HIStalk Interviews Elad Benjamin, VP, Philips

Elad Benjamin, MBA is VP and business leader of clinical data services at Philips of Amsterdam, Netherlands.

Tell me about yourself and the company.

I run a business within Philips called Clinical Data Services. We are responsible for integrating and delivering acute patient data to physicians, nurses, and any other caregivers who require it. We also provide analysis of that data to help with clinical insights and improvement of care.

I have been in healthcare informatics for the past 25 years in various roles around medical imaging, medical devices, radiology, and AI. I’ve been both on the entrepreneur side, having formed a few startups of my own, and also now on the larger corporate side within Philips for the last three years.

What progress has been made and what challenges remain for health systems to connect their own internal systems?

We have made a lot of progress within certain niches. For example, the medical imaging niche has made a lot of progress in being able to move and communicate medical images with each other. The medical device niche has made a lot of progress, such as with products that we have developed, in integrating medical devices and the data that comes out of those devices.

A gap remains between those silos. If a healthcare enterprise wants a full picture of a patient across imaging, acute general care, lab and other areas, the integration of all that data into one view still remains a bit of a gap. EMRs fill some of that gap, but not all. We still have a ways to go in helping enterprises bridge the gap between those different care settings of patients.

How well is that information made actionable for those on the front lines of patient care?

For some information, we have a relatively robust set of alarms and alerts that can be provided to the care staff. The problem, and this is talked about a lot in the industry, is alarm fatigue. It’s hard to understand which alarms are more relevant than others, which alarms are actionable versus others. Over the past couple of years, we as a provider of solutions have embarked on not just creating an alarm and delivering it, but understanding the content of the alarm and delivering it only if it’s relevant and actionable.

We have been delivering smart alarms and alerts to the market for the last few years. They are not as simple as, “A patient has gone over a certain threshold, so let’s beep or let’s send an alarm.” We look at trends and a multitude of factors, and only if there is real patient degradation or a real actionable alert do we send something. We have made a big effort over the last couple of years, and will continue for the next few years, in moving from simple alarms to smart alarms that can reduce alarm fatigue and improve care. You are acting only on those alarms and alerts that need your attention as a caregiver.

Does AI play a role in that analysis?

It absolutely does. Today, rules and alarms are relatively rules based. They are not as complex. But we are beginning to explore AI-based rules, primarily for the purposes of prediction. 

You don’t necessarily need AI to understand what is happening at this exact moment with a patient because there are a lot of parameters that you can analyze in real time to say what’s happening. But if you want to predict something, even if the caregiver hasn’t seen anything or felt anything, a certain trend is leading the patient in a certain direction. For that, machine learning and AI tools are absolutely coming into play as we start analyzing millions of patient inputs to see patterns that allow us to make more accurate predictions.

Does the burden of manually entering clinical data remain, or has it moved mostly toward automatic data collection from medical devices?

That has been automated over the last couple of years. When we go in to our healthcare enterprises, there’s absolutely no manual work involved. Once we set up the system, all data is moved automatically from the devices into our system. It is automatically stored. It is sent automatically to whoever needs it. The whole process of large-scale data management, at least as it relates to our realm in clinical data services, has become automatic. No manual intervention is needed.

That trend is slowly taking over other care settings in the hospital as well. In the relatively near future, we won’t need caregivers to manually move data around. We will have systems that understand where a patient is and where the information regarding that patient needs to be delivered in that specific setting. The system will make that information available to the caregiver.

What are the technology implications of the COVID-driven change to move patient monitoring outside of the ICU and even outside the hospital?

Al the technologies that were very, very good inside the four walls of the hospital didn’t necessarily extend to the community or to the home. As those needs accentuated over the past couple of years, we need that connection. We’re getting there.The need is understood. 

Financial questions need to be answered about how those services get reimbursed and whether they are covered by private sources, insurance, or the hospital. These are not technical or clinical issues, but financial ecosystem questions that need to be resolved  to make that true, seamless link among clinic, home, and hospital. We’re not there yet, but we are putting a lot of resources into making that a seamless connection. It is understood that the connection is inevitable and it needs to happen. We just need to accelerate it.

We’ve moved from bold and possibly irrational predictions that AI would replace radiologists to viewing it as a helper. How do you see the role of AI in radiology and radiology informatics?

AI is here to stay and it is definitely helping radiologists be better in certain areas, whether it’s neurology, neuroradiology, or other aspects of radiology. A lot of research shows that radiology plus AI is better than radiology alone. I think that will continue.

As to bold statements that were made a few years ago that we won’t have radiologists, we are still far away from that being a reality. But we are getting closer and closer to where AI can be like a first-year resident. It can do some basic things. It has solid basic knowledge and it can help reduce some of the more menial, repetitive tasks and open up some time for radiologists or other senior physicians to do the more complicated tasks.

Can AI help healthcare amplify and extend services beyond the limits of physical buildings and hard-to-find clinicians?

I think so. That question also connects to providing care outside of the hospital environment. Not just AI, but smart medical type devices will allow us to provide care. You won’t necessarily have to go in somewhere to receive care. You might have a smart device that is able to get vital signs or early blood work and transmit that information so you can receive care remotely.  

Some of those things are happening at a small scale, but will become part of this changing ecosystem. Not all care will be delivered even in the same place physically as it is delivered today. Over the next decade, we are going to see a big change in that.

What are the most promising use cases for AI in healthcare?

I wish I had a crystal ball to know the most promising use case. But I can tell you that we see three main uses — clinical, operational, and financial. 

The clinical use case is the one that will benefit patients the most, but it’s the hardest to deliver at high quality because of all the challenges we’ve spoken about with data and data availability. It’s hard to diagnose people accurately and consistently. On the scale of value and difficulty, the clinical one provides tremendous value, but it’s hard to do.

Existing financial or operational AI tools are not necessarily as hard to deliver, but their value in terms of improving patient care is also reduced. They focus on making the operations of a hospital more efficient, which is great and important, but it’s a bit of a different way.

I don’t know which one will advance the fastest, but I really hope that we are on the cusp of seeing the breakout of clinical AI contribute in a meaningful way over the next few years. That will make the difference for patients in the future.

Healthcare’s move to the cloud provides new options for centralization and scalability and also brings big tech players into the industry. How will that develop?

You can divide healthcare’s moving to the cloud into two main implications. One is technological, in that hospitals no longer necessarily have to invest as much in their own IT infrastructure since they can rely on off-the-shelf, large-scale IT support. That’s a good thing. It helps reduce the overall cost of managing large, complex IT systems.

The second part involves the data. If you have the ability to not worry constantly about how much storage you are using, and it’s cheaper to do it besides, then you will start to amass this large quantity of data. Then the question is, what do we do with it? Because everything is connected, it comes back to AI and analyzing the data. We see more insights coming off of the data rather than what healthcare used to be, which was just delivering data from Point A to Point B and relying on the caregiver to understand the data, the context, and the next steps.

Where it is going is that we are not only delivery mechanisms of data, but we are also decision support tools. We are helping determine care pathways for patients and treatment protocols. That is the opportunity that some of these cloud technologies open up for us. Now that the data is more accessible, there’s a broader set of data to be looked at, and that opens up a lot of great opportunities.

What developments will be important to the company and the industry in the next few years?

At Philips, we continue along a few main paths. We have a strong imaging portfolio that includes software, hardware, and services that we will continue to develop. Alongside that, we have other connected care businesses that follow the patient along the different settings. We are working hard to integrate a lot of that into solutions that allow taking care of the patient across the entire continuum without having to necessarily throw data or pieces of information over the fence. The company will be investing to create that holistic view for our caregivers.

We are also deepening the technology that we use. We spoke a lot about AI over the last few minutes. We will continue to use deeper, more advanced technologies to move from retrospective or real-time to more predictive and decision support.

HIStalk Interviews Jaffer Traish, COO, Findhelp

Jaffer Traish is COO of Findhelp of Austin, TX.

Tell me about yourself and the company.

I’m the son of two parents who grew up in poverty. One parent lost two siblings due to food insecurity. At 15, I became a community organizer, working to improve the health of families living near old power plants. Over the years, I’ve worked in government, health IT, and advisory, My focus is on improving the health and wellness of the vulnerable. Our CEO also had many experiences that led him to found Aunt Bertha, now called Findhelp. He worked on streamlining benefit enrollment in state government and became the guardian of a relative who had a rare disease.

The mission of Findhelp has remained the same since founding, to connect all people in need to the programs that serve them with dignity and ease. We are focused on the social drivers of health, such as food, housing, transportation, and other human services. We work every day with communities and government to modernize the social safety net of health and human services by providing open, focused, and contracted social service networks and integrated software for healthcare plans, employers, education, government, and community organizations. We are seeing something interesting happen. Nearly 1 million new adults use the network every few weeks, and that’s humbling and sobering.

Our US healthcare model is an world outlier in being very much driven by profit. What are the challenges in creating a safety net and connecting people to it?

There remains enormous friction in the way people apply for benefits, determine their eligibility, and source post-acute care, social care, and placement. The social service sector and the post-acute care sectors are just catching up to the age of digitization and basic interoperability. It’s interesting to see the first White House Conference on Hunger in 50 years and some new investments, like broadband investments, that are showing some greater federal attention to the safety net. There are more than 240 bills in Congress right now with social care components and over 80 with health equity components, though still today, public policy is slow to address root causes of disparities. With a mostly private-funded safety net, it’s difficult to achieve that scale under our current program.

In terms of the role of government, there are waivers in 23 states with social care reimbursement elements. We believe that government can fund capacity of services, streamline enrollment, require reporting, and accelerate interoperability certification, though they should offer guidance to states on this work and not necessarily suggest paying vendors large sums of money as as solution to social drivers of health.

What is the effort involved in finding hundreds of thousands of programs and maintaining their information?

We call that team our human curation team. It’s hard work. Our team is on the phone every day talking to service providers across the country, validating important information such as the languages they support, eligibility rules, and sliding scale cost structures. We believe that providing individual seekers the dignity of being able to explore their own options is important in this country to empower individuals to find the best services. That information has to be as accurate as possible, as they don’t have the luxury of extra resources, and we want to build the best connections for them to those providers.

That team is our largest investment in the company. We believe that some degree of automation is important and can help us in that curation work, though we receive thousands of signals every day about how programs change and our team is responsible for reviewing, vetting, and processing that feedback. That’s a commitment that we have as a public benefit organization to serve the country and ensure that we make Findhelp.org a free service to the nation. 

The network is important. On top of the network, we provide, on the private sector side, the software and tools for care coordination to support connectivity between private industry and the social services sector.

We’ve seen a lot of non-profits engage with us because it helps them with their overall operations. Most folks don’t know, but we provide free case management tools to non-profits, and when they sign up with us for no fee, they have the ability to publish their appointment slots. They can run reports to show their funders how they are serving people. They can see who’s using search terms to find their organization. They can publish an eligibility screener so they can automatically respond to people to let them know whether they qualify for their service or not. They can even integrate referrals into their own non-profit system of record so they can continue working in their own workflows.

What is your business model?

Our business model is relatively simple. We didn’t want to take the approach of traditional health tech companies and charge user licensing or have a PMPM model because that restricts the number of helpers that can engage in this work and the number of people that can self navigate. Early on, we decided that we would have a simple annual subscription model to the software and to the network to integrate and embed into your own navigator workflows. That has been quite appealing to healthcare, government agencies, community colleges, and even large employers who have come to us to help their employees.

Each industry has their own drivers for why they sign up. Some, it’s financial. Some, it’s recidivism. Some, it’s clinical outcomes, student retention, and so forth. The broadness of the network appeal creates a network effect, and that’s why we are seeing somewhere around 50 new large systems join us every quarter right now.

What is the role of the health system that joins?

For our customers that have helpers — and this could be a social worker, a discharge planner, or a navigator of sorts — they are quite interested in assessing individuals for their social needs, generating outbound connections, referrals, or applications to the non-profit sector. Even ordering goods and services, which is something that has emerged in the last couple of years, like diapers or car seats for a new mom to leave the hospital on time. They are interested in building these connections and even funding and supporting some of the service delivery for those connections.

They are interested in tracking the service delivery outcomes and eventually marrying that information with their own clinical or cost information so that they can begin to study the impact of doing this work at scale within their populations. Integration is a key part of their vision. For example, our bi-directional referral integration with Epic’s Compass Rose is a big investment to bring smoother workflows to these tens of thousands of navigators.

What does that integration look like to an Epic user?

We’ve built four integrations with Epic to meet customers where they are in their investment into social care. The first is to give dignity to the population, and that is an integration with MyChart. That is where customers like Trinity Health have embedded their social care network directly into MyChart so people can self-navigate and self-refer to programs at scale. That’s tremendous, by giving people the dignity of access.

The next integration is bringing the network live as a SMART on FHIR application embedded into the care navigator’s workflows. With that integration, navigators can send referrals, process applications, and text and email program information to people who may not be ready for a referral and otherwise navigate the entire network.

There are advanced customers who want to leverage Epic Healthy Planet and Compass Rose to natively have the network living inside of the Epic tools. That’s where the integration is using APIs to allow helpers to directly surface information about programs and send referrals bi-directionally to the non-profits without ever needing to use our software.

How did your work change during the pandemic?

We saw over 100 healthcare organizations join us during the pandemic. We saw major EHR companies reach out to us to accelerate the development of this integration. We added around 4,000 COVID-19-specific support programs to the network during the pandemic. We saw significant volume increases around the country of people looking for help and of navigators using the network. We were up late at night for more than a year working hard to improve the system scaling as well as the software features to support such growth.

How does United Way’s 211 program integrate to support people who lack broadband access?

There are around 240 different 211s around the country. We think the work they have been doing is incredible over the years. Many of them operate call centers, and that’s the first place many people think to call when looking for a service. 

We view them as complementary to the work that we do in many communities. In fact, we collaborate with more than a dozen 211s around the country, and some of them are actually our customers. We see the potential for 211s to not only operate as hubs in communities, helping with care navigation, but also being able to collaborate on the program network and the quality of the program information, as we often both do that curation process in communities. I think there’s an evolution of the 211 model that we are seeing happen around the country.

KLAS has reviewed the small market of social determinants of health networks, in which Findhelp earned top scores. How do you see that market evolving?

We were doing this work 12 years ago, before the term “social determinants of health” was a buzzword. We called it “poverty alleviation.” There were around 15 companies in this space. Over the last 10 years, most of them were either acquired or closed up shop. 

It’s interesting because we see three key issues coming to light. The first is privacy. How do we ensure that individuals can control their private referral information and share it when they are ready and not force an oversharing model? The second issue is interoperability. Are we willing to make the investment as a company and integrate and interoperate with the right systems around the country? Third, how do we work with government? Do we enable government agencies that have helpers to do this same work, or do we depend on government funding to build infrastructure? Our approaches to those three have resonated with many industries, including healthcare. That’s what I would attribute our momentum to, alignment with those that are doing this work to those principles.

What developments do you expect to see over the next few years?

Software is only a small part of building bridges between healthcare and social care providers. Our most successful customers are in the community with us, building trust with the service providers, hiring community liaisons, and organizing coalitions. That is real network building. We are going to see a plethora of funding, and we must be mindful that we direct that funding as much as possible to capacity of these service providers, who are the ones doing the hardest work to serve our communities. That’s where we should keep our focus and attention, serving the service providers and the navigators that do this work every day.

HIStalk Interviews Patrice Wolfe, CEO, AGS Health

Patrice Wolfe, MBA is CEO of AGS Health of Washington, DC. This interview was focused on women as health IT executives.

Not to hit you with the hardest question first, but if you see a company whose executives and board members are nearly all white males, how do you convince them that they may have chosen unwisely?

No kidding, you’re asking the hardest question first. Maybe I’m just an optimist, but I like to believe that the best way to convince people is through performance and through results.

I was on the board of a large company recently and it was nine white men, mostly in their 70s, and two women. I had a hard time convincing the rest of the board that when we had open positions, we needed to be a little more open minded in terms of how wide we would set the aperture for the candidates for the roles. 

I’ve noticed that often when we do searches for senior positions — whether it’s a board position or an executive member of an operating team — all the search descriptions end up sounding like the person must have won a Nobel Peace Prize and walks on water, because we are trying to make the job sound as complete and as attractive as possible. Sometimes we create job descriptions where we’re ratcheting down the aperture so much that five people in the entire country can fit this job description.

When you are trying to drive diversity, you have to make sure you open that up a little bit. You have to let in people who might not be traditional candidates, and you have to be willing to take a chance. To me, the thing that has been the hardest is convincing people that the answer isn’t, “We’re going to hire the best person for the job.” Because the best person for the job often looks like a very traditional candidate, and that does not help us gain ground on diversity.

Is that because it’s comfortable to hire candidates who are like us, or is it the perception that those other candidates aren’t as qualified as they actually are? And would you see the same biases toward female candidates if the company leaders were mostly women?

There’s an element in this that we all gravitate towards people who are more like us. That’s human nature.

I don’t have enough experience with all-women leadership teams to know if that bias exists. There’s not enough N’s out there for me to have a good feel for the answer to that. If I look at my own leadership team, we’re about 50/50 in terms of male/female. That puts me in a great position where I don’t have to worry quite as much about gender diversity.

I’ll tell you what I am typically the most focused on — cultural fit. Is the candidate someone who can thrive in the culture that I’m trying to cultivate? That’s definitely not a gender thing.

I don’t think I have a perfect answer to your question. I’d love there to be more examples of women-only leadership teams out there so that we could tell if they suffer from the same bias.

Given the frequent importance of networking in getting hired, how does networking work differently for women than men?

This is such an interesting point. It’s something that I talk a lot about when I speak about gender diversity at the senior executive level.

The good news is that if you are hiring at the executive level, you are most likely at some point, maybe not initially, going to use an executive search firm. For me, that has always been a great way to meet people I don’t know.

But in terms of the networking element, no doubt the more networked you are, the more likely you are to get tapped for a wider range of opportunities from a career perspective. One of the things that women have struggled with is finding themselves in those situations that maximize networking. Are they invited to certain types of meetings? Are they included in a small group of leaders who might be attending what now are incredibly expensive conferences?

