers to tell the company how to improve its revenue cycle product and to ensure accountability as they did so. Will other companies do something similar instead of just talking to those customers themselves?

I’m not sure I fully understand the Cerner-KLAS thing. I was reading something about it this morning, in fact. One of the most important things a healthcare technology company can do is to get honest feedback about what’s working and what isn’t working. However you do it, I think it’s great. We seem to be getting more and more requests to help with it.

How do you see your business changing over the next few years?

It’s an exciting business. I have learned over the years that I don’t know as much as I think I know. It’s going to change in different ways. You look at some of the big companies that are spending money and hiring people and doing things and clearly there will be some shakeout from that. I hope they have the staying power and don’t get exhausted before they deliver some real products and capabilities. With the IPO activity and the buyouts that have happened, there will be more investor appetite for innovation. That guy or gal with a great idea won’t have any problem finding investors. It will be interesting to see where the products have an impact.

What goes through your mind when you walk the HIMSS exhibit hall?

I’m one of the people who actually enjoys going to HIMSS. Not because of the environment, but because it’s the business I’ve been in my whole career. I love the energy. You can clearly see who’s doing it right and who’s not doing it right. There’s a bunch to be learned from it. It’s a pretty amazing business, and a fun thing about the business I’m in now is that I can have a broader view of it. The roles I had before, in hindsight, were fairly narrow considering how wide the healthcare space really is and all the ways it is interconnected.

It’s clear that companies need to have their A-game for HIMSS or they shouldn’t go. We’ve helped several clients get ready for HIMSS and to do it right, but we’ve also counseled some clients not to go to HIMSS. They wouldn’t be heard above the noise. Awareness and creating client interest is a key opportunity for any company. They really have to pick their spots, whether it’s HIMSS or HLTH or any of the other regional or local shows. They have to have their act together.

Do you have any final thoughts?

You and I are fortunate to work in a business that’s evolving, growing, and consuming technology. It’s a business that all of us will depend on at some point in our lives. My view is, let’s make it better. We get to work with diverse business leaders to simplify the complexity and buying patterns of the healthcare technology market. That simplified buying process, with a clear understanding of what a product does or doesn’t do, is good for everybody. It’s win-win. No one, especially today’s providers, has time or money to waste. We think effectiveness and efficiency matter. That’s what gets us up and going every day.

HIStalk Interviews Ken Misch, President, Medhost

September 9, 2019 Interviews 3 Comments

Ken Misch is president and CFO of Medhost of Franklin, TN.


Tell me about yourself and the company.

I began my career on a traditional finance and accounting track with Price Waterhouse in Cleveland in the late 1980s. After going back for my MBA in the early 1990s, I determined that I wanted to do something other than just auditing.

For the last 20 years, I’ve worked with smaller, growth-oriented, private equity-backed companies, either in the technology or the healthcare space. After a personal health issue surfaced about 15 years ago, I decided I wanted to spend the rest of my career in the healthcare industry. Obviously since Medhost is a healthcare IT company, I’m fortunate that I can combine my interest in tech with my passion for healthcare.

Medhost serves over 1,000 facilities. We provide these facilities with inpatient electronic health record systems, related implementation, revenue cycle, patient engagement, and hosting and other managed services as well.

How would you characterize the market that you serve?

Medhost mainly serves what we would consider to be the community or the rural healthcare market, which is a different market than the traditional tertiary care market. The urban academic, large research healthcare facilities that you find in very large cities, is a different space than the healthcare facilities that we’re serving, those out in rural America. Those facilities are really challenged. Maybe all of healthcare is challenged to some degree right now, but rural healthcare probably more than others. Rural America is shrinking, but there’s still a need for providing healthcare in those communities.

Al the IT vendors that serve the healthcare space have been challenged recently by the increased regulation that’s been coming out of DC with respect to Meaningful Use, interoperability, et cetera. All of us have had to spend and invest significant dollars in upgrading the systems. Not only to comply with increased regulation, but hopefully provide better optimization and efficiency for our customers.