What I’ve seen over the years is that you have to almost make a deliberate effort to include women in these types of activities that end up being great networking opportunities. It has to be a deliberate action. It works well when it is tied to things like recognition of high-performance employees. If you do a good talent review in your organization every year, you can pinpoint those members of your employee base who are high potential. You can deliberately do things such as say, we’re going to earmark these people for attendance at a particular conference, or we’re going to earmark them for presentations to the board on a particular topic that they’re focused on. If you don’t do that stuff, those people lose out on the networking that might make them more well known as a candidate for an executive role.

How do men and women apply and interview for leadership jobs differently?

The Harvard Business Review published a study on this many years ago. I may not quote this exactly right, but I believe that the findings were that women would put themselves forward for a role if they fit 90% of the criteria for the job, whereas men would put themselves forward if they felt they met 60% of the criteria. There’s definitely a difference there, obviously in general, but I do think that this is challenging.

When I mentor women, I raise this point a lot. What’s the worst thing that could happen? You could be told no, you’re not qualified enough for the role. Too often, people might build up in their minds an outcome to putting yourself out there that is far more daunting than what really happens. Sometimes I think it helps just to get people to talk through, how could this play out? And are you OK with how this might play out? Why not try?

This is a general challenge that we have to deal with through mentoring women. Also, modeling the behavior that comes from saying, what the heck, I’ll give this a shot. Maybe it won’t work out, but I’ll probably learn something in the process, at least.

Bias sometimes exists against women who have current or future family obligations. Are the trends of remote work and increased work-life balance changing that?

This is a really interesting point, because so much has shifted generationally. I was guest lecturing at a Wharton Business School class a couple weeks ago in the healthcare track, and I had several interesting comments from the students. They were interactive, it was so fun.

One of the students, a woman, raised the point that nowadays men and women are particularly focused on work-life balance. There is more of an acknowledgement, with younger professionals, of the important rule of maintaining both a balance in your personal and professional life, but also maintaining a level of mental health wellness that people my age never really paid attention to. This woman was saying, what about men taking paternity leave and other types of family related time off? Isn’t that part of how we achieve some of this balance in the workplace?

That is exactly right. Younger professionals are more focused on work-life balance in general, and it’s not a gender issue. We are seeing men taking this seriously also. That’s an interesting thing, that some of this gender distinction is going away.

In terms of work from home, I do believe that the trend towards work from home has made it easier for women to take on roles of greater responsibility. I see this in India, where there traditionally has been a big drop-off in women in management roles, because once they start having children, many women have enormous pressure to not go back to work. Work from home in India has helped to shore up the growth of women in management roles in all kinds of industries. I’m fascinated by how the whole workforce dynamic has shifted with work from home.

What career advice would you give to a woman who is in a director or senior manager role and wants to move to VP or the C-suite?

If you want to get to the top echelon of an organization, it’s important that at some point in your career, you get experience managing P&L. Maybe you just manage a cost center, and maybe there’s no revenue attached to it. Too often, you see women working their way up the ranks in support functions, things like marketing or HR, where they don’t get an exposure to enough of the business side of the organization. Having the ability to run some type of operating unit inside a health system or a software company is an extremely important role, because it gives you exposure to a wide range of the key operating metrics for the organization that are important when people are assessing you for the very top of an organization. I don’t often see that as a focus for people’s career paths, and it’s important.

Always be intellectually curious. Raise your hand when something interesting is going on in your organization that you think you could learn from and that you could add value to. Be willing to step out of your comfort zone to show that you can make a difference in a way that’s maybe a little bit different than how you’ve traditionally been spending your time.

Those are great opportunities to expand your understanding of your organization, to expand your networking. You might work with different people than you’ve traditionally worked with. Also, to expand your knowledge of what you personally enjoy, because too often, we find ourselves down a path incrementally that maybe we’re not happy with.

It’s  important for women to find mentors and folks at senior levels who will support them throughout their career,. I’ve been fortunate to have people in my life like that. Actively searching out the men or the women in more senior roles in their organization who they admire or they think they can learn from, and actively build a relationship with those people, because they can be hugely helpful to you.

The last thing I would say  is to believe in yourself. Stand up for and pursue things that you’re interested in, because we are always our own best advocates and we deserve to be good advocates for ourselves. Having a level of confidence to do that is important.

HIStalk Interviews Matthew Condon, CEO, Bardavon Health Innovations

Matthew “Matt” Condon, JD, MBA is founder and CEO of Bardavon Health Innovations of Overland Park, KS.

Tell me about yourself and the company.

I’ve been in employer-driven musculoskeletal health for the  last two decades. I grew up in Iowa, went to grad school and law school, and got passionate about this space. I was fortunate post-law school to relocate to Kansas City, which was the home of Cerner. There’s a Cerner halo here in Kansas City and a lot of people, including the founders, were important to me in the early stages and helped guide me in my career.  

I have been on this journey for a couple of decades, building companies that were specifically aimed at supporting employers in how they optimize the musculoskeletal health of their employees. I’m really fortunate to have built a couple of companies here and I am proud and thankful to call Kansas City my home.

Bardavon was formed in 2014. It is absolute love of mine, intellectually. We partner with employers, or the carriers who represent them in some cases, to optimize the musculoskeletal health of their employees. This ranges from preventative through post-injury solutions that are offered in a hybrid manner at work, in the clinics, and at home. All coordinated, all collaborating, and all aimed specifically at improving the lives of the 60 to 80 million US workers that make up the labor workforce in this country.

Our biggest differentiating factor is that we have seen the spectrum move from all-in clinic to this digital-only focus, and I believe that we are the only people in this space that offer a truly hybrid approach. We have digital solutions that we incorporate, engage, and coordinate, but we also have a nationwide network of over 25,000 physical and occupational therapists that utilize our solutions in an integrated manner aimed at improving the health of the one patient-employee in front of them and the tens of thousands we serve on an annual basis.

How competitive or cooperative are you with the providers that contract with you?

They are partners and we are really proud of that. The first business I had was on the provider side, where I built a company and sold it to a publicly held company. That understanding of the provider realities, the environment that they work in, and what they are aimed at is important to who we are, and maybe why we bring such value to them. We partner with those providers. They get out of their EMR and into our platform for the patients that we send them from the employers that we work with, who want exceptional care for their injured employees.

It is double-sided marketplace, but one that I am proud of on both ends. We feel partner-focused. It is our job to get employers around the country the best healthcare for their injured employees. It is also our job to make that environment for the providers who are treating them efficient, clear and communicative, and collaborative so that they know what success looks like for their employers. They can aim at it and they are rewarded for achieving it.

We’ve seen MSK technology evolve from range-of-motion home exercise coaching that ran on consumer gaming systems and now to technology platforms that include apps and analytics. What is the best use of technology for MSK issues today?

Acuity levels drive the appropriateness of the solution that you put in place. But in the end, the in-person provider relationship experience has never been more important than it is now. Coordinating that with digital solutions that enhance it, especially as you get to a certain level of acuity, just makes sense, and it works. 

The provider community was maybe generally reluctant to engage with digital solutions, but now at least the 25,000 providers we partner with use it because they see that when it is added into their plans of care and added into their care experience for their patients, they are getting better outcomes.That is what those providers want, especially when they are rewarded for it with more referrals from those employers that are looking for that better experience.

All this digital solution application was thrust at the marketplace. Ironically and tragically, though, there weren’t a lot of innovative solutions provided for the American worker, that 60 to 80 million men and women that build our roads, build our buildings, fight our fires, and protect our streets. There’s a unique engagement environment for them. They are unique in that with regard to MSK, their job is the biggest risk factor to their health. No solutions were targeted specifically at them. We think that is a mistake and an opportunity that Bardavon is uniquely fulfilling.

Do employers see workers’ compensation as a problematic expense where providers may take advantage of them or bill for services whose value can’t be proven?

It’s all of that, and there is validity to all the reluctance to enter into this marketplace. Some of it is more structural. Workers’ compensation care — how we address and impact our associates that are hurt on the job — is siloed in a completely different and often disconnected part of the structure. It’s actually property and casualty that your workers’ comp comes under. Your trucks, your equipment, your property, and the workers’ comp injuries are housed in a different silo of the insurance industry. That has created an environment that historically had us treat these individuals as widgets and line items on Excel spreadsheets. 

Today’s reality is that we have this labor shortage and this massive need for these people to be healthy, happy, and productive at work. That has created an environment where the perspectives are evolving. That is tailwinds for us for sure, that employers and carriers are understanding that we have to reevaluate the way that we address this marketplace. They aren’t widgets and they aren’t line items, they are people and they carry with them functional issues that either do or don’t help them do their job effectively. Bardavon is leading in this solution set of providing that group with appropriate, effective tools that they can engage and utilize to improve their lives and improve their productivity and work culture as a result.

A lot of people are trying to solve MSK and workers’ compensation. The MSK health of the American worker has been historically neglected, but we feel that the evolution that needs to happen in the MSK space is best launched from workers’ comp. There’s a number of reasons that make it the most advantageous place to launch it, and we believe that that will happen and are excited about it.

You realized that your previous company, ARC Physical Therapy+, had reached a scale problem where you could only grow so much being tied to bricks-and-mortar operations. You also found that the insights available from data were more valuable than actually delivering the service. How did you apply that experience to Bardavon?

That’s exactly right. We went in with a belief in this unique way of addressing the marketplace, going to employers, building clear value propositions, and clearly aligning the incentives of the provider and the payer around the function of the patient. We believed that was the right thing to do. And as you indicated, we changed a marketplace because of it. We had employers change the way they helped their employees navigate the healthcare system to get access to our clinics for the data.

As I mentioned early on, I was fortunate that we built a great company and I was really proud of it. It was, in part, the founders of Cerner — Cliff and Neal a little, but Cliff in particular – who challenged me that we had a national business that we were choosing to operate locally, and shame on us that we were not thinking bigger. At that time, the world had changed. The cloud had come along, and housing those solutions within the bricks and mortar of the couple of dozen clinics that we owned didn’t change a national marketplace, it only changed a local one. 

We believed that we could evolve the company to no longer be beholden to the bricks and mortar, but to partner across the country with providers and payers that cared. And in so doing, not just change the health and healthcare experience of the employees, but find out which providers in every ZIP code of this country were healing patients in a way that was quantifiable and objective.

That is an exciting part of what we do today. We get stronger every day in knowing who is actually healing patients in a way that we can measure, not based on CPT codes or bills, but whether or not their patients are returning to a level of function. That is, I believe, the most transparent and beautiful reflection of healing in healthcare.

How much of the company’s success and ability to scale was driven by requiring providers to document patient progress in your own proprietary platform?

It is bi-directional. It’s not just that they are documenting and sending us the data. We are telling them at eval what success looks like for that employer, what success looks like for that employee who is injured, and what their functional job demands are. There is no guessing, there is clarity. Then we create this beautiful feedback loop that updates and gets better every second of the day about what providers are doing in other parts of the country with like patients with like return-to-work requirements, that are optimizing their outcomes and doing it efficiently and effectively.

All of that is a dream and a vision. Healthcare providers went to school with the hope that they would be in that environment. Most of them, or maybe all of them, got pushed into an environment that historically and traditionally didn’t facilitate that. We had to ask the providers to do something unique to get there. 

Asking them to get out of their EMR and into our platform is not easy. It’s incumbent upon us to make it as seamless and intuitive as possible, but more than that, it is incumbent upon us to make the providers believe that their dream of why they went to school is our dream. To create a system where good providers get more patients and benefit from that, and bad providers don’t. Creating an environment where providers know what their incentive is, and where employers or payers know that because they are partnering with Bardavon, they are getting access to the best providers in every community that are uniquely focused on the same goal that the employer wants, getting that employee back to work and effectively doing their job.

You used the word “grind” several times in an interview, talking about your college athletics experience where a bigger and more athletically gifted opponent knocks you down and you have to get back up and do it again. How does that personal philosophy translate into a business culture, especially in an environment where employees might not be as willing to sacrifice their lifestyle for company benefit?

I was blessed to not be exceptionally good at anything. It taught me the importance of work and that I could succeed if I would outwork others. My parents and growing up on a farm were surely a part of that, but the fact that I wasn’t blessed with any exceptional talent really was a blessing. It helped me, and that transcended from sports to business. The Midwest is part of that.

In all of the healthcare, and specifically now in every industry like this, I guess there’s always a level of negativity and a level of suspicion about whether people are doing the right thing. This business has been my choice to pursue my entire life, in large part because if you spend time with these patients, they are incredibly inspiring.

My entree into workers’ comp was working with professional athletes who were hurt. I saw all the technology and all the science that was aimed at getting a professional basketball player back to the court or professional football player back on the field. When you are able to take a piece of that and provide it to firefighters, police officers, and laborers who are doing their job very specifically to support their husband, wife, kids, families, friends, whatever … there are always bad actors and characters, but predominantly it is a remarkably inspiring client base and I’m proud of what we can do. It keeps me guided to grind every day.

The other side of that is those providers, specifically the physical and occupational therapy providers who spend so much time with their patients. An hour a day, three or four times a week, for five to six weeks. It’s a very intimate relationship. They put their hands on them and they help them regain the function they once had. They hear about their families and they hear about their personal lives. It is a really beautiful sector of healthcare that has been historically neglected and forgotten. I’m proud of the focus that we can put on it through our own grinding effort.

How will the company change over the next few years?

Cliff and Neal were always clear about having a vivid description of a desired future state. Keep that at the forefront of everything you are doing and why you are doing it. We believe that Bardavon will continue to evolve into a company that represents excellence in the way that employers treat their employees, specifically around MSK health. We will facilitate meaningful and intuitive technologies, services, and when appropriate, exceptional patient care for those associates, so that they know that when choosing an employer, they will assess whether or not that employer works with Bardavon. The providers they work with around the country will see that as a part of brand associated with quality and caring for them as people in their roles and jobs and lives.

I believe that we are on the precipice of that. I believe that as we grow and become the company that we can, that others in this space copy us and take that approach to other parts of the healthcare spectrum and continue to improve their lives as well. That’s probably a bold prediction, but I believe it.

HIStalk Interviews Joshua Pickus, JD, CEO, Net Health

Joshua “Josh” Pickus, JD is CEO of Net Health of Pittsburgh, PA.

Tell me about yourself and the company.

I am a serial CEO of technology companies. This is the second healthcare tech company that I’ve run. Net Health is a EHR and analytics company that is focused on medical specialties, such as therapy and wound care.

How do the EHR needs of skilled nursing facilities, senior living operations, and home health differ from those of hospitals?

Let me give you an example to make this real. I’ll do it in terms of physical therapy. In some respects, there are real commonalities. In all cases, you need to accurately document the care in a way that is compliant with the reimbursement codes. You need to do that whether you’re in a hospital, a skilled nursing facility, or an outpatient clinic.

But there are very important differences, and they often end up having to do with things like integrations. In a hospital context, in most of our situations, it’s critical that our systems interoperate with major hospital EHR players such as Epic, Cerner, and Meditech. Making those integrations seamless is frankly as important as the functionality that we have in our own product.

If you contrast that on the other end with, say, a outpatient clinic or facility, that’s a much less critical piece of what they do. They probably don’t have a direct interface with Epic, and that’s not that important to them. Skilled nursing facilities are somewhere in the middle. There are key integrations, principally to PointClickCare and MatrixCare, but it’s different players. Our functionality may be quite different, but the integrations to other systems are quite different among settings and are very important.

The early days of COVID forced hospitals to coordinate with post-acute facilities to free up beds, and CMS added some requirements around that coordination. Is that data sharing relationship among types of entities improving?

Yes. We are unique in that in the specialties we serve, we are really hospital-to-home. We have to think about that stuff. You are right that the pandemic brought those issues to the fore. As a result, the pace of progress has improved.

But the core issue is still simple. There isn’t a common system or even a common accepted language to go from hospital to home, to transmit core patient data seamlessly, easily, and accurately. We are focused on the FHIR standard, which is the closest thing we have right now to a standard that lets different systems at different parts in the continuum talk to each other.

A lot of our work is on improving our FHIR capabilities and making it truly seamless, so that basic information can easily pass from one setting to another in a way that the recipient and the provider of the information actually know what’s going on. You would be shocked that basic stuff — like if you’re a nursing home and you want to know something beyond the patient’s name and age, such as the existence of any behavioral health concerns —  isn’t as easy as you would think given that it is a specific, easy thing that you get every time. Working through FHIR to improve that interoperability continues to be a key focus and challenge for us.

How do you expect the hospital-at-home and remote patient monitoring concepts to play out?

I would respond differently to the two things you mentioned, in terms of the timeframe. Remote patient monitoring is here. It’s real. It’s in use. It’s quite valuable. I think it will expand and pretty dramatically. Hospital-at-home is interesting, but in its infancy and less likely, in the near to immediate term, to affect the way that care is delivered. 

We are more focused on remote patient monitoring and all types of remote care, even if the locus of care is still a hospital-based physician. There are a lot of things that can be done by that physician or caregiver without the patient in the room. That feels real to us, and we are introducing all kinds of capabilities to support that trend.

Will device connectivity and integration issues present challenges?

In the grand scheme of things, the technology is the least of the problems. If you break it down, think about the most basic form of telehealth, which is simply a audio and video call between a caregiver and a patient. That exists, it works pretty well today, and it turns out that it is really valuable. I live in Utah, and about half the time when I see my providers at the University of Utah, we do it virtually. To me, that’s here, that’s ready, that works.

Then you get into slightly more sophisticated stuff. Can a patient who has a wound that needs monitored get that captured by their iPhone and send the picture to the hospital that’s caring for them so they don’t have to make a two-hour journey? It turns out that’s available, too. You could go on and say, can you monitor a patient who is undergoing physical therapy and you want to accurately gauge their range of motion through sensors? That’s available today. too.

I don’t want to minimize the technology challenge. There is plenty of improvement, but it is much more behavioral change that is the obstacle to that than the actual technology.

What are skilled nursing facilities doing with analytics?

SNFs don’t have the budgets that hospitals do. As a result, spending on analytics isn’t anywhere near as large as it is in hospitals. But they are doing important things. 

One that is critical to both hospitals and SNFs is readmissions of patients. If a hospital sends a patient to a SNF and then the patient bounces back, that is bad for everyone concerned, especially the patient. So, one of the things that SNFs are focused on is preventing hospital readmissions. How do you do that?

It turns out that oftentimes what causes a readmission is something as basic as a patient falling, reinjuring themselves and needing a more acute level of care. If you can monitor fall risk and accurately determine which patients are at greater risk and take steps to prevent that fall from occurring, you will reduce readmissions. And if you reduce readmissions, everybody, including the patient, is a lot happier. There are some tangible things that SNFs are doing with analytics, and many of them actually relate to the hospital that sent the patient in the first place.

Are hospitals rewarded for discharging patients to facilities that perform better, and do they provide technical or financial assistance to those organizations to improve outcomes?

There are two ways in which that is occurring, and it’s real. There’s kind of a formal and informal way.

In the formal way, you will have hospital-based ACOs, or accountable care organizations, and they will have formal arrangements with downstream providers. The payments to the provider will be dependent on specific metrics, of which hospital readmission is usually at the top. That exists, but it’s not yet terribly widespread.

The more common arrangement is that many, if not most, hospitals maintain networks of skilled nursing facilities and are deciding where to send the patient. Increasingly, they are focused on the patient experience. There are very different levels of sophistication that this is being done with.

Well-managed networks will pay attention to five or 10 metrics, ranging from readmission to customer satisfaction, about the patients who they send downstream. That will affect where the next placement goes. That incents the SNFs in a very real way to achieve against those metrics, because it will determine the patient flow. That became less powerful in some respects during the pandemic because there was such a bed shortage that it didn’t matter. But as we exit that period, that’s becoming relevant again. It does impact their top line, in terms of their census, based on whether hospitals are sending them patients.

How did your Tissue Analytics product earn FDA’s Breakthrough Device status and how are customers using it?

This is genuinely cool, and it is novel. In fact, it was novel to us, because it’s called Breakthrough Device status and we don’t make devices, we make software.

It turns out that software that makes predictions that affect outcomes in care is regulated by the FDA as a device. Breakthrough Device status means is that you have built something that is so novel and potentially so beneficial to patients that FDA is going to put you in this Breakthrough Device category. They will expedite the review that you need to get an approval to have your product sold and used for particular applications. It was a journey for us, as a software company, to enter the FDA regulatory scheme.

We are doing things like predicting the velocity at which a wound will heal, predicting amputation risk, and ultimately predicting which kind of treatments are most likely to lead to an expeditious and effective piece of care. We have demonstrated that we now have enough data that we can accurately predict that “this patient needs this many visits of this duration to achieve that result” or “this patient is at materially higher risk of amputation if action isn’t taken immediately.” It’s making a real-world difference out there. We probably have 50 or 70 customers using these modules, so it is becoming an accepted part of wound care practice.

Will the experience that the company gained from working with predictive AI and the FDA influence future product development?

Very much so. We view analytics as a key piece of where EHRs are going. If you think about it, EHRs have traditionally been systems of documentation. They exist so that you can document the care given. That’s a baseline requirement, but it’s not really where EHRs are going. EHRs are becoming systems of insight and systems of engagement, in addition to systems of documentation.

By systems of insight, I mean that if you are the system through which the clinical workflow is happening, you have a unique opportunity to collect data about what works and what doesn’t. This is the piece that people miss. You also have a unique opportunity to put insights back in the workflow to alert a clinician at the precise moment, which increases the quality of care that they can deliver.

The analytics piece for us and the predictive piece for us is very much about the next chapter in what an EHR is. It’s really about harvesting the data to yield insights that you can feed back to clinicians that enable them to deliver better and more cost effective care. It’s at the very heart of where we’re evolving our systems.

You’ve said previously that a lot of EHR frustration is due to entry of that isn’t used to change outcomes and doesn’t directly support the clinician who is expected to enter it. How will that evolve?

General purpose hospital EHRs like Epic and Cerner will also include analytics and predictive analytics as key parts of what they are doing. Those are sophisticated companies. They understand that this is the next chapter for EHRs, and they will participate in that. We view ourselves as additive to what they do, because the workflows and the data that we capture are unique to the specialties we serve. To be able to deliver accurate predictions and useful clinical insights, you need that unique workflow and unique data.

We think that what we are doing and what they are doing are complementary. We work in many hospitals with both Epic and Cerner. Virtually every installation of our Tissue Analytics product is with a system that runs Epic or Cerner, so it is important for us to be complimentary and to interoperate with them.

What changes do you expect in the company and the industry over the next few years?

If I were going to give you two words, it would be more interoperability and more analytics, especially predictive analytics. Both of those things will become so embedded in what we do that you can’t really separate that piece from us. The importance of connecting with other systems and the importance of using the data that you have to deliver insights is really the future that we see as Net Health continues to evolve.

HIStalk Interviews George Dealy, VP of Healthcare Solutions, Dimensional Insight

George Dealy, MS is VP of healthcare solutions for Dimensional Insight of Burlington, MA.

Tell me about yourself and the company.

We’ve been building analytics technology for the last 30 years. My group uses the Dimensional Insight technology, the Diver analytical platform, to create healthcare-specific analytical applications that solve various problems within the healthcare system, primarily focused on the provider environment, but we also have payer and manufacturer customers.

I have been with Dimensional Insight for 15 years and in the healthcare IT space for 27 years. Before that, I was in the data management database area, working for companies such as Sybase in the early days of RDBMS technology. I was there for 10 years before I moved into healthcare-specific technology.

Do customers want a platform that allows them to develop their own analytics or do they prefer pre-built solutions that have been proven to work elsewhere?

We’ve seen a transition, over the course of the last five or six years, from folks wanting to build their own solutions to their own problems to being open to pre-packaged solutions like the ones that my group builds. Then, extending them for their own purposes.

But even beyond that, we’ve seen some of our larger health system customers essentially almost outsource their analytics process to us. They consume the data and they decide what problems we’re going to focus on solving, but they look to us to do the actual development work. A consequence of that is that they are able to put more focus on actually using the data versus building the systems.

Do they just give you a description of their problem or do they already suspect its underlying cause?

It depends. We have a family of eight healthcare solutions. We will typically start a conversation with a customer for a particular problem. I’ll use the example of a surgical service line where there’s lots of information. There are challenges around things like throughput and patient flow. They’re turning ORs around. We have a solution that provides common KPIs for that particular class of problem. They are able to extend that to more specific manifestations of those problems. We typically start with a pretty well-defined starting point for a particular problem. If their problem is something other than what we have a pre-packaged solution for, we still have a starting point in terms of the way that we go about developing applications.

We’ve created some technology that sits on top of our analytics platform and simplifies the process of defining and then calculating KPIs. One of the things that that tool has allowed us to do is to get the folks who understand the data and the problem they are trying to solve more directly involved in the process of defining and creating these analytical applications. That has also put our customers in a position to create their own applications in a similar style to the ones that we create. Among the organizations that have the wherewithal to do that, typically the larger health systems, we’ve seen a lot of innovation around things that we hadn’t thought about for one reason or another. They are solving the issues that are important to them.

Does the challenge remain that executives commission reports that frontline managers don’t use?

Two observations. One is that it starts at the top. You get good results if a CEO, COO, or C-suite executive who has operating responsibility is watching those numbers and holding the folks who report to them accountable. They have to then do the same thing right on down the line. I have a few customers where that’s the case and their execution is very good, largely as a result of having the information, but also selecting the right information to focus on.

The other thing is that my sense is that being data driven is something of a generational change or evolution. Folks who grew up with electronic media, understand information, and aren’t afraid of it are more open to incorporating it into their thought process. That’s not to say that folks in my generation aren’t open to it, but I think there’s more consistency around the younger side of the workforce because it’s what they’ve grown up with.

Do people have eye-opening moments when analytics shows them something they didn’t suspect?

All the time. There’s tremendous confirmation bias all over the place. You hear the story told frequently about surgeons and physicians who have this intuitive sense that their particular approach to a procedure or a diagnosis is the only way that you would do it and that it’s as effective as it can be. Then they start looking at the data from their peers in similar situations and realize that they didn’t know some things. Similar lessons apply on the operational side pretty much wherever there’s data. 

We have that in our personal lives, too. We think that something is a certain way, but when when we start quantifying it, we realize that it’s very different. You’re used to going a certain route and your GPS system tells you to go a different way that you never even thought about, and it turns out to be shorter and faster.

What are examples of customers using analytics to solve a vexing problem?

I would break this down into a couple of categories. Operational efficiency is a big area where it’s really not clear what is going on in complex processes. You look at patient flow through a hospital, where a patient comes in through the ED or maybe is going for elective surgery, and there are all these way stations along the way where there are potential bottlenecks that get in the way of freeing up beds for patients, getting patients discharged on time so that you can bring more patients into the hospital. Hospitals make much of their revenue on fixed-fee DRG hospitalization, so moving patients through the system as efficiently as possible is key.

Our customers use KPIs that break those work processes and flows down to where they can identify where the issues are. For example, moving certain bottlenecks out of the way to discharge patients from the hospital more quickly, or at least by a particular threshold that they’ve set. That would be one example of something that improves patient flow. Further back in the process, the emergency department, where a variety of bottlenecks can emerge, largely around the ancillary services, getting appropriate turnaround times on things like imaging and lab procedures.

Those are some operational areas where our clients have been able to improve using information to identify the problem, solve it, verify that there was an impact, and then monitor it to make sure that it doesn’t regress back to where they started, which can often happen if you don’t have ongoing visibility into the information.

On the clinical side, I’ll give you one example of a academic medical center customer that we began working with fairly recently who has come up with an algorithm for assessing mental health issues, specifically suicide risk. We work with them to integrate that algorithm into information that was compiled from EHRs. The patient clinical data is combined with the algorithm to come up with a risk assessment for suicide that can be used directly by providers when they are interacting with patients or prior to interacting with them in a formal healthcare setting. Or, to identify cohorts in a population that are at high risk for suicide.

Do customers often learn from analytics how to identify and replicate their own best practices?

That’s the whole premise and the opportunity for some of the advanced techniques around analytics. We have tremendous amounts of data, starting with the Meaningful Use era, where EHRs with clinical capabilities came into the healthcare environment in a way that they weren’t there before. You have 10 years of data that is getting better as time goes on. There’s still a data quality issue and data standardization issue, but as those issues get dealt with and interoperability becomes more standardized, you can compile a more complete picture of a profile of patients and populations. 

Then you are in a position to assemble this big base of information and use it to compare to outcomes over time and determine what care processes, what approaches have been most effective for improving outcomes or attaining a particular target level of outcome and eliminating some of the adverse events and consequences that can come when things fall through the cracks where processes aren’t followed. Or maybe there are suboptimal processes to begin with.

How have health system expectations for return on investment changed with the pandemic?

The big issue during and coming out of the pandemic is around staffing. The physician staffing shortage was there prior to COVID, but nursing is largely a consequence of COVID. Efficiency and productivity become that much more important because you’re dealing with limited staff resources. We have a lot of prospective clients looking at solutions to that type of problem. How do you objectively measure and improve efficiency and productivity given limited personnel resources?

I just realized that I haven’t heard the term “big data” used lately. Do health systems still need external data or they they have enough information of their own to make decisions?

That’s interesting, I don’t think I’ve heard the term “big data” in a while either. I think that may have come and gone. Maybe it’s just taken for granted at this point, with the likes of what we see with Google or Facebook. The amount of information that you can deal with is almost infinite from a practical standpoint. The capability is there, but the issue has shifted to, what big data? What are you going to use it for?

I was reading a research paper that came out of the MIT Healthcare Learning Lab, where they are they are experimenting with what they call multi-modal approaches to machine learning in healthcare. They are looking at not just the traditional, highly structured, tech-based information that comes out of EHR, but combining that with voice recordings, video, waveforms, and time series imaging, teasing value out of that to predict certain well-defined outcomes. This particular paper was looking at predicting length of stay in hospital, 48-hour mortality, and a few other things. They found that they could get a boost — it wasn’t a huge boost, but it was still a meaningful one – by employing some of these other modes on top of what we think of as the traditional information that gets collected and structured within an EHR. That’s huge data, maybe the next step up from big data.

What will be important to the company and the industry in the next few years?

Continuing to get the data house in order. There are tremendous opportunities and possibilities around these advanced analytic techniques, but it requires good data. We are focused on identifying what that data is and curating it to the extent that it’s meaningful within the organization. In other words, you don’t have five different ways of measuring exactly the same thing. There may be some meaningful variation, but reducing that duplication and quantitatively defining outcomes. Once you have that, you open up more opportunities for using these advanced techniques to become more efficient and productive and to improve outcomes.

Things like the standardization of vocabularies on the clinical side. SNOMED, RxNorm and LOINC have been around for a while, but they are gradually making their way into practice. As you get more standardized data, it’s higher quality in terms of what you can do with it. The HL7 FHIR standards are going to help in terms of being able to compile the standardized information around a patient or a population of patients so that you have more and more high-quality data to work with.

A lot of it is somewhat routine blocking and tackling, but until that happens, the potential for the more advanced techniques is going to be limited. But healthcare in general is very much looking forward to what advanced analytics can do. As you look around other industries, it’s pretty clear that it has the potential to make a huge difference, but you need to have the data in place and you need to understand what it is you’re trying to do with it.

HIStalk Interviews Eric Meier, CEO, Owl

Eric Meier, MBA is president and CEO of Owl of Portland, OR.

Tell me about yourself and the company.

I’ve been in the healthcare field for the majority of my career, both on the software side as well as the technology and medical device area. This area is probably lagging other specialties in technology, software, and analytics. This is the realm of behavioral health, which is the largest category spend in healthcare — I think it’s over a quarter trillion dollars spent on services. You can look at the impact from our productivity in our society. I don’t know the current prevalence of behavioral health conditions, but I think that an excess of 16% of the American population has suffered from behavioral health issues. 

We came into the market realizing that unlike other specialties, there was really not a good way to determine and understand if care is working correctly. Behavioral health has been a people-based therapy and involves medication as well as psychotherapy. The ability to assess whether treatment is working has been lagging. Somewhere between 11 and 13% of clinicians are practicing measurement-based care, but it has been shown clinically to be extremely effective way to deliver effective and efficient care.

We were founded at University of Washington, looking to deliver an approach that would allow clinicians to understand or address the fundamental question — is care working, and to what extent? We’ve built upon that over the last five or six years.

What’s encouraging about it is that this methodology of measurement-based care clearly works. The platform was designed by clinicians for clinicians. When you take that type of approach, you can get an understanding of how treatment is being delivered and how effective it is at every step of the journey. 

We are seeing engagement rates well in excess of 90%, which means it is integrated into care effectively and is able to understand what’s the patient’s status at intake from a screening standpoint, but also being able to work alongside the treatment throughout the entire course of treatment. When it’s time to discharge, step down care, or have patients transition away from receiving services, understand the effectiveness from admit to discharge, and then if needed, to see if in fact there is a relapse, being able to detect that early on so care can be administered correctly if needed down the road.

What kind of measurements are used, and how many of them reflect the patient’s perception?

Patient-reported information is a true proxy of the patient’s status, not only for screening, but throughout the course of treatment. It minimizes clinician burden and it has been shown to remove quite a bit of subjectivity or bias. If you look at the early days of capturing assessments for clinical care, a lot of these were physician-reported scales. Over time, what has been increasingly accepted and recognized is that the patient can provide a far better status of their own condition. That also avoids the pitfall of many technologies in burdening clinicians with additional work.

We adopted the approach at the outset of capturing the patient’s status using patient-reported outcomes measurements or what is referred to as PROMs, in addition to looking at social determinants of health information, which in many ways can be key indicators of the patient’s status. Often in many cases, even a leading indicator — one needs to address issues like food insecurity, homelessness, et cetera. We provide this information to clinicians to help understand the condition at the time of screening or intake, then risk stratify populations, then being able to monitor or track treatment effectiveness over time.

Will those measurements became a standard for payers, similar to prior authorization?

I would look at the issue and say, why to date has it not been broadly accepted? I think it’s because of a number of previous solutions were fairly burdensome, relying upon either the clinicians to administer these tools or not fitting into the clinical workflow. We’ve taken a deliberate approach to make it fit into the existing behavioral health practice, whether it’s ambulatory, partial hospitalization or intensive outpatient, inpatient, or residential. You have to look at the clinical workflow and make sure that whatever you’re doing to capture critical information, like what we capture in Owl, fits in the existing environment.

On top of that, I’m pleased to say that there are existing CPT codes to support the capture of information that feeds into measurement- based care. We have customers being reimbursed for this. But you could also look at this information to be critical in the utilization management process, if you want to know that effective care has been delivered or if you need to extend treatment. We have customers using this information to help provide greater transparency around the type of services that have been delivered and how effective they are.

Behavioral health providers have been reluctant to use some technologies because of privacy concerns. Is that an issue?

We really haven’t seen that be an issue. The major questions around adoption are, how does this fit into my existing workflow, or how does this help me institute change management in a way that’s not overly burdensome and can actually make the capture of information easier? 

Around privacy concerns, we have developed a HIPAA-compliant system that is observant and supports conditions around privacy. There are additional requirements as it relates to substance use, but at least from our vantage point, we have not seen that be an issue around adoption of technology. It’s more about just making sure that it fits within the existing treatment model and doesn’t overly burden the clinicians, but actually give them greater information around the kind of care they’re delivering and making sure that using a platform to help improve the overall effectiveness and efficiency of care.

Who makes the decision to implement the concept as well as the technology?

If you look at our customer census — Ascension Health, Oregon Health and Science University, Texas Children’s, Inova Health System, and Carilion Clinic — it starts with leadership that is thinking strategically on how to deal with the basic questions of, how do I deliver the most effective and efficient care? How do I deal with access issues and try to address wait lists that may be occurring? How do I better understand, from a population health standpoint, the type of care that is being delivered within my ecosystem and also support alternate payment schemes, such as value-based care?

All of that hinges upon the understanding of the type of care that’s being delivered, which has been well accepted through the capture of clinical outcomes. With any new technology, getting leadership buy-in up front is crucial to embark upon measurement-based care, but also make sure it’s being utilized by the team on an ongoing basis.