How has the move of Epic and Cerner into smaller facilities as well as Meditech’s efforts to rejuvenate its business changed the dynamic?

Certainly competition is increasing and is getting more intense every day. Epic and Cerner have tried to provide offerings to come downstream. They’ve had different degrees of success with that. We’ve had customers that have tried both and have come back to Medhost. We’ve had customers that have been forced to do one or the other through a health system connection. We typically get feedback on how that’s going. 

We think we provide the right solution with the right level of functionality at the right price point for these community facilities.It’s hard for these larger systems to come downstream to de-feature those systems at a price point that makes sense for these community hospitals without cannibalizing their existing base. It’s challenging for those facilities to come downstream.

Meditech is is trying to do more with some of their current offerings, but they still have three basic platforms out there that they’re supporting. Their SaaS offering might add a fourth to that mix.

The marketplace is competitive. We recently announced a large win with Quorum Health. Quorum was spun out of CHS. They needed to find their own standalone platform. They went out in a competitive and rigorous bid process and eventually selected Medhost to be their system of the future.

Why do investor-owned health systems almost never choose Epic or Cerner when their large, non-profit counterparts almost always do?

You’re touching on the basic point — it’s about who you answer to. The investor-owned facilities or the investor-owned providers are answering to a group of shareholders and stakeholders. A lot of their systems and their choices are being run by processes that look at return on investment or cost.

It’s hard to justify a return on investment in any IT space in healthcare right now, but looking at it from a cost perspective, those other systems are at a price point that might not make sense for an investor-owned provider organization, whereas the not-for-profits don’t exactly have that same mission. They both have a mission of taking care of patients, but the investor-owned providers probably have a little bit more of a financial hurdle, as they need to answer to their investor group.

Do hospitals worry more about their image in buying Epic or Cerner because their large competitors did instead of looking hard at return on investment?

In the urban communities, the bigger metropolitan areas across the US, that might be more relevant than in some of the spaces that we’re serving. We’re serving communities that probably only have one hospital and the next hospital is 50, 75, 100, or 150 miles away. There isn’t a lot of true provider competition in the markets that we’re serving.

I could certainly see when facilities are competing for talent in a large city that they might want to recognize that physicians seem to have a preference for one or the other. Physicians don’t like really any system from everything I can read and gather. They have more of a tolerance than a preference. Perhaps they have a tolerance for one more than another, and perhaps they’re getting training on one versus another as they come out of med school. That could be a decision for competing hospitals.

We have a large, investor-owned company here in Nashville that we talk to on a regular basis. A lot of what they talk about is providing the physicians with some tools. They may not need to invest in the largest system that’s out there, that may be run by some of large health systems in the country. They may choose to go a different route, but provide their physicians with robust tools that they need to do their job. But the back-end engine might be something a little bit different.

What are small health systems that are too successful to close yet aren’t being considered for acquisition doing to remain in business?

It’s tough for them. They’re facing a lot of challenges. A lot of those facilities are going to be more heavily Medicare and Medicaid versus commercial reimbursement. That’s been getting squeezed. There is more competition and some of their higher-value procedures are being siphoned off by the urban centers. They’re still being forced to comply with the same regulations as the large facilities. They still have to chin the bar on all the various regulatory items with respect to Meaningful Use and the other items that have come out of DC.

We’re seeing innovation starting to happen with some of our customers. How can they innovate their business model? How can they come up with strategies to help their communities? How can they engage a little bit more with those communities to help offset some of those challenges? It’s tough in the rural space right now.

We are seeing rural aggregators that are popping up and buying some of these facilities. They’re not going to be as big as a CHS or even a Quorum, which has about 25 facilities currently, but they’re acquiring maybe a handful to 10-12 facilities. They are realizing they can run those with scale. They can leverage some of the infrastructure and spread that investment across numerous facilities. We’re seeing some degree of private equity money coming into that, although most of that is an individual investors or small partnerships.

What vendor service offerings can help small hospitals gain some level of scaling?

We’ve been investing heavily in our service offerings. It started with the IT and hosting side and other managed services. As facilities were forced to upgrade their IT platforms, they were staring at either investing in hardware to put on-premise and then they would have to have the resources, both from a human and a capital perspective, to support those and maintain those technology resources. These small facilities realized that they would prefer to have somebody else do that, so we started to invest heavily in our hosting services about six or seven years ago. Now we’ve built a world-class hosting operation here at Medhost. Most of our standalone facilities have now elected to move into our hosting environment. In fact, we’ve had some of our recent corporate customers make that same decision.

More recently, we’ve started to expand our revenue cycle services, our back office services, and business office services. The smaller rural aggregators want us to do that for them because they don’t have the skillset that they need in the facilities. They don’t want to make the investment at the corporate location, so they are outsourcing that to companies like Medhost.

Is technology, specifically maintaining IT infrastructure or supporting regional interoperability, a big driver of small hospitals affiliating with larger ones?

At times. But technology replacement is a disruptive activity. A lot of the facilities, especially the inpatient facilities, have a system that they’ve chosen here over the last three to five years, maybe even longer than that. They have  decided who their partner is going to be. They are looking for that partner to help optimize the system.

The government, with the 21st Century Cures Act and a lot of the regs that are coming out with respect to interoperability, are requiring vendors like Medhost and others to make their systems more open and to begin to share data. That it isn’t going to require significant investment on the facility side to just link up a similar system. The systems will be able to communicate with each other, so that they can get the largest return that they can on the existing investment that they’ve made.

Typically there has to be some type of triggering event for a customer to make a change with an EHR. Maybe they see an end-of-life coming at some point and they will need to make a different choice, so they may go out to bid. It could be through a merger and acquisition, where they’re becoming part of another entity that wants to consolidate on a single platform. It could be dissatisfaction. Certainly not all customers are always happy, and so they may just get fed up with the existing system. But it takes a lot to get to that point because of the disruption that rip-and-replace causes.

What is the demand for interoperability in your market?

We’re not seeing a lot of proactive demand. A lot of it will be reactive to what regulations comes out  to make sure that they can comply.

As these community facilities evolve, being able to capture some information from other providers, other avenues, and other platforms will be helpful for them. They’re going to have to evolve from the traditional episodic care center that they’ve been in the past. The community hospital of the past will certainly change into the future and will need to provide different kind of tools and services for the residents of that community. Opening up the systems to enable them to capture patient data — or resident data, let’s call it — from other systems will be helpful for them. In the mean time, what they’re thinking about right now is just, how are we going to be able to comply with this?

Do you have any final thoughts?

I mentioned that I had a personal health issue surface about 15 years ago. It presented again about three and a half years ago. I have an extreme case of coronary artery disease. After receiving all the best possible surgeries and treatments from the best possible physicians and facilities, my symptoms continued to present, even with the smallest exertion, so I was forced to look for alternatives and to think differently.

I was fortunate to get connected to thought leaders and researchers who suggested a significant lifestyle modification. It involved a complete overhaul of how I thought about nutrition, fitness, and stress management. After three years of adopting this lifestyle, I’m off all medications. I have no symptoms, and I have a vigorous daily exercise routine that serves as a stress test for me.

It might be a stretch, but I look at the challenges that are facing rural healthcare today in a similar fashion. Traditional strategies, business operations, and the wonderful clinicians at these facilities are being stressed every day. It will take innovation led by the residents and employers within these communities, in partnership with local civic and government leaders, to identify business models that can help these organizations not only survive, but hopefully to evolve and thrive in the future.

HIStalk Interviews Vince Ciotti, Retired HIS-torian

September 4, 2019 Interviews 17 Comments

Vince Ciotti retired from a 50-year career in health IT in 2019. He documented the history of the industry’s companies, people, and trends over that time in his HIS-tory series. He can be reached at vciotti@hispros.com.


A reader of your HIS-tory emailed me to ask that I provide more information about you, which is why we are talking today. Describe your background.