We have been fortunate that our customers tend to think strategically on addressing the fundamental question of how effective is the care, how good a job am I doing? Then making sure that as we look at this from an implementation standpoint, it needs to fit the existing ecosystem, which typically consists of integration with their EHR, whether it’s Epic, Cerner, Athenahealth, or behavioral health EHR such as Netsmart, Streamline, and others. Then secondarily, make sure that information can be used on demand by the clinicians as part of an encounter, but also used by the leadership to assess the effectiveness and efficiency of care across their different clinical programs. 

When you think about the ability to benchmark, let’s take for example eating disorder service lines that may be spread across a health system in different locations. What you would like to understand is, how good a job am I doing? Am I seeing kind of best practices in one location that I can now, based upon the outcomes data that the Owl is generating, replicate and standardize on? 

The other point that needs to be understood is that people delivering behavioral health have probably one of the toughest jobs in healthcare. It is a really challenging job. Well accepted is its ability to not only provide effective care, but get more out of existing resources. For example, we’ve seen about a 56% reduction in time to remission from those folks that implemented the Owl versus those that have not.

Secondarily, given some of the resource constraints that have unfortunately become a consistent problem across the United States, we’re seeing about a 30% improvement in staff efficiency. You take an organization that may have 20 to 25% attrition, there’s a need to backfill those positions, but also make sure the consistency of care is happening across a health system, whether it’s in one geography or multiple. The beauty of the Owl is it provides a systematic way to deliver evidence-based care, and when you think of faster time to remission, I can treat more clients with existing resources.

How are measurement-based outcomes being used in telehealth?

We are an enabler to that. We were designed from inception to support telehealth, long before the pandemic occurred. Virtually 100% of our customers, going back to probably the second quarter of 2020, by necessity pivoted to a virtual healthcare model and, there was no interruption of the use. In fact, one of the things we’re proud of is that our platform has been used to assess the overall effectiveness and efficiency of care in both the on-premise as well as virtual setting. We’re seeing a consistent response. The upside for the patients is you have the ability to receive treatment services in probably a more relaxed setting. You avoid having the transportation and having to go to your appointment. Our platform has been used to give confidence to the providers that the quality of care is not compromised.

When you think about what is happening right now with the fact that there’s been a big focus on access to care and our platform is being used to support improved access to a faster time to remission or whatever your treatment target is, as well as the ability to be able to treat more in patients with existing resources, we’ve been well accepted in providing those values. I would say as you look forward, we think there’s going to be increasing focus on quality. As the access issue begins to abate, we are seeing health plans is saying, that’s great, let’s make sure that the quality of care is not compromised. The payers or the health plans are demanding more data, in the form of clinical outcomes, to document and validate that the treatment services have been administered correctly.

That’s the work we do. Think of us as not only supporting the providers and being able to deliver evidence-based care through the Owl of the measurement-based care platform in a seamless way, but secondarily provide the health plans to better understand the performance of their networks. There’s no better way to do that than to have well-documented, patient-reported clinical outcomes and social determinants of health information to make sure that the best care has been provided at the right level to the patients.

What changes do you expect to see over the next few years with your customers and the company?

In the early days of the company, it was around providing or enabling providers to capture clinical outcomes in a straightforward way. We’ve been able to provide information capture to our customers.

If you look at the evolution of measurement-based care, the next piece of the puzzle is providing detailed reporting and analytics to support internal needs around as a health system. How good a job am I doing relative to where I want to be from a performance standpoint? I think of this as a population health support.

The next area has been in supporting clinical decision support. Not only can I use measurement-based care to determine those clients or patients that may be likely to self-harm or harm others, so looking at suicidal ideation, our platform is designed to provide a safety plan to not only notify the clinicians and staff that immediate attention is warranted, but also say, what do you do? We’re building upon that now to look at different conditions such as depression, anxiety, substance use, et cetera, to provide supportive clinical decision-making so you are administering the right care algorithm.

The fourth area I would speak to is providing greater alignment between providers and plans. Providing visibility, which to date has been opaque, around the overall care that has been delivered by both the behavioral health specialty and primary care. Having an understanding of how a health plan’s network is performing, and once you baseline that information, then it provides the opportunity to be aligned around moving towards alternative payment schemes, such as value-based care.

As we look forward, we see not only continued and growing acceptance of measurement-based care by providers, but health plans using this information to understand the quality of care that has been delivered and making sure there’s alignment around payment schemes and addressing total cost of care.

From a business strategy standpoint, where we are focused is having a balanced portfolio of customers. Not only serving health systems, large community mental health clinics, and health systems supporting both behavioral health specialty and those that move into collaborative care or integrative care model, but also making sure the health plans are able to understand the type of care that’s been delivered. Not only behavioral health, but also recognizing that these behavioral health conditions can adversely impact medical care. This whole concept of whole person care is going to be critical and recognizing you need to address the behavioral health component of it.

We benefited from taking a clean slate five to seven years ago and the ability to develop a measurement-based care platform by clinicians, for clinicians. The area we focused on was number one, making sure we integrate in the clinical workflow in a seamless capacity. This is across different clinical approaches to delivering behavioral health services, everything from ambulatory to partial hospitalization, intensive outpatient, inpatient, as well as residential. We’ve extended that to support when behavioral health is being delivered in a primary care setting as well. Secondarily, once you fit the clinical workflows, to make sure you’ve got a broad enough amount of content that support all the different subspecialties, whether it’s eating disorder, substance use, depression, anxiety, adolescent, or late-life care. 

The upside of this is we’ve got a high engagement level, upwards of 90%. You need those kinds of numbers to fully utilize measurement-based care and capture the benefits of accelerating time to remission and improving effectiveness of care as well as efficiency. Once you accomplish that, you start to address one of the primary issues today, which is access to care. In other words, how do you make sure clients are receiving care in a timely capacity? As I mentioned earlier, we’re seeing compelling and supportive statistics with faster time to remission of 56%, as well as being able to get more out of existing resources.

With that in mind, with this information, then it becomes meaningful not only for providers, but also obviously those that are doing accreditation work, such as the Joint Commission or CARF, as part of their audit process. Lastly is making sure that the health plan has a better sense of the type of care that’s being delivered by their network.

We have been fortunate to have supportive strategic investors in the form of the Ascension Health Network, First Trust, Cardinal Partners, Blue Venture Fund, and the Entrepreneurs Fund.

HIStalk Interviews Ben Albert, CEO, Upfront Healthcare

Ben Albert, MBA is co-founder and CEO of Upfront Healthcare of Chicago, IL.

Tell me about yourself and the company.

I have been in healthcare for my whole career. Prior to starting Upfront, I founded a company called Care Team Connect, which was a care management platform for population health that was acquired by The Advisory Board. We did a lot of care management work through a digital platform that enabled care managers to support the high-risk patients that they were serving and supporting in a shared risk agreement.

That experience it led me to found Upfront, because every patient, not only those who are high-risk in some population health agreement, deserves to be navigated to the care that they need, and technology is required in order to scale that type of navigation for every single patient across a health system. That is the foundation of Upfront Healthcare, to help every patient get the care they need.

How do you differentiate the patient engagement and digital front door technology market?

It’s a confusing market, for sure. The digital front door is mostly tied to patient acquisition. Where Upfront focuses is on how to retain every single patient that you serve. If the digital front door is going to bring in a bunch of new patients, how do you use personalized engagement and access to optimize the experience for that patient so they stay with the system for the long term after the digital front door is activated and you engage that patient initially?

Health systems are starting to understand how to get patients into the system. Do they also study why patients leave the system?

They definitely study why patients leave the system. They look at referral patterns and if patients are leaking out. If they are being used as a retail service and the front door generates only retail visits, how can they convert that patient into an empaneled patient on the primary care side or the system of choice for that patient for the long term?

They definitely look at that conversion and understand how to keep that patient and retain them. Especially in light of all of the specialized services that are coming to market, Amazon and Oak Street Health for example, that are focused on particular types of patients, to help attract those patients to their services. Our clients, the health systems, need to focus on how to differentiate and keep their existing patients.

How do health systems engage with patients whose encounter was one-off, such as in an urgent care center or telehealth visit, and determine how much of a relationship those patients want?

They need to engage those patients through a more personalized experience to help understand the needs of those patients and then guide them to that service proactively. Patients are often left to figure that out on their own. They might get a simple text message thanking them for their visit or preparing them for a visit, but they aren’t really aware of options within the system and how to best use the system to meet their own needs.

We often talk about patients as the most underutilized resource in healthcare. How does the health system look at that initial encounter or initial event as a way to help educate the patient about all the services that are available to them in a personalized way, so that only those services that are going to be the most impactful for that patient are put in front of them?

How is that different from retailers, who are happy to sell you whatever you want to buy and hope you keep buying, when what patients want isn’t always what clinicians think they need?

The patient will make the right choice if they are given the education and the appropriate information to enable them to make that choice. Often the clinician might be communicating what the patient needs, but the patient doesn’t understand it at the time that communication is provided. It’s not as personalized in some ways as it could be.

You can give patient the alternatives in how to get that care. Let’s say it’s a flu shot for example, something very simple. You give them the alternatives of, you don’t have to go to your primary care physician because we have these different options for care for you, including our urgent care, where you can get this flu shot. We are going to help guide you and let you pick what service is most convenient for you to get that care that you need. It flips it around a little bit to give that patient choice to meet the needs that they have by availing them of the information to optimize their own care.

Is there any comparison to dental practices that message their patients effectively, albeit with list of services that is much shorter and predictable than that of a health system?

It will be as simple as that. It’s not the complexity of the system, it’s the communication of what pieces of the system meet the needs of the patient. 

There is a way — we call it care traffic control — to understand all the services that a health system can provide to a patient, and then to personalize that service and the access to those services so that the patient will know exactly where they’re supposed to go and when they’re supposed to go there. They will get that care that they need from the system and it won’t feel so complicated. It won’t feel like there are so many choices because it has been tailored for them and guides them directly to where they need to go.

So yes, it can feel like the dentist. Does it today? No, because it’s a lot of fragmented communication coming through different channels that confuses a patient as opposed to one omnichannel communication that will ultimately all be on the same page to enable that patient to get where they need to go.

How will you apply the consumer science capabilities of PatientBond, which Upfront acquired in August 2022?

We are excited about the acquisition of PatientBond. Psychographics, in combination with the behavioral analytics that we already do at Upfront, will help us understand how to best engage a person. Psychographics are a consumer capability that helps create these personas of individuals, so that we know exactly what communication pathway to take to engage that person so that we can ultimately understand how to best communicate with them.

You use the right imagery, you use the right language, you use the right time of day and super tailor and personalize the experience for that individual. You tie that in with the behavioral knowledge that the Upfront platform has and that really understands that when they go for care, where they need to go. You optimally tie those things together to have a communication pathway, then access that pathway for a patient that is unique to them and scalable. They are getting to that care 40% more than they were before because of that communication pathway.

If value-based care ever becomes significant and maintenance of health becomes more financially important to providers, will the same messaging platform support it?

Yes. From our point of view, whether it’s value-based care or not, every patient should be getting these necessary preventative services. How it gets paid for on the back end, we certainly understand the value of that. But ultimately if you take the patient-first approach, everybody should be getting that annual wellness visit who needs it and everybody should have those care gaps closed who need them, not only if they’re in some value-based care arrangement.

How do you help every single patient, regardless of what the economics are behind their care, get to the most optimal care for them? It’s informed by what type of care they need to receive and what type of model of care they’re in to make it super efficient for the health system while still enabling every patient to get the same level of care across the system. In a value-based care context it’s incredibly important, but it’s equally important in a fee-for-service context where these patients still need that same care.

How do health systems change their philosophy about consumerism and then choose systems to support it?

They all want to be more consumer centric and they’re on this journey to be so. They have built all of these services, retail-type services like urgent care, virtual care, on-demand care services, asynchronous care, and in-person services like traditional office visits. They have built all of these services to be more consumer centric, tried to increase access points, tried to make themselves more convenient.

Ultimately, though, they have not optimized that for the patient. What they are doing now in that next wave is saying, we have all these services and we can compete for access, convenience, and efficiency for the patient. How do we tie it all together and enable the patient to understand which one of those services they should be utilizing within our system to ultimately get the best experience for them and get in for care when they need it?

We see a big effort in tying that all together to make it feel seamless for the patient, even though we know that under the hood, it’s not as seamless as it probably should be in the long term from a health system point of view. You can enable the patient in a way that feels seamless and guides them across those services. That’s how they are digitally transforming right now. The first step is how to enable that consumer even if you can’t fix everything across the system on the back end right now.

Does consolidation into larger health systems change the scale and speed in moving to a more patient-focused direction and the use of technology to support it?

In theory it’s helpful, but ultimately you are now on multiple EMRs. You have to reconcile all of that data and all of those services across the system. Unless you have something that can sit beside the EMR, sit outside of that ecosystem and look across multiple EMRs to understand what services are available and guide patients, it doesn’t actually advance the cause. It can slow it down because of the focus is so heavily on the EMR itself and not on how to activate your patients and help all those patients navigate through the integration of a couple of systems coming together, which is incredibly complex for patients to navigate, but also for the system to execute on as well.

How do you see the consumerism aspect of playing out over the next few years and how will the company change in response to it?

To us, healthcare needs better personalization for every single patient. The more we can delve into truly understanding exactly what service the patient needs and enabling them proactively to get that service, the more efficient we will be at a macro level. For us, it’s continuing to enable patients through personalization, through psychographics, through behavioral data, through the right type of communication and omnichannel communication that is integrated across the system so that access and appointment booking is frictionless and easy to get to. 

I would love to say that it’s a one-year journey to be able to tie all of that together, but those of us who have been in this industry for a long time recognize the complexity of it. We will just stay with it and keep doing more of it over the next few years, and you’ll look back at the body of work and say, wow, we’ve made a big impact. More patients are getting the care they need. They are getting a personalized experience that feels much more consumer centric, and they are actually healthier as a result.

HIStalk Interviews Douglas Fridsma, MD, CMIO, Datavant

Douglas Fridsma, MD, PhD is chief medical informatics officer of Datavant of San Francisco, CA.

Tell me about yourself and the company.

I’m the chief medical informatics officer at Datavant. Before that, I was president and CEO of the American Medical Informatics Association. Before that, I was the chief science officer at the Office of the National Coordinator for Health IT during the Meaningful Use era, as we were trying to get electronic health record adoption.

A lot of the work I did at ONC was to set up the basic infrastructure for collecting data. The goal, for many of us who were working on these projects, was to make sure that once we collected the data, we would get rid of the lazy data. That is data that would  get collected and then just sit there and not be used for population health, a learning healthcare system, or those sorts of things. That’s my history and where I come from — let’s figure out ways to make data useful for patient care and for healthcare delivery.

Describe how tokenization is performed and how the information that it enables is being used in healthcare.

A lot of data out there is fragmented. If you were to try to get your medical record, you’ve got bits of your information that might be in a claims record, some of it might be in a specialty pharmacy, and some of it might be with your primary care doctor or within a hospital in which you were seen in the emergency room. The problem is that when data is distributed like that, it’s hard to bring it all together into a longitudinal view of that particular patient’s experience in the healthcare system.

If you want to link a record from one hospital to another hospital, you have to have some kind of identifiable information. But if you are using the data for research purposes, HIPAA doesn’t allow us to release that kind of information without lots and lots of safeguards, IRB approvals, and things like that.

It is possible to strip out all of the identifiable information from the medical record — eliminating names, genders, changing birth dates from a month and date to just a year, removing addresses, maybe abstracting ZIP codes to a higher level. Datavant strips out that information and replaces it with an irreversible hash that we call a token. It’s like baking a cake — you cannot go back and get back to the original ingredients. This hash is derived from a lot of that personally identifiable information, but that hash has nothing that would point that back to the original person.

Datavant allows people to de-identify their data within each of their organizations. Then we have the ability to link that data back together without ever revealing a person’s name, Social Security number, or phone number. Using these tokens allows data to  move in ways that protect patient privacy and that reduce the risk of re-identification.

How reliably can the process generate a token that correctly matches the same patient across multiple data sets?

We did a lot of work when I was at ONC on trying to make sure that we could optimize patient match. Patient match is determined by three things — the algorithm that you use; the kind of data that you use, whether you’re doing it based on a phone number or a name or something like that; and the quality of the data. Probably the biggest impact is making sure that you have high-quality data that can then go through this process to generate the tokens. We work with organizations to make sure that their addresses, for example, conform to the US Postal Service standards.

With high-quality data and the algorithms that we use to generate these tokens, our metrics can be very high. It can be almost comparable to what you would get if you had a Social Security number, the name, or all of the identifiable information. It’s quite comparable as long as you’ve gone through the process of making sure that you’ve cleaned up the data and made sure that it’s accurate and an accurate reflection of the patient’s record.

Does that raise the same challenges as in interoperability, where matching data from multiple systems then brings up the new issue of semantic interoperability, where systems represent the same data concepts differently?

You raise a really important point. Datavant can link two records together and do it in a reliable way while protecting a patient’s privacy. But suppose you have one record that has all of the diagnoses in an ICD-10 code and another one that has all the diagnoses in a SNOMED code. You’ve linked the records together and you know that it’s the same patient, but now you have semantic incompatibility between a record that was collected in ICD-10 code and another one that was collected in a SNOMED code.

That’s not part of the problem that Datavant solves. We do find, though, that in the work that the NIH has done with the N3C — the National COVID Cohort Collaborative – before they run data from everybody who is contributing data through the tokenization engine, they normalize the data to an information model that consistently represents diagnoses and consistently represents things like vaccination status or other things like that. Often you can normalize the data and make it semantically consistent at each one of those sites, and then when you combine them, that data flows together much more easily.

There are ways to do it after the fact, after you’ve done the linkages, because now you might have two records that are inconsistent. The National Library of Medicine and others have ways that you can transform, say, one code into a different code to make that happen. The issue that you raise around semantic interoperability is a critical one, but it isn’t one that is solved by the process of tokenization.

Life sciences, public health and particularly COVID research, and real-world evidence would seem to be good use cases. What opportunities and users do you see for tokenization?

Let me break that down into a couple of use cases that you mentioned and give you some examples of that.