I started in the business 50 years ago, in 1969. I was an English major at Temple University. I couldn’t get a job in any kind of English. There was an ad in the Philadelphia Inquirer for a programmer trainee that said, “see Clyde Hyde.” He  was one of the three founders of Shared Medical Systems. The rhyme caught my eye — Clyde Hyde.

I went up for an interview and Jim Macaleer, the president, was dumb enough to hire me. I didn’t know squat about hospitals, computers, or accounting. I learned it pretty quick and had 10 great years at SMS. Then I left them and went to about half a dozen smaller vendors. The first 15 years of my career were with vendors selling to hospitals, the usual job.

Then I got into consulting, first with Sheldon Dorenfest. I met a guy Bob Pagnotta up in New Jersey who’s a real HIS pro, one of the veterans in the industry. We started our own consulting company in 1989, HIS Professionals. It lasted for 30 years, which is probably a world record for consulting firms. Sadly, we just shut it down this year. Now I’m retired.

What will the future hold for health IT consulting firms?

When we started 30 years ago, there were small firms that gave advice to hospitals who were experts in HIT. Sheldon Dorenfest is a classic example. He started many vendors. He started telling hospitals how not to get snookered so bad. Other guys like Ron Johnson, a whole bunch of individual experts, were consultants. Today, I used the word in quotation marks because consulting firms are merely staffing firms. They’re gigantic, billion-dollar corporations that sell you people to do an implementation or to staff. They charge you roughly twice as much as the salary they pay and they make billions.

I’m a little out of touch with this stuff, but the four biggest, I think, are Computer Sciences Corporation, Xerox, Dell — which used to be NTT Data — and Leidos, which got the big Cerner DoD contract. They’re billion-dollar firms that just sell people. Their services are simply to do the implementation of Cerner, like they’re doing for the DoD. Whatever vendor you have, they’ll claim to have somebody that knows it. It’s probably a junior who you’re going to teach to become a more expert person, who they will then charge you more for in the next engagement.

Consulting has gone downhill in my mind. In the early days, it was wonderful. We gave hospitals good advice, saved them a ton negotiating contracts, and felt good at the end of the day to collect our few thousand dollars, not the few million dollars these guys collect today. A different world.

Is it inevitable that a company, regardless of its principles, will eventually get big enough to sell or perhaps to be managed differently?

Two-thirds of hospitals are not-for-profit, one third are for-profit. The non-for-profit ones just don’t know what life is like in a proprietary company. You start a tiny consulting firm, two or three guys, you barely make a few thousand each per month. You struggle to get into six figures. You start hiring a few people, then a few dozen people, you sell more and more, and you grow to hundreds of thousands of revenue, millions of revenue. The next thing is, let’s try to find a sucker to buy us and we’ll get $10 million for our pension fund.

It’s inevitable that a small firm — be it consulting, HIT, or whatever their business happens to be — grows. If they succeed, they’ll look for a buyer, because the original people are now getting kind of old and approaching retirement, like they have a huge stack of funds. So yeah, I’d say it is inevitable. Small consulting firms sadly grow, become giant consulting firms, and look only for the money, not for the good that they could do for their customers.

Your HIS-tory suggests that the same people repeat their success at making fortunes by selling companies that hire them as executives to do just that. What’s it like for the employees who have to just keep rowing down in the galley?

If you could see a bar graph of salaries, it’s mind-blowing. A typical vendor’s C-suite makes tens of millions a year, the managers make high six figures, and what the employees who do the bulk of the work get either in the five figures or just about $100,000. It’s a staggering variance and proportion of income from the C-suite to middle management down to the rank and file.

Where it’s nicest is the tiny startup firms. I was so lucky. SMS was almost a family, just wonderful people. They really gave a damn about their customers. Made sure they delivered the product. The first five to 10 years were just glorious. Then slowly they went public, became a giant, billion-dollar company, and those standards changed. It was purely the money. How can we cut costs and increase income? I bet that’s the truth of almost any company, be it a vendor, consulting firm, or even a for-profit hospital.

How has it changed as hospitals are seeing dollar signs in innovation and startups?

Not much. Every small firm that started way back then had the intention of making money. The successful ones did and got bought up, or bought up others, and eventually sold out themselves for even larger sums. I don’t think that has changed. That’s part of capitalism. I don’t mean to be critical. Believe me, I’m not a communist. I hated communism and Gorbachev is gone. But capitalism has its flaws, too. If making money is the only goal of everybody on earth, it’s a pretty ugly society. It’s the small firms that really care. That family kind of orientation that I really loved. They were the best years, the early years of a small firm.

Last time we talked, I threw out a few company names for you to react to. Let’s start alphabetically with Allscripts.

I get confused. They have bought so much stuff and have so many products. They’re a confusing company. Cerner, Epic, Meditech keep saying just what they are, just what they have. But Allscripts is a little more complicated. I wouldn’t be too optimistic about their long-term future compared to the monsters, Cerner and Epic. But they’re pretty good capitalists and I’m sure they’ll keep making money. I just don’t get too excited about their product line.


They’re the monster. My god, the VA and DoD will keep making billions for them for decades and it’s our tax money. Very sad.

In the original DoD contract, the majority of the money went to Leidos. Of the $8 billion contract, Leidos is going to get something like $7 billion and Cerner only $1 billion for licensee fees. For the VA, wow, the opposite. I think the last note on your site was something like $15 billion is the latest budget estimate for the first part of the VA to go on Cerner. Most of that money is going to go to Kansas City. So I’m very bullish on Cerner from an economic standpoint.

From a product standpoint, they still have a terribly weak revenue cycle. You seem to get a headline every couple of months of a hospital with a catastrophe. Great EMR, solid clinicals, but they still haven’t fixed what used to be called ProFit that’s now called Cerner Revenue Cycle. It still seems to be their weak link.

How will the company’s culture change now that Neal Patterson isn’t involved in running the company his way as the passionate founder?

Brent Shafer was an odd choice. You would think Zane Burke as president would have been the perfect person to be the CEO. He knew Neal real well, knew the culture and all that stuff. Then for some reason they go with this outside search and bring in an outsider. He’s going to be a pure revenue guy who will just want to make money. He doesn’t know much about hospitals or Cerner’s product line. That’s the classic capitalism problem, pure dollars. I don’t think they’ll sell many hospitals, but they’ll make a fortune out of the taxpayers on the DoD and the VA. They’ll stay at the top for a long time.


Oh, Judy. Such a miracle. No sales and marketing. She’s so different. It’s just staggering that she’s made such a success and I think it’s going to continue. You know, the large hospital sales are all going to Epic. Many from Cerner, many from Allscripts as the old Siemens customers buy a new system.

Judy has a stunning future. Staggering success. It’s true hospital businesses, not taxpayers and DoD and VA. It’s really hospitals. She refuses to buy another vendor. Has had the same product now for almost 40 years, but the only vendor that has never acquired another vendor. I can think of no other that has been just their own system, period.

They have their weaknesses, too. They’re human. The kids, the young youngsters that they hire that don’t have much experience. The partner consulting firms that rip you off to give a lot of staffing for an Epic conversion. They have no homegrown ERP. Just like Cerner, you have to go buy another ERP and build interfaces. But boy, overall Epic … if I were a large hospital, that’s where I’d go.


Neil Pappalardo gave Judy a lot of advice when she formed Epic. She has followed his rules, which was never acquire anything, just build your own product. In those days, Meditech hired their own people fairly young like Judy did. Built all their own products, no interfaced partners, and they’ve got a complete set of applications.

Meditech probably has the most comprehensive set of apps of any vendor out there. With Expanse, they finally came out with a physician practice system. The last piece they were missing was an integrated doctor piece. So I’m very bullish on Meditech. Their sales were slow for a couple of years. I think for four years in a row, their sales declined, their revenue declined. Last two years, its finally come up. So hats off to Ms. Waters. 