One example that you mentioned was around COVID. We as a country were trying to understand COVID and who got vaccinated, and if they were vaccinated, what their outcome was compared to people who were not vaccinated. The challenge that we had is that people had their vaccinations done at the public health agencies, their primary care provider, or CVS and Walgreens. Their hospitalization or their care might be in an outpatient clinic, the emergency room, or in a hospital setting. The problem was this fragmentation issue. The only way to understand who got vaccinated, who got infected, and who got long COVID was to link together all these different data sources. It’s a tremendously complicated thing to do, particularly because you have to have identifiable information to be able to link, say, your pharmacy record with your emergency room record.

We worked with the NIH to create tokens across this ecosystem from pharmacy, public health, and most of the major medical research institutions in the country that were part of a research program at NIH. That allowed us to pull together all the data and then create data sets that basically said, here are the folks who got vaccinated. Here are the folks who got hospitalized. Here are the people who had long-term complications related to that. That has provided a lot of rich research for the folks at the NIH who are doing that.

We see other use cases in life sciences. When pharmaceutical companies want to do a clinical trial, they get consent to collect information as part of participation in a clinical study. They have identifiable information that they use for that study. But it’s important for drug safety to be able to monitor patients after they have left a clinical study to see if they have long-term follow-up or other things that may happen as part of their participation. That can be tremendously expensive. Those are called Phase 4 clinical studies.

We have found that a lot of life sciences companies are getting permission to tokenize the information of those patients and their record. Then they can find that patient at a population level — not at an individual level, but at a population level — to identify cohorts of patients that might, say, have an increase in their cancer risk. O they may find that their five-year follow-up was fine, but their 10-year follow-up might be more challenging. That has been tremendously valuable within real-world evidence and using that for clinical studies in the life sciences. By creating those tokens as part of that process, they are able to do a lot more of the Phase 4 studies, which are expensive and they take a long time, but to do those efficiently by using this real-world data and being able to collect it directly.

As this becomes increasingly relevant, we are finding that a lot of hospitals and providers are starting to see de-identified data as not just a nice-to-have, but part of a strategic approach to how they use data. For example, within a large-scale academic medical center, there are hospitals that will de-identify and tokenize these very large data sets, and they’ll have them within their institution. They provide the ability to link that data together and reduce the risk of breaches, reduce the risk of other problems, because the data has already been de-identified and can then be used for research purposes.

Other hospitals are taking a look and using de-identification to enhance the data that they already have. They might create tokens within their hospital, but use that as a way of drawing in other data, matching it into their population, and being able to do a richer analysis at a population health level because they have augmented the data with mortality data or with social determinants of health data that allows them to get a better picture of their population. Again, not to the individual patient level, but at that population level.

Many of the providers are using this data to participate in some of these clinical studies, to be able to take their data, de-identify it, and then make it accessible to life science companies and to people who are doing research in a way that is respectful of the patient’s privacy and that prevents that lazy data. They are able to have the data that has been collected as part of their provision of care and make it be useful for other purposes that advance our understanding of how to deliver better health and healthcare.

Could tokenization be used by an EHR or other system to de-link a patient’s identity from their detailed information so that if a hacker exfiltrated their entire database, they still couldn’t connect a patient’s identity to their data?

This whole notion of being able to take two data sets potentially that have been tokenized and not be able to link them together is a fundamental part of the Datavant technology. We have probably 100 billion records and 300 million covered lives that have been tokenized using the Datavant technology. Should someone inadvertently get a copy of, say, one hospital’s tokenized data and the records from another hospital’s tokenized data, our system creates different tokens for each of those sites so that it’s impossible, even if someone were to get that information, to be able to link it together and potentially re-identify a particular patient.

If you had a list of everybody’s name, and you tokenize that and then use that to link to other data sources, as soon as you got a link, you’d say, “I know the name of this person.” We don’t allow those kinds of linkages to occur except under strict review. We also do other reviews to make sure that, even after you’ve linked the data, it is no longer re-identifiable. That’s a fundamental piece of the puzzle.

To your second point, how does an organization reduce their liability or risk if somebody were to breach their system and get access to this data? Obviously, if you have lots and lots of research data sets that are lying around that have identifiable information, the more identifiable information you have, the greater the risk. If, however, you have those data sets that have been de-identified, but it’s still possible to link them together even within your own institution, there are organizations that use that as a way of helping mitigate the risk around research data and still make it useful to people, because it’s not as if you’ve de-identified it and now it can only be used for one purpose. You can de-identify it, but by making sure you’ve got those tokens, you can still then reassemble different kinds of data sets for different purposes as long as you’re being very careful that the risk of re-identification remains low.

If FDA receives tokenized data that requires urgent follow-up with individual patients, would it be possible for them to go back to the contributing source?

If it’s your data, if you’re a provider and you have data within your electronic health record, you can maintain a look-up table that will have the patient’s identity, your medical record number perhaps, and the token assigned to that as well. But that would be something that an individual hospital would maintain and it would never become public knowledge. So the short answer to your question is, absolutely, if the FDA said, “There’s a safety concern, and we’ve identified within this population that there are specific patients that we need to reach out to,” you can go back to the contributing hospitals and you can ask them that question – “We have some folks, here are their tokens, can you help us identify who they are?” If that organization has maintained that look-up table, then yes, we can get back to those things for those safety needs that the FDA or others might have. That look-up is not something that Datavant does. That would be something that would be within the purview of the owners of the data.

Is there a consistent de-identification method that is being used by all these companies, EHR vendors, and even providers themselves who are selling de-identified patient data?

We take maintaining the de-identification of the data pretty seriously. We provide the ability to remove the PHI and to add in the tokens. But you can imagine, you might have one dataset that is perfectly de-identified and another dataset that is perfectly de-identified, but when you combine them, you increase the risk of re-identification.

Suppose the first dataset has specific diagnostic information and the second dataset has specific geographic information. You combine those two and you might say, we have a geographic area in which there’s only a single diagnosis of this particular disease. That becomes highly re-identifiable if somebody connects some of the dots. De-identification, in and of itself, doesn’t necessarily mean that it can’t be re-identified when combined.

For folks who have complex data or complex linkages, we always recommend expert determination, which is a statistical approach to analyzing the risk of re-identification. You can run a series of algorithms across the dataset that can tell you that you have too much geographic specificity or diagnostic specificity. Given the kind of study that you’re trying to do, maybe we need to aggregate this at a less granular geographic area so that you can still ask the questions that you want about the details of a particular diagnosis. That expert determination is a way of assuring, even if the data has been de-identified or linked to other data sources, that you remain compliant and that the risk of re-identification remains low with those datasets.

What kind of expert performs the expert determination?

There aren’t a lot of rules out there around this. A provision within HIPAA says that expert determination is the statistical approach that has a low-to-no risk of re-identification. Typically, you have academicians who are doing expert determination. It’s really about controlling the release of information in a way that has statistical controls around it. There are companies that do this.

Within Datavant, we have a firewalled relationship with a company, Mirador Analytics, that does this expert determination. They work essentially independently when it comes to the expert determination effect. But it’s offered as a service so that people who are doing this tokenization and then linking have the ability to then, in an efficient manner, determine whether there is a risk of re-identification. There’s a whole host of folks that are out there, from academicians that have a shingle and they do a good job of this, to an organization like Datavant that provides that as a service to folks who use our tokens.

You’ve seen healthcare grow data-rich going back to your days working on Meaningful Use. What issues remain on the table for using the wealth of data that is suddenly available?

The Institute of Medicine had a series of articles going back 10 or 15 years — I think it predates some of Meaningful Use work I did at ONC and has has continued since then – describing this notion of the learning healthcare system. To me, that is a societal goal that I would love to see, where every interaction that a patient has with our healthcare system becomes an opportunity to learn how to take care of the next patient, and the next patient after that, in a better way.

There’s a whole host of problems that we have to overcome to get there. One of them that Datavant is addressing is that when your data gets fragmented and you want to get that longitudinal record, is there a way you can do that that preserves a patient’s privacy?

We have got lots and lots of regulatory frameworks in which your data is used. If you are a student and download your student healthcare record, combine it with your electronic health record information, download it to your Apple Watch, and then use that information on your Apple Watch to support a clinical trial, you will have traversed five different regulatory frameworks. People tend to think that if it’s health data, it must be covered by HIPAA, and that’s not the case. For the data that is in an app or that is part of a commercial venture, it’s that 80 pages of stuff that you just scroll through and you click OK because you want to be able to use the app that defines what they can do with your data. One of the things that we’re going to have to address is getting a consistent way in which we address privacy.

The last thing I’ll say about that is that because there is this notion and there are some concerns that data that is outside of the healthcare environment may need some additional protections that the FTC or that Common Rule or whatever doesn’t necessarily cover, we are seeing a lot of states that are starting to come up with their own privacy rules about how health data gets managed. We run the risk of having inconsistent definitions of what de-identification and expert determination is, and that’s going to create a tremendous burden on the industry and it’s going to create potential holes in which patients’ privacy could be otherwise compromised.

As we begin to solve these technical problems, there becomes other kinds of problems that come up. Keeping consistency across all of the different states, as well as integrating the different frameworks that we have, even at the federal level, becomes important, because if we’re going to use data in this learning healthcare system, we need to have consistent, reliable, and effective means of making sure that patients’ privacy is protected and done in a consistent way.

HIStalk Interviews Clement Goehrs, MD, CEO, Synapse Medicine

Clement Goehrs, MD, MSc, MPH is co-founder and CEO of Synapse Medicine of Bordeaux, Nouvelle-Aquitaine, France.

Tell me about yourself and the company.

I’m a public health physician. I have been involved in a lot of research. I was a researcher in biomedical informatics, first in France and then at Stanford University. I returned to Europe, where I co-founded Synapse Medicine with another physician. Synapse is improving medication safety and helping clinicians achieve medication success. We help physicians, pharmacists, nurses, and patients with prescribing, deciding what drugs to take, and how to take them. We provide reliable information on drugs.

How does your offering improve on existing technologies such as as point-of-care drug information, clinical decision support, and order checking?

As a physician and in talking with my colleagues, we were aware of clinical decision support inside the EHR and various resources online. But we came to the conclusion that for a good number of people, it was frustrating to use these tools. They aren’t always up to date, sometimes you have to use several different tools to get your answer, and it can be too time-consuming. As a result, it was not really used. If you ask a pharmacist or physician if they love the clinical decision support tools that they have, such as those found in their EHR, most of them will answer that they don’t use them and aren’t even opening them because there are too many alerts and too many things in the EHR.

We want to improve on that in two ways. The first improvement concerns the content itself, by providing information that is always up to date. We do this using algorithms. It’s using a lot of natural language processing that goes through all the guidelines from the FDA continually, every day and every night. The algorithm processes all the documentation regarding how you should use the drugs and builds a huge knowledge base regarding drugs that is always up to date. The content part ensures that you always have the best-in-class information and that it is always up to date.

The second way that we are trying to improve these tools is by displaying this information in a good way, not just a long list. We have developed software and components are used as standalone products or plugged directly inside the EHR to display drug-drug interactions, side effects, and contraindications in a way that is super easy for the physician or the pharmacist to understand.

How does the EHR integration work?

We are Europe based and we have completed a number of integrations with basically every major EHR. We see a similar context for EHR integration in the US and Europe, where a number of leaders say they want to interoperate with startups, but in reality, we see a lot of resistance. You have to find ways to do deals and motivate them to do their part and do the interoperability work.

We are just entering the US market. We are working with Vanderbilt University Medical Center and Brigham and Women’s Hospital in Boston. We are in the process of integrating with Epic, but for the moment, just inside these two hospitals.

The study description says that pharmacists on rounding teams will use the system. What does that look like and what results do the organizations hope to achieve?

The use case is for very complex patients. Let’s take a patient who is on 15 drugs for several comorbidities. You want to do a complex medication reconciliation. It’s complex because this patient has a regimen of 15 drugs and you want to determine what the best possible medication history is. You need to check for side effects, drug-drug interactions, and contraindications. 

As a pharmacist using our tools, you would log into our app on synapse-medicine.com. You are getting all the information on the patient and the medication history from Epic, because there is interoperability. You are going to do first a complex medication reconciliation, where you will have a visual representation of the different sources of information regarding the patient’s current drug regimen.

Let’s say you have one set of information from Surescripts and another set of information from the main caregiver or the nurse. Using the software, you can compare the different sources of truth for this patient’s medication history. As the pharmacist, you’re going to choose which source of truth you want to follow for each drug, and you are going to complete the best possible medication history. Then you are going to go through a complete pharmaceutical analysis. Our tool is going to give you insights regarding drug interactions, managing side effects, and managing contraindications, so that you can write the best possible prescription for this patient at discharge. Lastly, you are going to be able to automatically generate the necessary documentation for the patient and their care team as a record of their treatment, along with any changes that were made and why.

Your website mentions the platform’s use in telehealth. How would those providers use it?

That’s a cool story. Three years ago in Europe, just before COVID-19, there was a growing number of telehealth companies. Basically every single one of them was building their own EHR for their providers. A number of them came to us saying, we want to improve our EHR. We want to have a best-in-class clinical decision support system for prescriptions. We want to improve patient safety inside the EHR.

These were young companies that didn’t have the resources to integrate drug databases and for build the complete system that they needed. We came to the conclusion that we would be able to help them by creating components. It’s not just an API, but rather like an API with a UI on top of that. You write one line of code and you can import them inside your tool.  We created an entire library of components. We have, for example, a drug-drug interaction component, a side effect component, and a number of other front-end prescribing tools.

The value proposition here is for a young telehealth company or a more mature one that wants to improve the EHR for their provider. You can easily integrate this library of components, and in less than one or two days, you can improve the entire clinical decision process for prescribing by adding the components that your prescribers need. That’s how we partner with telehealth companies. In Europe, we are the leader in prescription assistance for telemedicine and telehealth.

Can it support pharmacovigilance and reviewing a patient’s profile for opportunities to de-prescribe?

Our objective is to save as much time as possible for the provider in the case of a 12- or 15-drug regimen. This means also to consider de-prescribing. Our business model is constructed so that we are not incentivized based on the number of prescriptions, because we want to advocate for fewer prescriptions and de-prescribing.

When it comes to pharmacovigilance, we are trying to close the loop . You and I have been talking about prescribing, dispensing drugs, and reconciling medications, so let’s talk about patient information and that last item of pharmacovigilance. In that way, you’re closing the loop for the entire pathway of a drug after commercialization. In terms of pharmacovigilance, we’ve been working with the French FDA on a tool that saves time for the people in charge of assessing side effect reports for their level of severity and classifying the side effects.

This solution is driven by the same technology. It uses natural language processing. It can interpret the side effect reports very efficiently. For example, let’s say a patient says, “I took acetaminophen this morning and then I felt lightheaded.” The tool will understand everything that is reported and will recognize the side effects to make a first assessment of the severity of the case. Subsequently, a pharmacist and a physician can just say, “We think the technology made a good assessment” or they can correct what the system has been doing.

This is already up and running in France nationwide for all declarations of side effects. Every single side effect reported in France goes through our system first, and the initial assessment is made by Synapse.

How are you working with First Databank?

We are just starting our collaboration. We will see how it evolves. There is a lot of movement in this space, and First Databank has been trying to do more and more. We have a long history of partnering with commercial drug databases, which may be surprising, but we help them find new ways to ensure that their content is always up to date. On the Synapse Medicine side, we use this commercial database as a gold standard for our algorithm to think, “This is the truth.”

What opportunities and challenges do you see in increasing your presence in the US market?

The key for the US market will be EHR integration. The strategic path that we have chosen for Synapse is to offer a tool that has already been proven clinically. In Europe, our tools are used to prescribe, to do medication reconciliation, and to manage complex regimens like oral chemotherapy. We are directly inside the workflow, which is super important because in healthcare, nobody wants to add another tool. If you are outside the workflow, you will have low adoption and will probably end up with no adoption and die. Or, you do the hard work needed to be inside the workflow.

To do this, it is necessary to focus on EHR integration, and integration with the systems that are already in place. This is definitely difficult. It takes time, but then once integrated, you are there for the long term. This is exactly what we are working on right now with a number of EHRs that are being used for prescribing.

HIStalk Interviews Bill Grana, CEO, HCTec

Bill Grana, JD, MBA is CEO of HCTec of Franklin, TN.

Tell me about yourself and the company.

I started my career as a lawyer with the largest for-profit health system in the country. Since then, I have been a tech entrepreneur since for close to 30 years, mostly in software. HCTec is my first stint in a pure services business, but I have run enterprise software companies that had exposure to healthcare.

HCTec is a 12-year-old, Nashville-based IT services firm that is focused exclusively on the healthcare provider sector of the market, so hospital systems and other providers. Our people have specialized skills in different areas of healthcare software and technology. They provide services according to the needs and circumstances of our clients.

What is the labor dynamic in healthcare today?

It is fascinating on one level and maybe terrifying as well, depending upon your perspective. A lot of what you see in the media centers around clinical labor and staffing challenges, which continue to be significant. But I would say that those challenges also extend into non-clinical areas of healthcare, including IT. The great resignation has changed the workforce of our clients. Certainly in compensation, where there has been significant wage inflation over the last two years. We’ve seen that within our own business and with our clients as well.

The dynamic of remote work certainly has had a big impact. In certain type of roles, remote work is here to stay. For those that require of face-to-face interaction and collaboration, hybrid is the model. For many of us, I don’t necessarily see a full-time return to the office the way that it was before the pandemic. As the leader of a business, I’ve had to adjust my thinking. I’m very much a face-to-face type of person who feels that teams are most effective when they can be face-to-face on a regular basis. But I also recognize that the world has changed, and so leadership thinking has to change as well relative to the work environments of our team members.

How will your business change as your clients increase their use of remote work?

I would have expected more of a transition, or at least an increase in the level of open-mindedness, over the past couple of years to outsourcing certain functions within our clients’ IT organizations.  We are seeing that in certain areas, particularly the help desk and service desk arena. But many others that are necessary but not strategic are ripe for partnering with a firm like ours. Because of our scale and focus, we can typically do those functions at a lower cost and a higher level of quality. 