I’m fairly bullish on their future. It’s just, darn, there’s not a lot a hospitals that are going to change EMRs. They stick with what they have. They spent so much money on it, they’re reluctant to go to the board and ask for a couple of million dollars for a new system. It’s just hard to get sales.

How much weight do you give technology when you choose your own doctor or hospital?

None. I go for the personality of the doctor. Do you like the guy or the gal? Does she like you? Can you get along with them? Can you smile? Can you talk?

I’ve got a family physician here in Santa Fe who’s so good that I’ll fly here from Florida 2,000 miles just to see him if I’m sick and then fly back. The ones I have in Florida suck. I just can’t stand them. To me, for a doctor, it’s the human side, the personality. Can you talk and you trust them? Do you think they really care about you?

For the hospital side, I had no choice. You may remember that I had a grand mal seizure in January. It’s kind of ironic. After 50 years in hospital computers, I retire and I go to my doctor’s office for a checkup and I have a seizure and they put me in a hospital and stick a computer in me. I got a pacemaker inserted in me and it saved my life. I’d have probably died. Still don’t know the cause, some kind of micro-stroke, but the pacemaker has been a damn miracle. Doctor’s say the battery’s good for 14 years. I told him I may not be good for 14 years. I’m thrilled to have it and it’s working like a charm.

The technology for the patient, when it’s interfacing with you personally, is priceless. Boy, the advances are glorious. You know, my father or grandfather would have dead with this seizure, and I’ll probably get 10, maybe 15 more years. So I love technology on a personal standpoint. But as far as the hospital’s computer system, I couldn’t care less.

I went to UCLA Medical Center and they have Epic. It was phenomenal to be able to see my whole chart on the screen with the security code and all that stuff. That was nice. And if I go to other Epic hospitals, they’ll know all about me. But a fourth of hospitals are are Epic, a fourth are Cerner, a fourth are Meditech, and a fourth are CPSI. If you’re admitted because of an emergency, you have no choice. If I had the choice, I would probably go with Epic now that I’m on that with my UCLA record, but again, when there’s an emergency, you have no choice. You go where ambulance takes you.

How do you see the dynamic among health IT vendors, salespeople, and health system executives?

In the early days at SMS, I was an early education manager. I had to train the new installers, as we called them then. Today they’re consultants, I guess, but then they were IDs, installation directors. I had a two- or three-week class to go through every single report, every single profile option, every master file, every transaction, whew. Took two to three weeks to train them and then they could still go out and botch up their first install. Took a couple of installs before they knew what the heck they were doing.

We hired salesman at SMS and they spent one day walking around all the offices, saying hello, shaking hands. Who are you? What do you do? Oh, OK. Then boom, after one day, they were out there selling. They had no idea what they were selling. It doesn’t matter. Sales is commissions. If you sell a lot of systems, you make a lot of money and you get promoted and you become a big cheese. If you don’t sell any systems, you get fired. You’re going to go to another company and try again.

You don’t learn the product. You haven’t been an installer or a customer service rep. You haven’t worked with the system. You have no idea how the system works. What you know how to do is smile, be pleasant, buy lunch, buy dinner, shake hands, be charming, have people trust you, get them to sign the contract, and then run like hell because you’ve got to make some more sales. 

That hasn’t changed to this day and never will. It’s capitalism. There’s nothing wrong with it. It’s just what life is like. Think of a used car salesman. What does he or she know about the engine, the transmission, or the differential of a car you’re buying? They know that they want you to sign quick before the end of the day. It’s not immoral. It’s not nasty. It’s just the truth.

Hospital, it’s so sad, they just spend time talking to salesmen. Hospitals should ask to talk to their installer. Who’s going to put the system in? I want to see him or her, have them walk around my hospital and tell me what good or bad things are going to happen. No hospitals do that, but that would be the dream, to see your installers before you sign that contract. Salesmen again are not immoral. They’re not liars or nasty people. It’s just their job. The job of used car salesman is to get you to sign that contract and HIT is not much different.

What do you think about the recent health IT IPOs?

It’s part of capitalism. Initial public offering is inevitable. The reason you form a firm is to get that stock on the market. Get double, triple, quadruple and away you go.

I joined in SMS in 1969. I got the 200 shares that Jim Macaleer gave to every new employee. I went to my boss and said, what’s a share? He explained it to me, and I said, what’s it worth? He showed me that it said 1 cent per share, so my 200 shares were $2. I was going rip it up, but he said wait five years, you’ll  be very glad. Sure enough, we went public around 1975. I think it was $14 a share. The stock had split several times before then, so my 200 shares were now like 800 or 1,600 shares. I was suddenly a very rich man. That’s the goal of capitalism, money, and it’s going to be the future as well as the past. That’s the American way. Nothing wrong with it, nothing immoral, it’s just the truth, it’s what our economy does. Nothing but money.

The only time I’ve sensed that you were star-struck was when you visited Judy Faulkner at Epic’s campus as you described in your HIS-tory. What surprised you about that visit?

She’s a very humble person. I walked into the lobby. There’s nothing massive, it’s just a lobby. Usually what you get is that the executive secretary comes over, asks if you want coffee, takes you into some big, glamorous conference room, and then after five minutes — there’s always a delay — in comes the executive. Shakes your hand, has two or three assistants on either side of them because they don’t know all the answers to your questions you’re going to ask.

I walked into Epic. I’m sitting in the lobby, you know, handsome couch. I look in the bathroom over there. There’s only a toilet, there’s no urinal. It’s a very female-oriented company. It’s kind of cute. All of a sudden, across the lobby, here comes this lady walking towards me. I suddenly recognize that it’s Judy Faulkner. No executive secretary, no setting me up in a big conference room.

She walks over, shakes my hand, takes me into her fairly small office, sits down, and says, “What are you here for? What do you want to do?” She’s such an open, humble, honest person. If you went to visit Brent Shafer at Cerner, you would probably get 45 minutes of introductory talk from other people before he finally came in the room, with seven assistants to answer all your questions. Boy, she just sat down and talked and said such honest comments. It was amazing. So yeah, she’s unique in our industry. Very a wonderful lady.

The one sad thing about her and Epic is that she is the company. I think she’s as old as me, 74, 75, something like that. At some point… she won’t retire. She’s not that kind of person. Epic has been her life and she’s very proud of it. I don’t blame her. But at some point, she’s human. She’s going to die, she’s going to retire, she’s going to have a heart attack. Who knows? Her successor can be nothing as good as she is. The company cannot have as bright a future once Judy is gone. She is the company. The company is her.

Sort of like Cerner and Neal Patterson, maybe Meditech and Neil Pappalardo. Neal and Neil slowly started to give the power of the company to their subordinates. I think Judy still runs Epic completely. I just can’t see a replacement for her. She is the company, personally.

Who are your heroes of our industry?

The folks at SMS, just because it’s the company I knew. Jim Macaleer and Harvey Wilson were the two bosses. Jim was just an incredible guy. He could be a mean son of a gun at times. A real Theory X manager. He was tough, but then the other half of the time he was funny, he was charming, he was pleasant. He just died, I think it was last year, 18 months ago. I’m really sad that we had to lose him. Harvey’s still around and doing wonderfully well. He not only helped form SMS, he was the number two at SMS, but then he formed Eclipsys and sold out to Allscripts.

We’re having our SMS reunion in a few days, the 50th reunion of SMS. One hundred and fifty people are showing up in King of Prussia and Harvey’s giving an introductory speech. To me, that’s a wonderful life, to have such a success and so many people coming to see you again and such a family feeling.

I can’t think of too many others that I really respect, that is until you get to the current vendors, and Judy would be at the top of that one.

How has retirement been versus what you thought it would be like?

Well, that’s an interesting point, because frankly I’m bored to tears. I’ve always been into motorcycles, Honda motorcycles. I started as a kid and that’s become my full-time occupation. I have six of them. I just sold one. I used to have seven, one to ride every day. 