Application support around the enterprise EHR would be one area. The daily care and feeding and maintenance that is required of an enterprise EHR is a perfect opportunity for outsourcing. PC and desktop support is another arena. Provisioning applications, and system provisioning, is another area. We aren’t seeing that trend develop the way that we would have predicted and continue to predict, so that’s an interesting dynamic.

How much business impact are you seeing from Epic’s move to Hyperdrive?

Hyperdrive is the move to a pure browser-based interface. We have seen some opportunity from that, but not a tremendous amount.

What types of consumer-facing technologies are providers considering?

Obviously telehealth, which the pandemic really catalyzed. Usage is down, but still much higher than what it was pre-pandemic. I think it’s fair to say that telehealth is here to stay, certainly for certain use cases. 

Patient portals are playing an even bigger role in how health systems give the patients what they want in terms of access to their information and scheduling and that sort of thing. We’ve seen a huge demand on the help desk side for patient-facing support, much of it related to supporting patient portal applications. We’re doing some remote patient monitoring support as well. As we look forward five years, we think we will be doing a lot more of that. We all know that technology doesn’t always work as designed, and sometimes users don’t understand how to use it and need channels to reach out to get the support that they need.

How has system training changed?

Training continues to play an important role in the ability of users, whether clinicians or patients, to take advantage of the technology that’s in front of them. Most of the patient-facing technology is fairly simple, but depending upon your demographic and whether you grew up with smartphones and computers, training is critical.

How will support needs change as systems are more widely rolled out to patients and caregivers in homes?

That is happening as we speak. Within our help desk capability, we have a specific offering and specialty geared to patient-facing support, recognizing that there are some nuances and differences to how you support a patient end user versus a doctor or non-clinical provider user. The support experience is always important, but for a patient who is calling in or chatting in, that experience is even more important. These are the customers of the health system and their experience with the clinician and the care they receive is obviously critically important, but the experience that they have with supportive technology is equally important. 

Some health systems understand that very well and deeply. Others are getting there with their thinking. We are huge believers that patient experience is critical for these providers, and that isn’t just about clinical care, that absolutely is about their experience with the technology that is being put in front of them.

Several big health system IT and revenue cycle outsourcing deals were signed in the past couple of years. How will that trend progress?

Financial stress is a driver. We are seeing that play out in real time right now, with half or more of health systems operating in the red, partly because the cost structure and partly because the of the revenue side. I’m not sure that things are ever going to return to normal, at least with respect to the cost structure of both labor and non-labor related items. That will force systems to think differently about how they do labor resourcing in certain areas.

Back to my comment earlier, health systems don’t necessarily have to build large organizations of IT professionals to be effective as an IT organization. There are plenty of opportunities to outsource aspects of IT, those things that are necessary but non-strategic or where it’s hard for individual health systems to build real competency. Part of this is a bias, because it’s a big part of what we do, but I believe that there is going to be a trend to more outsourcing within hospital IT functions. It’s going to be more surgical in nature than if you look back 15 or 20 years ago, where there was wholesale outsourcing of IT functions. It will be limited to certain aspects of a hospital’s IT organization.

What are health systems doing strategically after putting plans on hold for the pandemic?

We have a lot of dialogue occurring around help desks and service desks, and much of that around patient-facing support. The pandemic also spurred the notion of patient-centered thinking and the related technology investments that support that. The shift out of inpatient settings and their heavy fixed assets and into light asset settings — with the home being the lightest that you can imagine — is a big trend. That is creating opportunities for us, both on the staffing side as well as the outsourcing side.

What will the company’s strategy focus on in the near term?

In the environment that we are in, it’s important to have a long-term vision. It’s hard to do strategic planning much more than a year or two out given the amount of uncertainty that exists. We are heavily focused on our own team and making sure that we are positioning ourselves as an employer of choice. We have seen some turnover in parts of our business that is higher than we have ever experienced, and we are not alone in that. But we think and talk a lot about how to source new team members for our business more effectively, how to train them to be successful in their jobs, and how we continue to make HCTec in an attractive place for them to stay.

Interestingly, pay is typically not the most important thing. We are finding that the most important thing for keeping people is around is to define clear pathways from a career and professional development perspective. 

We made an acquisition in July 2021 of a company in Winston-Salem, North Carolina called Talon Healthy IT Services. That was a fantastic acquisition for us. It bolstered our capabilities in the help desk arena, but also gave us new capabilities in the ambulatory and smaller provider space, where we have the capability to be the outsourced IT function for those providers. We are continuing to look for other complimentary businesses to expand our service portfolio and to increase our market presence and footprint. That’s a big part of our strategic focus, and where I’ve spent a lot of my time.

We are now back to where we are actually seeing our clients in person after a two-year hiatus where not a lot of that occurred. We are staying close to our clients; looking at their demands, needs, and opportunities within their organizations; and making sure that we are delivering high quality services and staying ahead of those needs.

HIStalk Interviews Guillaume de Zwirek, CEO, Artera

Guillaume de Zwirek is founder and CEO of Artera of Santa Barbara, CA.

Tell me about yourself and the company.

I founded Artera seven years ago. We recently rebranded from Well Health. I had never been in healthcare before I founded the company. I was going through a personal experience with cardiac issues and had a really frustrating time interacting with all of my care providers outside of the four walls of the hospital. The question kept coming back to me — why is healthcare not amazing at customer service?

I founded this company with a simple mission, which is to make healthcare the very best industry when it comes to customer service. I came into it with a lot of naiveté and ignorance. We spent seven years thinking about how to build an effective patient communication system for hospitals that is open; that allows every vendor to deliver its interactions through that platform; and that allows health systems to control the flow, rhythm, and prioritization of their communication so they can have an effective and convenient relationship with their patients.

Is it harder in healthcare where health systems have a large volume of customers but see them infrequently and often involuntarily?

Healthcare is complicated for good reason. It’s protected information, and we want to be sensitive to the privacy of patients and their medical records. There are a lot of stakeholders, even within the hospital. You have your primary care doctor, specialists, labs, pharmacies, clinical trials organizations, payers, and employers. Those parties are are all competing at some point in time for the patient’s attention.

There isn’t a library of five care journeys. This isn’t like an airline, where people are only booking one-way flights, return flights, or getting connecting legs. An infinite number of scenarios could happen for a patient, which makes this so challenging,. Then you layer in all of the ecosystem of vendors who are all trying to help make that experience smooth. When you think about streamlining that communication, that’s a lot of people to consider.

Health systems will have different ways of thinking about the priorities. That’s what we’re trying to solve. How do you consider all of those voices; bring that and surface that to the hospital in a way that is easy to manage, control, and manipulate; add and remove players; and then have that experience feel completely seamless to the patient? We are largely SMS, but the dream is that you are on your phone, your doctor is saved as a contact, you have an issue, you send a text, you get a response back. Whether that response is automated, a human being, a PA that reports into a physician, I’m indifferent to that as long as we get the right answer to the patient every time in the medium that is most effective to them.

If I can just share a quick story, this came to life for me last week in a wonderful way. I got a call from one of our customers with a story. This customer, their population, is rather elderly. They skew probably 70-plus. They had a patient who had a fall and they were wearing an Apple watch that had their emergency contact saved as that hospital. When the new Apple Watch detects a fall, it will text your emergency contact. That text hit our system, a staff member saw it right away, and they got in contact with the family and arranged emergency services for that patient. There are so many scenarios like this one that we haven’t considered yet. That’s what makes this complicated, the infinite number of scenarios and players.

Amazon has set up its own personal monitoring program that is linked to Echo devices. Could a user’s preferred health system replace a third-party call center as a local first step for medical issues?

I had never thought of that, and I think that’s a very logical assumption. My wife works at Google and she just got a pamphlet in the mail for a 24/7 urgent care service where you can jump on the phone, and within two minutes, somebody’s on the other end triaging you. That’s actually driven by the payer, circumventing the health system that she would normally go to. The same thing could apply in this Apple example or Amazon with Echo.

It will be interesting to see where they start. If you can be that first point of contact, you have tremendous influence over where the care gets delivered. If that care is acute, if it’s a specialist type of visit, that’s where the money is made. It could be a big threat to hospitals.

My personal opinion is that competition is great and we should all challenge ourselves to do better. At my core, I believe in the physician-patient relationship. I believe that to be thoughtful and proactive about your care, you have to have a relationship with your PCP. You need to feel like you’re disappointing somebody and somebody has your back if you don’t adhere to directions.

I’ve been using the gym more regularly for three months. I went to see my PCP and he said, great news, your cholesterol has dropped 50 points, what changed? I said that I had started going to the gym. Now I’ve kept it going and I think of him every time. Maybe that’s just me, but I believe that when people have a great relationship with their PCP, they never leave, kind of like the dentist. That’s who our energy is going to be focused on serving,

How does a health system define their customer when people move around, change insurers that take them into or out of network, and perhaps don’t want to hear from providers until they have an acute need?

There’s a whole market around that with population health. Many companies are tackling who to reach out to and onboard, how to bring panels into the system. That’s why the relationship outside of that visit is so, so important. I texted my PCP to see if I could get the third booster, for example. There are so many opportunities for the physician to engage with you, or for you to engage with them, outside of the point of care.

When you think about the younger generation, if you can create that relationship with the parents, many children will follow in their parents’ footsteps. I hope that there doesn’t have to be an art of engaging this lost population who never got care. COVID may make that necessary for us to catch up. I hope that we can build those types of relationships from birth and it can be a habit that is sustained throughout a patient’s life. I hope that’s the norm that we can get to as a civilization.

We don’t expect to have a telephone conversation with an actual human employee when we need to interact with a big company like Amazon, where most communication is via an online form, email, or other electronic message. How has that expectation affected healthcare?

Access is good. The mode of the day may be messaging, but it will undeniably change. You see this with connected devices. The example you just highlighted presents an interesting opportunity for health systems and providers. These big tech companies are actually going to a further extreme, which is attacking the labor problem. They want to optimize, they want margins to go up, and they have started making everything automated.

I had an issue recently with a ride hailing service. I called the company and couldn’t talk to a human being. It only gave me automated menu options. I went through it five times just to keep saying I was dissatisfied. I wanted them to know five times that I was dissatisfied. There’s an opportunity for health systems to give real human care and not over-rotate the way some of these big tech companies are doing because of pressure from the public markets. It’s an interesting thing to explore. I’m going to bring it back to the team.

Who within a health system defines the messaging to customer personas that include both active patients as well as potential ones?

In the seven years since we started this company, this has changed. Seven years ago, it didn’t exist. There wasn’t anybody making those decisions. People were thinking about how to make sure patients show up to their appointments. It was a very specific point in time with the acute problem of making sure that we don’t have wasted slots. There’s more and more competition for the patient’s time right now, and there are more and more people who want to engage with a patient. 

The role that we have seen come up increasingly is chief digital officer or chief patient experience officer. They may be VPs or SVPs. Maybe the most famous example of this is Aaron Martin when he was at Providence. Right now, he’s at Amazon, going back to one of your earlier points, which should probably make us a little more scared of Amazon. I have seen the role of chief digital officer that focuses on end-to-end patient experience. Cedars-Sinai has a similar role. We’re seeing this more and more, and we are also seeing a lot of folks outside of healthcare being brought into these roles, pulling from places like Disney and AARP and other brands that have done a decent job of building those relationships with their customers. I like the trend and I hope it continues.

Was it a big change for EHR vendors to open their system to third-party applications? Do you expect further EHR integration developments?

There were couple of announcements recently. You wrote about this, with Larry Ellison at Oracle Cerner making a big push around partnering and saying that partners were really important to them. I love to hear things like that. It warms my heart. Epic has done a lot of work with their App Orchard, and they’ve announced a lot of enhancements to that program. That significantly expanded the APIs that are available. We have a close relationship with Oracle Cerner and Meditech as well, and we have seen them be open in terms of data sharing. It certainly is moving in the right direction.

With the interoperability that just went into play, there was some disappointment by a lot of folks in the space that it was pared back a little bit. There’s a lot of hoops that we have to jump through in healthcare. Even when we think about these feeds, APIs may cover 20% or 30% of the use cases for a vendor if you’re lucky. For the remaining 70%, you’re doing custom HL7 or going to FHIR or Interconnect web services.

That stuff is custom, and it rarely translates from customer to customer. That makes it significantly more complicated. It’s not like an app in the App Store, where you deploy it to Apple and anybody can download it. It requires an implementation. There’s a whole industry in healthcare around professional services and consulting firms that do this for a living. So we are definitely going in the right direction, but we are nowhere near where some other industries, like high tech, are.

A lot of technology adoption happened during the pandemic. As we try to find the new normal, how will that experience be applied?

I have this belief that in the universe, everything has to balance out at equilibrium. This is true for politics, relationships, you name it. Everything needs to find its balance. Things went off balance during COVID. What I’m seeing now is that we are going to shift to the other extreme, and eventually, we are going to find the middle ground. There was really quick adoption of lots of different forms of technology, purchasing cycles, and shortened deployment cycles. We solved problems very quickly.

I’m hearing more and more about consolidation. What does my EHR do? How much of this can I bring back to the EHR? I think we will see a significant paring back of the ecosystem of vendors that provider organizations maintain, along with a shift towards bringing things to the EHR that can be brought to the EHR. We will probably go to that extreme a little too much, and it will likely be a year or two before we find that balance again, where the EHR continues for those core investments and the truly additive things get prioritized and integrated and built on top of it.

How does the market for innovation look if EHRs replace some of those third-party applications and health system consolidation creates bigger but fewer prospective customers?

There’s a famous saying in Silicon Valley that down markets are where the best companies are formed. That creates pressure and forces entrepreneurs to the right places. If a health system can get “good enough” from their EHR, they’re going to go with that. Innovation will need to be unique, differentiated, and tough to replicate. It will do a good job of weeding out the possible solutions in the market, which could be good for healthcare IT overall. In the markets, it will look like investment dollars are slowing into healthcare IT. It will look like fewer purchasing decisions and like more consolidation. But the very best companies will form out of that pressure.

It will be net positive, but it will feel rough for a while. It may hurt health systems that adopted a lot of those technologies during COVID. Some of those technologies may disappear because the company goes out of business or is gobbled up by somebody else. It’s more important than ever to provide differentiated value and to understand the problems du jour of our customers, because they are very different than they were during COVID. It’s a totally different set of challenges. Now it’s labor shortages, labor costs, and margins. We see this in the news every day. We see a tremendous number of layoffs despite a really strong jobs market. It’s a confusing time.

What will be the direction of the industry and company over the next three or four years?

We absolutely have to be added to the EHR. We need to work with the big EHR players, understand what they’re going to tackle and what they’re not going to tackle, and fill in those holes. We need to pair that with what our customers are telling us they need, that are must-dos for them to get through this. It will  be a dark period for the next couple of years. 

We believe in creating an open platform. It will be important to create and invest in our infrastructure so that anybody in the healthcare IT space, any vendor, can route communications through us. I’d like them to be able to do it with no friction. Plug in to Artera once and you can send communication to any of our healthcare partners who enable you.  That’s where we need to get to. We need to create that network. That will create a lot of value for healthcare IT and health systems.

HIStalk Interviews Mike Alkire, CEO, Premier

Mike Alkire, MBA is president and CEO of Premier of Charlotte, NC.

Tell me about yourself and the company.

I’ve been in my role as CEO for the better part of a year and a half. Premier is an evolving business and has been an evolving business in the 18 years I’ve been here. We started as an organization that was focused on supply chain cost reduction and healthcare system quality improvement. We’ve morphed into doing those two elements plus many other capabilities, including standardizing the way that clinicians practice and pharma and med device looking at utilizing our capabilities to help them in real-world evidence studies and in identifying patients for trials.

We created a couple of subsidiary companies in the last few years. They are focused on helping our healthcare systems as they think through new revenue models and are working more closely with the employers in their market. That’s our Contigo Health initiative. We also have an initiative called Remitra, which is all about e-invoicing and e-payables.

Everything we do and contemplate doing is about helping healthcare systems become more efficient, using technology to reduce labor usage and to help them generate more revenue and more profitability.

How can technology make the health system supply chain more efficient?

During COVID, we stood up a coalition of all of the suppliers and distributors of PPE, personal protective equipment. Then we melded that with HHS , FEMA, CDC, and FDA. Because what became painfully apparent in March 2020 was that the federal government didn’t have a real good idea of the location of products to protect caregivers. We quickly stood up that coalition and started getting some traction on getting access to product and getting that supply chain up and running. We understood the utilization patterns of PPE in New York. We used some AI and machine learning capability to forecast from our data as well as the Hopkins data on the progression of COVID. Then we layered our utilization patterns on top our models so that we could help health systems determine the amount of product they needed.

That was important, because everybody was in the market at the exact same time looking for product. That was driving up the cost. Everybody was trying to stockpile against those that actually needed the product. We needed to bring some sanity to that madness. We developed that technology. Some federal agencies are looking at it today as something that they might want to continue to use going forward.

Another element is labor extenders. It’s amazing that 75% of healthcare invoices are still paper. Or focus is to use technology to automate that or digitize those invoices. We have some pretty cool advanced optical character recognition capability and some machine learning capability to make that more effective. But the point is that this invoicing and payment function is still fairly antiquated, and our goal is to bring that up into the 2020s as opposed to being something that has existed for 25 or 30 years.

We are also looking at products and drugs and the outcomes associated with those. We’re so much better at that with our acquisition of Stanson Health. Writing standards of care in Epic, Cerner and Athenahealth that are based on data, how the patient presents themselves, and lab values and other screens is critical. That will evolutionize healthcare. We want to continue to proliferate technology like that all throughout the healthcare system.

You launched Contigo Health three years ago and it recently made a big acquisition of contracts and technology. How is that business doing?

It’s going incredibly well. Thank you for asking. It is meeting its growth profile. Health systems are obviously under a great deal of stress and pain, struggling with high labor costs and supply cost inflation. We are creating new models for them to get access to revenue that maybe they hadn’t had access to in the past. 

Contigo is just one of those ways to do that, to help build plans and capabilities so that health systems can go directly to employers, both in their market and at a national level. That program is doing really, really well. We continue to build the high-value network of health systems that provide care to a significant number of large national and international companies. We bought a third-party administrator a few years back for the centers of excellence programs that most advanced employers or innovative employers use, so that when folks need a knee or a hip done, they can be sent to a national center of excellence. The TPA supports that function.