I literally do ride a motorcycle every day. I get home about 1:00 or 2:00 from lunch and then wonder, what the heck am I going to do? I usually take a nap on the couch and I’m bored to tears. So I’m looking into some hobbies, other hobbies, maybe learn the piano, some other stuff. I love to look your site every morning, five minutes to get an update on what’s going on. Still keep up with a lot of good old CIO friends and consulting friends and even some people from vendors and we get together often.

Retirement is a bit of a shock. I had no idea what I was going to do and I still don’t. I work one day a year. I teach a class at Brown University, in their MHA program. I’m going out there two weeks and I probably spend about a week updating my vendor review and present it to the students. I should say “students” in quotes because they are CFOs, CMOs, CNOs, very sharp people. I probably learn as much from them as I teach them. But that two-hour class is the only thing I do all year.

When you meet someone and they ask what you do, they expect you to describe your job as your primary identity. How do you introduce yourself now?

I’m usually on a motorcycle when I meet somebody. We start talking about Hondas. I don’t meet professional business people any more, but if I sit next to someone on an airplane who wants to know what I’ve done, I tell them that for 30 years, I was a hospital computer consultant, and then for 20 years, I used to work for vendors in hospital computers, and now I ride motorcycles. That kind of sums it up.

You’ve got to think ahead of retirement. I didn’t and I’m sorry for it. I didn’t have any plans at all and I’m struggling with it now. If I didn’t have the Hondas, I’d go crazy.

Do you feel any springtime pull toward the HIMSS conference?

I live down in Orlando right next to HIMSS. I used to go every year, and the thing got so big. I started to get totally bored to tears with 40,000 people in one hall and hundreds of vendor booths. At the booths, the few old guys or ladies I knew were just not there any more. Dozens of young sales reps. So no, I have lost my affection for HIMSS. When it was small and you knew everybody, it was wonderful. It was glorious. It was a family kind of thing. As it has grown to the gigantic size of today, I haven’t gone for the past two or three years.

When I presented there, that was a lot of fun. Thank you for having me to do that HIS-tory presentation there and dress in the wacko hippie suit. Got me into the whole HIS-tory file, those 120 episodes you ran on your website, but I had never presented at HIMSS. If they wanted me to present the HIS-tory thing again, I would do it. That I love. But to just walk around the halls and meet all those green salesmen who I never knew and they never knew me bores me to tears. I can’t stand it.

Not many people seem to be interested in health IT’s past. How would you convince someone to read your HIS-tory, either now or 25 years from now?

It’s the same as reading the history of the human race, history of America, history of Europe, history of homo sapiens. You can only learn from the past. You can’t learn from the future. It’s not here yet. The mistakes made in the past will be made in the future unless you learn from them and change them. It’s such a priceless thing.

I just bought a book on the history of warfare. I’m a reader, I own thousands of books. And the first page has an incredible statistic. Of the past 5,000 years of human history, roughly back to 3000 BC, only in about 300 years have we not had a war. If you haven’t read history and learned that, you’re not going to appreciate the risk that we’re going into World War III with nuclear weapons and all this horrible strife between small countries around the world. You have to learn from the past to be able to avoid those mistakes in the future.

In HIT, what vendors did back in the sixties, seventies, and eighties, they’re doing today in the 2010s into the 2020s. Only when you read it and learn what they’ve done will you know what they’re going to do in the future and how you can avoid it. You avoid being a victim and help your hospital get a little bit of its money’s worth. I think it’s priceless in any industry — automobiles, transportation, education, automation, you name it. You learn from the past to do better in the future. If you just go into the future blind, you’re going to make the same mistakes.

What will your epitaph say?

If I could be remembered for anything, it would probably be my HIS-tory files, which I thank you for posting over such a long time, two and a half years. I hope some of the future CIOs read them and learn from them. I hope that’s what they remember me by, the guy that warned them about not repeating these mistakes of the past.

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