As you said, we recently ran an acquisition of an organization that has access to a 900,000-provider contract. Our healthcare systems that have health plans can leverage a wrapper that is very economical and has a number of providers who can fill the needs of those health plans outside of the region of where that care is being delivered by that provider. We are excited about the direction that Contigo is going.

Will health system consolidation continue to the point that we have just a dozen or two regional and national health systems?

It’s tough to tell. They are battling against the sheer scale of health plans. Optum and UnitedHealth Group have $500 billion in market cap. You have Anthem, Aetna, and Cigna with market caps of tens or hundreds of billions of dollars. Then you look at the health system, HCA being the largest at $60 billion. It’s a huge issue in access to capital. Do you want our health system being innovated by the providers, or do you want it being innovated by the payers? These health systems are trying to create enough scale to bring a bit more balance against the payers on this.

I don’t necessarily have a prediction in terms of what large health systems will look like. I think you’ll have a lot of regional health systems and then still have local health systems, because those communities have specific needs to the point that they will probably need to remain independent, especially as healthcare continues to move outside the four walls of the hospital.

The way that we will look at health systems in 20 years will be much different than today. We have these big acute settings, non-acute settings, clinics, physician practices, rehab, labs, and all those kinds of things. But health systems are trying to move as much into the community as possible. That means trying to figure out ways to lower overall variable cost and fixed cost. The way that care will be provided in the future is going to be dramatically different, and advanced technology will be needed to help drive that transformation.

Optum is hiring a lot of physicians and buying practices, and at the same time, big retailers could be planning to cherry-pick the most profitable parts of the health system business. How are health systems responding?

When you have well-capitalized companies getting into any space, you’re always going to keep an eye towards that. Our interest, and that of many of our health systems, is to figure out ways to partner with those entities and help them meet the needs of what they’re trying to accomplish. That’s one of the reasons that Contigo got started. It was driven by Walmart trying to figure out ways to get more value for their healthcare dollar. I don’t think this is going to go away. With the rising cost of health insurance, you will see employers continue to look at unique models. We want to be there with capabilities, services, and technology to help them as they transform their healthcare costs.

How is the data connectivity between health systems and life sciences companies changing?

The most important aspect is data security and data protection, making sure of de-identification capabilities and using things like avatars to represent people. Those will be essential in research going forward. That scale will be important. That pharma or med device doesn’t have the ability to reach out to 5,000 hospitals, so scaling all that data and technology is going to be important.

How you consume the data and serve it up will be important in the future as well. Everybody will have different needs in terms of what they’re trying to consume from a data standpoint. You’ve got people in the middle of trials, you’ve got real-world evidence studies, you’ve got off-label utilization of products, you’ve got identification of patients just because of the need for more heterogeneity in these studies and those kinds of things. It depends on the prevailing needs. But the most exciting thing is that technology is coming to a place where we can meet all those challenges just because of a lot of the work that has been done over the last 10 years.

How do you see the business environment playing out over the next two or three years, especially for smaller companies?

It is incredibly important to have strong ROIC, return on invested capital. We want to have nice return for our shareholders and to drive our EBITDA and our cash flow and those kinds of things. Those are the most important parts of a business. When you launch new businesses and you’re making investments in those kinds of things, you have to make sure that you have the right plan in place and that you are getting the right level of returns. Organizations that have great ideas, a strong history of delivering ROIC, and a strong history of delivering performance will generally do well going forward.

The other side of that, as you were talking about it from an investor standpoint, is that it is even more important that we are creating offerings that can show short-term, mid-term, and long-term returns for our customers. It is no longer the day that you’re implementing something that will provide a a return in a year. Health systems are under such duress. You have to be able to walk in with options, services and technology that will help you drive results very quickly. Then, as much as possible, get a lot of that information and insights embedded into the electronic medical record so that you have long-term sustainable improvement as well.

What will be important for the company over the next three or four years?

A couple of things will be critical for us. Even with market’s labor factors being the way they are, this is all about getting great talent into the organization. Recruiting great talent is so interesting. I had a conversation with a student in an MBA program that is top five in the world. I was impressed with her and asked, “Where are you thinking about doing your internship, Google, Apple, or Amazon?” She said, “Yes, I’m considering those because I’m really interested in what they’re doing in healthcare.” I said, “One of the things that we think is unique about Premier is that we truly understand healthcare and have been building incredible technology capability over the years, as opposed to a great technology company that is trying to understand healthcare.” Getting access to great talent is going to be really important.

I constantly challenge my team. Are we continually pragmatically innovating? How are we taking the platforms that we’ve created and creating those next layers of innovation? We’re doing some amazing things using a artificial intelligence, machine learning, and natural language processing.

The sky is the limit for us. Now it’s a matter of getting the right use cases built and getting the right products developed to support our health systems along their journey to transforming the way they are providing care to their patients.

HIStalk Interviews Julie Bonello, Advisor and Former CIO

Julie Bonello, RN, MS is a career CIO who is now offering advisory services for integrated care delivery models.

Tell me about yourself and your career.

I began as a pediatric intensive care nurse. I got my bachelor’s at Rush. I also had an art background. I went into research after that, and I found through using all the statistical packages that I was interested in computer science. While I was still in nursing working in research, I completed my master’s in computer science.

At that point, I jumped into health IT and then went into consulting for several years. I became a CIO in 1990 and have had five CIO positions throughout my career, mostly in the greater Chicagoland area, except for recently with Presbyterian Healthcare Services in Albuquerque.

Did your nurse background make your CIO job easier or give you a trump card to play when sorting out priorities?

I guess it was known that I’m a nurse, but I didn’t often bring it out. Not only was I a nurse, but I also had the opportunity to be oversee medical records and rev cycle. Over my career, I had strong operational knowledge. My depth of knowledge in terms of how the business actually operated and how care was delivered was always my greatest strength as CIO and understanding how technology could be used to support the business in a way that didn’t overly complicate and didn’t fragment care. I could speak with the clinicians in a way they could understand.

Sometimes as a CIO or when you’re in IT, you can step into other people’s swim lanes because you are just trying to help figure out how to leverage technology successfully. Sometimes that would happen to me, maybe more so than other people because I understood the operation so much.

How have you seen the CIO role change?

IT has become several areas within a health system. Often you’ll have a digital team. Analytics has grown significantly, so how you divvy up the data side and the analytics side has become important. As you move to cloud, it is important to figure out a consistent IT service model for all IT areas.

As we have parsed out different IT responsibilities into some other areas and as we have also changed our operating model or our IT service model, it is important for a CIO to understand the business, how care is delivered, and health IT. You’ve always had third-party relationships, but now with population health and the move to the greater continuum of care services, many health systems are partnering with third parties that have very different technology platforms. The need to understand how they can all work together simply to improve care is important, as is your relationship with your payers and understanding how your contract strategy impacts your technology strategy and interoperability. It’s very complex and has many stakeholders.

Some health systems bring in technology outsiders who have no healthcare experience, while others prefer hiring C-level IT people who understand the business and how IT can support it. How do you contrast those approaches?

It depends on how you want to structure IT. You can’t leverage technology within healthcare unless you understand healthcare and healthcare IT. If you bring in someone from the outside and make the CIO a technology position, more like a CTO, then you need someone else to help translate how the functional side of your application strategy can meet your business goals. You’re going to have to figure that out. It all depends on how you want to organize all the pieces, but fragmenting IT makes it hard to ensure cost efficiency and consistent service levels while minimizing security risk.

We’ve already seen that with a lot of the technology startups. If they go too far into using technology people without knowing the business or healthcare IT, they’re not going to be able to meet their goals. There’s a balance. You must find out how you can get it all, and there are a lot of different ways that you can do it, but you need to leverage technology to meet your business. To do that, you must understand the business and healthcare IT while driving forward with technology innovation and measuring as you go. Healthcare and HIT is complex.

Health systems have gone from running innovation centers and investing in health IT companies to acquiring and running for-profit companies. What is the impact on the IT department?

There are a lot of avenues that health systems are taking in addition to investing in startups. As someone who has been in the business a really long time, you have to figure out a way to provide healthcare simply. If you can figure that out in a way that you can pull all your partners together into a service model that is integrated and supported by an integrated technology platform that you measure, everyone’s on the same page, and their goals are the same in improving care, then great. But if you’re not all on the same page, then you might not be simplifying care.

How did you, as a C-level health system executive, see value-based care?

I focused on provider-payer integration, leveraging technology for clinical redesign and aligned with the contract strategy. You have a partnership with all your payers. If you design your care, your reimbursement, and your measurement of that and design your contract strategy to go along with that, with your payers included, I’ve seen an improvement in quality. Payer-provider integration is important.

My last three CIO jobs have been focused on understanding payer integration. That can move the needle. Now I will say that often when we design our care and measure our care, it’s not done through integrated clinical workflow with payers and providers together. They’re separate workflows.

What kind of integration or cooperation do you see between health systems and payers?

In 2015 when I was at Rush Health, I was the CIO of the clinically integrated network. The clinically integrated network oversaw the entire contract strategy for the network. We worked closely with the payers on our technology and interoperability strategy. We received information from our payers and then derived intelligence from that. We worked on what was then a rudimentary system to get the derived intelligence back into the record for follow up by the providers and care coordinators.

When you have a feedback loop getting follow up information to the providers and the care team and you’re working on interoperability, bringing information into that record so that everyone has access to it, that’s where I started to see real change.

What are you working on now?

Provider-payer integration, implementing interoperability to support a longitudinal patient record, deriving intelligence from the shared data, and getting that back into the record to improve care. My focus continues to be in these areas because I know it can really improve care. I’ve spent the last three CIO jobs focusing on how you include IT in working together with the business in designing the different governance structures that you need in place and the different service models for integrated delivery.

As we start to think through how we want to provide care across the continuum and we establish new partnerships with new companies, you’re changing the staffing model. You’re changing your care team. You’ve got a lot of different providers, but you need a consistent service model, because your patients don’t understand how you’ve now organized across many different groups of people. You must come up with an integrated clinical workflow and an integrated service design and then ensure the design is built and integrated across the entire technology platform with technology services to manage and monitor across all as well.

Both our clinical/business operating model and our IT operating models are changing. With a shift to cloud modernization, we have new third-party IT relationships, so we are changing the IT operating model, too. A change in the operating model requires new integrated governance, structures, processes. and services to ensure success.

How are you going to manage and monitor that in your health system to do that? Because it’s not just going to be within your clinics now and within the inpatient environment. It’s going to be in your home. It’s going to be all over the place as you establish new third-party relationships. That’s what I’m really trying to do, because I see that there’s more fragmentation now than ever before, and it concerns me. Interoperability or sharing data and getting it into the longitudinal record will be key.

What reflections do you have on your long CIO career and what you hope to see in the future?

I hope to see an integrated care model with a technology platform and interoperability that supports it. When we look at how we manage our healthcare in the future, we will have leaders and management structures that manage across the continuum for all that we are doing for that patient, across all of our partners in the integrated delivery model and ensuring that an interoperable technology platform is managed and monitored across the entire continuum. It requires a more integrated approach across the continuum and one that includes our payers. I think we are getting there.

I’ve been a CIO for over 30 years on the front lines. I’m at the twilight of my career, so I decided to step back and devote my time and expertise in the areas I have mentioned, where I can make a difference. I want to help improve care.

HIStalk Interviews Erkan Akyuz, CEO, Lyniate

Erkan Akyuz, MS, MBA is president and CEO of Lyniate of Boston, MA.

Tell me about yourself and the company.

I’m a software developer by trade. I started in the PACS world, the imaging world, at a small company called Mitra Imaging in Ontario, Canada. I was a developer on a product called Mitra Broker, then did some display work, and from there I went into management.

We started Lyniate as a carve-out of Rhapsody, our flagship product from Orion Health in New Zealand, in November 2018. Shortly after that, six months or so, an opportunity came to merge Rhapsody with Corepoint Health out of Frisco, Texas, and we did that merger. A primary driver behind the merger was being able to provide a more full solution to the market in all the segments, with the ease of use of Corepoint and the extensibility and the multiple platform strength of Rhapsody.

We’ve been running the company in that mode for a while. Earlier this year, we also merged NextGate’s enterprise master patient index solutions into the portfolio. In late July, we also merged CareCom, which is a terminology services provider out of Copenhagen, Denmark, into Lyniate.

What is the current state of interoperability and what challenges remain?

When I started as a developer on Broker in the late 1990s and early 2000s, we had an interoperability challenge. As developers, we used BizTalk from Microsoft. Then Orion came up with Rhapsody. So even 22 or 23 years ago, there was a core technology issue about interoperability and being able to exchange messages between EMR and the PACS systems and the modalities.

In the years that followed, I would say that thanks to companies like Corepoint and then Orion Health, the problem of interoperability has almost gone away. Even though HL7 standard adoption, or its implementation in a standard way, by healthcare was challenging, companies like Corepoint companies and Orion Health provided solutions to make integration and interoperability more efficient.

Fast forward 20 or 25 years. We still have interoperability challenges. They are less in technical nature and more semantic in being able to help people interoperate with each other. Not only to send the right version of HL7 and then receive the right version of HL7 back, but to help a doctor prescribe a prescription accurately. Then on the pharmacist side, to receive that prescription and administer the right pills so that we minimize mistakes and we improve efficiency.

Interoperability issues are much, much less technical in nature. I don’t think that we have the issues of being able to exchange data now, It is more of a multi-organizational workflow. We hear about data blocking or a site that doesn’t want to share data, but that’s an easy way out by blaming the vendor, blaming the EMR vendor, blaming the hospitals, etc. And at times, our healthcare ecosystems — from payers to providers, multiple payers to multiple providers — introduce such complexity that one vendor, one provider, cannot really solve it.

In my view, we need, as a nation or as a globally, better motivation to make data available to the systems without any hassle, without any struggle, so that it can be used in care settings where the data is not produced. If the data is produced in an acute care setting but now needs to be accessed in a social care setting, that should be easy, without many bottlenecks.

Unfortunately today, we sometimes see legal, sometimes affiliation-related, bottlenecks. A social care worker will not be able to get access or even identify where the data that they need for the patient, for the baby or the person they are providing care for, is available, how they can find it, and how they can access it. We need to do better from every angle, every stakeholder in this picture – vendors, providers, and payers — to create a federated environment by providing our data, making it available to everyone who wants to access it. From the consumer side, we need to make it easier to consume this data from federated, basic data suppliers.

What interoperability needs are coming from payers and life sciences companies?

When it comes to technical connectivity, they are able to access the data. But they don’t understand how the data is stored and structured as well as a provider. If you’re a provider, you developed your EMR structure and made decisions about how to store patient data, so you have a very good idea of how it’s done. When you access a different provider, you can’t figure out how to navigate through it. If you are coming in as an outsider, if you have never been a hospital, if you never seen an EMR, understanding this data structure is not that easy.

You are interested in one bit of information. Let’s say you have a clinical surveillance system. You would like to monitor certain diseases, and they are spread in the hospital. Let’s say you are interested in getting a notification every time a patient is diagnosed with sepsis. In today’s world, in order to get that notification, an external party — let’s say in this case, life sciences or device companies — need to have good understanding of how to find the data and create an alert so they can get a notification. Our EMR systems were not designed to create those alerts. They don’t understand it as much.

We need to make accessing and consuming data much easier than it is today. We use money exchange, like ATMs, as our goal internally. Lyniate will be done when exchanging healthcare data is like paying an electric or gas company bill, riding in an Uber, or using Venmo. There are no barriers. You can pay someone independent from what that someone does, in multiple formats — check, cash, Venmo, PayPal, Wires, Zelle, or whatever. These different protocols and mediators are able to move currency. It’s so easy that we don’t even know how gas company accesses that money, but they do it. Unfortunately in healthcare, when a life sciences company is trying to get a imaging data, sepsis data, or clinical trials data, they need to have a deeper understanding of where that data is and how they can get it.

SWIFT’s [Society for Worldwide International Financial Telecommunications] currency exchange protocol is an example. We need to be able to provide services like SWIFT to the multiple providers of that currency — with healthcare data as the currency, and multiple consumers of that currency — without being held to understand too much in the intrinsics of how I keep the cash, how you keep the cash, and how we are going to use it. We need to bring it to the fidelity of the healthcare data and make that easily accessible, independent from the affiliations between organizations. We need to implement a SWIFT-like environment to manage those transactions. I don’t think we are very close to it yet.

Who would lead the charge for a SWIFT-type exchange in healthcare?

I think it has to be a shared effort, but bringing a group together around that solution is going to be difficult. As an example, I really admire how RSNA succeeded as an organization in providing leadership, and then came DICOM. I started my career as a developer in the DICOM world. RSNA came up with the IHE [Integrating the Healthcare Enterprise] idea. Their thing was, we are not going to reinvent DICOM. We are not going to reinvent HIE. But we are going to bring the parties together who are stakeholders to use standards when it comes to exchanging data.

I was a technical representative of my company. I would go to Chicago once a year, where we would spend a week around the table with different vendors and different providers. We would discuss, how are we going to do patient information reconciliation? Let’s say the modality acquired this study and then patient information changes. Which bits and bytes of the standards are going to be used? How we are going to populate it?

IHE and RSNA led this effort to create these integration profiles, saying that if this is a workflow, then all the EMR player actors are going to do this and all the modalities are going to do that. Representatives from vendors, providers, and standards worked together to define how that integration profile will do the job. We changed our code in Connectathons, we tested all that stuff, and it worked.

Today, when you look between the modalities, PACS, RIS, and whatever systems are doing their job, then exchanging data and who’s going to do what, quite honestly, we don’t. But now it’s a system. Every year we have Connectathons. Every year we are testing integration profiles.

They need something similar on the EMR side. Let’s say HIMSS can take this leadership since they’re a strong player. They need to bring life sciences players, device manufacturer players, EMR vendors, payers, and anyone and everyone who is interacting with patient information. How do we do this? What is the integration profile? Are we going to use HL7, FHIR, or DICOM?

Let’s say there’s an integration profile called Accessing Patient Information for Clinical Trials. The life sciences players should define what they need, how they want to use it, and what format they want to consume. The EMR vendors can describe how they can access the data. Providers will offer the legal structure they require.

It needs to be a joint effort and organization. HIMSS may be a good one, or it could be the American Hospital Association. An organization needs to take the lead to pull these players from the different corners and bring them together for a common cause. IHE is a stellar example of how it can be done, and right now, IHE profiles are working like SWIFT.

I did a little bit of research about SWIFT, asking why these competing banks don’t worry about losing – or let’s say “leaking” – customers to a different bank. We always hear that patient leakage makes providers not want to share their data to protect their customer base. I learned that SWIFT is a legal entity and all its shareholders are the member banks who are using SWIFT for money exchange. Every time then there’s a SWIFT exchange, banks pay a transaction fee, and at the end of the year, they basically receive a proportion as dividends. The bank that contributes the most funds into SWIFT receives the most funds from SWIFT at the end of the year.

So in the bank world, they created the SWIFT organization and they own it. There are no third parties. In healthcare, TEFCA may be a good example. Maybe we create an organization like that and mandate it jointly by a membership, a paying membership by the life sciences, payers, and saying that we want this organization to be the SWIFT of healthcare.

Where do you see the company going in the next three or four years?

We put a vision in front of us to implement an infrastructure layer that helps not only data exchange, but also helps manage the identity of data. That’s why we merged with NextGate. Then also to help translate the content of the data so that the consumer of the data doesn’t need to worry about the format the data was stored in and the data itself will be translated for them in the unit that they would like to consume it. We also want to expand it even more than being able to store that data so that our users and other healthcare IT providers like the vendors can access this infrastructure as a platform that they can use to exchange data. Then make sure that the data that they are exchanging is trusted — coming from a trusted party and belonging to the person that they believe that it belongs to — and then interpreting it to the format that they would like. If they would like to also store it more in perpetuity, they can also store it.

Our vision is staying as an infrastructure provider for healthcare interoperability to provide a more multifaceted features, such as what we did with Rhapsody and Corepoint in data exchange, identity management and identity assurance with NextGate, and terminology mapping services in and expanding that even to the coding services with CareCom. We will continue to invest in them and expand the infrastructure based on what we are hearing from our customers.

HIStalk Interviews Luke Bonney, CEO, Redox

Luke Bonney is co-founder and CEO of Redox of Madison, WI.

Tell me about yourself and the company.

I’ve been working at Redox, on Redox, for just about seven years. That’s a long time and a lot more gray hair. Redox is the platform to make healthcare data useful for healthcare’s builders, the people building and scaling healthcare technology.

What have been the most significant interoperability advancements of the past few years?

Our world at Redox is all about how to make healthcare data useful for builders, who to us are the people building and scaling technology and healthcare. We obsess about these people, because through enabling the people who are building technology, everybody will benefit. Patients will benefit, providers will benefit, and you and I will benefit. Great builders build great technology that drives incredible experiences. Those experiences are what drive outcomes. That’s where we need to see meaningful change in healthcare. How do we drive and inspire outcomes?

At Redox, we are constantly obsessing about imagining a world where people can build and scale healthcare technology and be completely unencumbered by the nastiness and complexity of healthcare data, which I know sounds crazy because it is nasty and complex. But we think about a world where with a couple of clicks, people could compose experiences for their users. That’s what we obsess about.

Over the last couple of years, we have continued to focus on healthcare data access and integration. Today, working with Redox means that you have access to existing connections to over 2,500 healthcare organizations across the US and now in Canada. We have integrations with dozens of major payer organizations. We have expanded to not just be focused on clinical data, but financial and payer data, connections into existing clinical networks like Carequality, CommonWell, and a whole bunch of HIEs. We are now connected to 50 out of 50 state public health departments.

We have a lot to be proud of that we’ve focused on in the last couple of years. When we talk to our customers, they say they work with us because we help them focus their engineering efforts and their product efforts on building a truly differentiated product by taking all this nastiness off their plate. We also help them accelerate their sales cycle. We help them get live and implemented faster at all these different locations.

Today, it’s all about data access and integration. As we look to the future of Redox, we will focus on additional problems where we can make healthcare data useful and valuable for builders.

Looking at the industry, I would go to the pretty exciting impact of regulation. I know that might sound weird since regulation is almost always a nasty word, but when it comes to 21st Century Cures, I am definitely in the camp that 21st Century Cures is a game changer, and in a good way. It is definitely not perfect, like any regulation that runs 700 or 800 pages, but it absolutely redrew some of the major goalposts and expectations around healthcare data. The requirements around info blocking and enabling FHIR are good. I think they are incremental. Access is only one component. Standardization and normalization of data are equally if not more important when we think about downstream use cases. We have seen a huge amount of positive change in the impact in the payer world and the payer landscape.

The saying we use at Redox is that what Meaningful Use was for providers, 21st Century Cures, and specifically the CMS patient access rule, is for payers. It has been a major forcing function for payers to modernize their technology. 21st Century Cures is fundamentally making healthcare a friendlier place for builders and innovators by curbing a lot of the power of major incumbents. From where I sit, that is fundamentally a very good thing.

Explain TEFCA and how it changes your business and the industry.

Where I’m super excited about 21st Century Cures, I think TEFCA is a different situation. Had TEFCA been regulated in a way similar to 21st Century Cures, with clear incentives and/or penalties,  we would be a huge fan, because we are fundamentally aligned with the world that TEFCA imagines.

To just state what that is, TEFCA has two core components. It’s a technical framework and a legal framework that allows networks to communicate with one another. It imagines what they think of as a network-of-networks environment. We love that. We think that that would fundamentally change the landscape.

However, as it stands right now — and this is where I think there is huge opportunity — TEFCA completely optional. It provides the framework. In an industry where large change is so typically aligned to hefty incentives, reimbursements, and penalties, TEFCA doesn’t have any of that. Maybe the long story short there is that we believe in TEFCA, we believe in the future it imagines, but we don’t have strong confidence that it’s going to meaningfully shift the industry because of how it is structured.

Having said all that, there’s a number of products we support, connectivity to Carequality, CommonWell, and other networks that we support. But we’re just not convinced it’s the game changer.

ONC is reluctant to apply a heavy hand and instead wants to clear the way for market forces to drive advancement. Where would that market pressure come from to make TEFCA universal?

TEFCA has the framework around what’s called a Qualified Health Information Network, a QHIN. Without going into the tactical details of what qualifies as a QHIN, a couple of networks fit that mold at a high level. CommonWell and Carequality would be classic examples. They support a use case, which is the treatment of care or the transition of care use case, where data is exchanged. The classic example is that your primary care doctor is in New York, you’re in Florida, and you get in a bike accident. CommonWell and Carequality allow that record to get pulled from New York to Florida so that the doctors treating you there have your medical history. That’s a clear use case with appropriate incentives for hospitals and clinics to participate.

It’s harder to imagine future use cases where those alignment of incentives occur, where people would meaningfully come to the date table and agree to share data. There’s some compelling stuff around payments and patient payments where there could be meaningful market pressure.

Your question is a really interesting one because while the painted future is interesting and exciting, it’s hard to imagine a path to get there simply through pressure from market conditions. This is where we need to think about the actual incentives of these organizations, their willingness to share data, and whether they see it as the right thing given the specific use case.

Has the original interoperability idea of paying those who contribute data and then charging for its use gone by the wayside?

I don’t think that model is off the table. I just don’t think it has seen a ton of traction. Where there is traction involves life sciences companies that want to pay for large, de-identified data sets for R&D purposes. But beyond that, there just hasn’t been a ton of traction. That is not at all me saying that we should disqualify that or put it to the side. If there was, I think that would be super exciting. Those are the questions that will be interesting to track. Is it going to enable that world or not? Do we see the early signals that something like that could emerge?

Technology vendors, startups, and health systems themselves are finding it profitable to broker a data connection between providers and life sciences companies. Will additional use cases emerge?

I think we are early days. There’s a ton of opportunity. Costs are high to administer clinical trials. The match rate, how easy is it or hard is it to identify patients to enroll in the clinical trials, is still super high and inconsistent. The data itself is part of it. Another huge part of it is decentralized clinical trials, where there’s a ton of innovation. 

We are early days. That’s a fun and interesting spot to look for for innovation. Drug companies have lots of money that they are willing to put to work.

Do we have now, or will we have in the future, a healthcare technology ecosystem?

There has always been an ecosystem. It’s the question of how big and how impactful that ecosystem is.

Going back to the conversation around 21st Century Cures, you can look at a lot of interesting data. Look at the total amount of funding over the past five years that has gone into digital health. It has been one of the fastest growing categories compared to any other technology sector over the past five years. That’s an incredible sign that people everywhere see healthcare as not just a place where innovation is needed, but for anybody who has been a patient or provider, that innovation is needed and possible.

We’ve been saying for a long time and with a straight face that there is an ecosystem. Now it is probably more apparent to a growing audience. But we also think that it’s necessary. Like many other industries, there isn’t a single person or a single company that will meaningfully move the needle. It needs to be many people working on many problems.

That is one of the fundamental viewpoints we carry. It’s about empowering this entire class of builders. It hasn’t happened overnight, but it’s much more significant than it was yesterday, and I think three years from now, it will be twice as big. It is super exciting.

Now that cloud has finally found its healthcare footing, including technology companies like Oracle and Microsoft acquiring big health IT vendors, where does it go from here?

I’m glad you asked this question. Big tech is making serious moves in healthcare. For those of us who have been in this space for a while, we’ve seen different moments where bets were getting placed. I now have conviction — and not just me, but others — that fundamentally, healthcare delivery in the US is going to look different three to five years from now because of the impact of Amazon, Microsoft, and Google.

The other thing I would say is that it’s not just big tech, but also groups like CVS, Walmart, and others that are making big moves, such as Amazon buying One Medical and CVS’s purchase of Signify. An interesting detail that stuck out to me when Amazon purchased One Medical is that alongside that, they announced that they are winding down what they had previously been calling Amazon Care, which was their initiative around a nationwide telemedicine offering. That tells me that that Amazon, in this case, is moving out of testing different hypotheses, having multiple bets, and solving for optionality and they are moving into a more unified, aligned approach now that they have been in market for a little while. This is a trend that I see across big tech. They have spent some time studying healthcare and now they are making their big bets.

It’s not just the cloud. It’s the technology companies that offer the cloud that are super interesting. When it comes to big tech and the ongoing shift to cloud infrastructure, this has been a core part of the Redox thesis from the very beginning. Hospitals, clinics, payer organizations, and life sciences groups are all right now making massive investments in their cloud infrastructure. It’s because what they all have is data, and what they are realizing is that these big tech companies and their cloud infrastructure has the most robust functionality when it comes to driving value from that data.

I see big changes. The dollars being spent will threaten some incumbents in the space, because change is always scary. But I also think if we all take a step back and look at it from the viewpoint as a patient, I’m incredibly excited, because this is what has happened in other industries and the end result is ultimately a more user-friendly, consumer-friendly experience. It’s real. it’s big. We are in the midst of it right now, and three to five years from now, healthcare is going to look different.

How will  today’s financial market activity change the industry?

On the one hand, healthcare is, and will continue to be, relatively resistant to recessions. As we know, the demand for healthcare doesn’t closely associate with the state of the economy. I would say that overall demand hasn’t changed a ton. Where we do see impact is more specifically related to capital markets and the fact that valuations have come down significantly. Companies that need to fundraise in the short term are finding it harder. This is concentrated in some of the startup and SMB folks. This means that a category of customers and builders in the space that are tightening belts to extend runway. There’s some of that in the short term.

In the long term, I don’t see it having major, major impact. Any time we have a cycle like this, in some ways, it’s pretty natural. It will impact some more than others. We are watching it closely, but overall impact to us hasn’t been significant. We have it pretty balanced. We support SMBs all the way up to the Fortune 5.

As we all know, this story is also not done. It will be interesting to see how this unfolds over the next couple of quarters and year because there are tons of investment dollars available. It will be interesting to see when those investment dollars start to come back into the market. History can help us learn from other experiences, such as recessions, 2008, and the dotcom bubble bursting. It’s not totally uncharted, but we are paying attention to it pretty closely.

What will be important to the company over the next couple of years?

Most important for us is to continue to obsess about our customers. You heard me refer to them as builders. We are early days with the impact that builders are going to have in healthcare. It has never been more apparent to me that now is a great time to be a healthcare builder. We will continue to obsess about the people we support and continue to obsess about the use cases that we support. Doing that means we need to continue to power broader and broader sets of data to exchange. 

We’ve broadened from being clinically focused to many types of data. Today, Redox is focused on data access and integration. As we look into 2023 and 2024, the interesting opportunity for us is to start to support more and more of that healthcare data journey on its path to ultimately being useful. We are working on some exciting things that you will start to hear from us later this year and early 2023. It will enable a whole other class of builders.

With all the craziness going on in the world right now, there has never been a better time than right now to be a health tech entrepreneur. Now more than ever, healthcare as an industry is primed for change. My closing statement is to all of the builders out there. Don’t wait on the sidelines. Come on, let’s do it. There’s plenty of work and plenty of opportunity for impact.

HIStalk Interviews Anders Brown, Managing Director, Tegria

Anders Brown, MS is managing director of Tegria of Seattle, WA.

Tell me about yourself and the company.

Tegria is a 4,000-person healthcare technology services business. We are focused almost exclusively on the healthcare provider market, but we also service the payer and insurance markets across both the US, Canada, and increasingly Europe, specifically the UK, where there’s a lot of activity happening. We were founded by Providence in October 2020. I’ve been with the organization for about four years since the inception after working most of my career in technology consulting services.

What is the strategy behind a health system acquiring and operating health IT companies?

It was quite exciting when I got the opportunity to talk to the Providence leadership team and join it. Providence is one of the largest healthcare systems in the nation, a 175-year-old organization with a mission-driven idea of creating healthcare for everybody, better healthcare systems for everyone.

The idea was, what if Providence took a lot of their learnings and a lot of the investment that they were going to make to transform their own systems and expressed that to the rest of the nation, to a certain extent, through an organization like Tegria to try to help everybody move forward in the current landscape and environment that we have? For me personally, it was a great opportunity to look at healthcare. I’ve been in many, many other industries and joined something at the very early stages that I thought could make a huge impact over time in the healthcare market.

How do Providence and Tegria work with each other?

The first important piece of context is that we have grown Tegria through both acquisition as well as organic, ongoing growth. We now count well over 400 customers in our active customer base, Providence of course being one of those. We are an independent organization, so we have to compete for work at Providence, like any other folks would compete. But certainly being close to them and having connections to them gives us some insight into how someone like Providence is trying to transform their healthcare system so that we can take those learnings out to the rest of the industry.

Does Tegria have Providence-created intellectual property?

We certainly have the idea that we would like to technology-enable many of the things that we take to market. Tegria is one of the commercial efforts that Providence has. You might have seen recently that Providence also spun out Advata, a software organization that is almost a sister company of ours, and we work together. But right now, Tegria is focused more on technology services and technology consulting.

Several big health systems have recently outsourced their IT services, revenue cycle management organization, or both. What is behind that trend and how will it impact Tegria’s strategy?

In some ways, that trend is exactly what our business strategy is and plays into. Our fundamental thesis over time is that many of the healthcare systems are better served by putting all of their capital into taking care of their communities and effectively building better healthcare for the nation. To the extent that Tegria can work with them to not only improve those on a project basis, but over time take over some of those operations so that we can essentially gain some efficiency and hopefully reduce costs for those healthcare organizations, that gives them more capacity and more capital to improve really their care delivery, which is the priority and the focus of many of them. We see the same headlines that your readers see and we are certainly are out there doing what we can to win our fair share of that work.

As big health systems get bigger and expand beyond a regional footprint, how will that change their use of technology to scale and become more efficient?

The scaling of healthcare, or the growth of some of these healthcare systems, provides an opportunity to standardize and modernize the platforms, which can now be at some scale and offer increased efficiency. That efficiency leads to reduction in costs and then an increase in capacity to deliver healthcare for people’s communities. The opportunity for smaller hospitals is to continue to look towards the larger healthcare systems for direction and for partnership. We talk to both of those kinds of organizations and are focused on delivering that kind of value across both of those segments.

How will digital transformation change the relationship between healthcare organizations and consumers?

Our position is that we are at a unique point coming out of the pandemic. On one hand, we have consumers asking for more and more convenience and are willing to change their healthcare provider for that convenience. On the other hand, we have the providers themselves, the clinicians and doctors, who are frustrated with burnout and trying to understand how technology will make their lives better. 

This idea of transformation comes up a lot in conversations that we have. The challenge with that word is that it means something different to everybody. Our perspective is that you have to meet people where they are. For some folks, transformation can mean simply moving some data to the cloud. For others, that could be full-blown EHR replacement and implementation. It’s important to move forward, but the pace and speed at which you do that will depend on exactly where our customer is in that journey.

Health systems that mostly competed only with each other are now facing big companies such as Optum and CVS Health that blur the line between insurer and provider in trying to attract the same consumers. What influence will those companies have?

You see a number of interesting trends, and you commented on a couple. One is this payer-provider connection. The idea of retail being a connection point for healthcare. The third, which just was announced, is big tech, in this case Amazon, entering these markets with their acquisition of One Medical.

Change is afoot. There are pressure points on these healthcare systems to respond to these external new entrants. Our viewpoint is that technology can help, but the idea is that people see the opportunity to create efficiency and see the opportunity to deliver better patient care. Our goal at Tegria is to help all of those organizations do that.

What is the future of deep-pockets technology companies like Microsoft and Oracle entering what seems to be an appealing healthcare IT market?

It goes back to what these large organizations, whether it’s Microsoft or Oracle or Amazon, see, which is the opportunity for technology to make a huge impact in healthcare. At the same time, the healthcare providers themselves will benefit, in theory, from some of the scale that these organizations can bring and take advantage of that technology. So again, they can focus on what they do best, which is the clinical care, having the doctors and clinicians that can take care of the patients and their communities.

Our view at Tegria is that we will continue to partner with these large organizations and help deliver some of the best solutions out there to these healthcare providers. But it’s certainly a trend that has started and that I believe will continue to move forward for a long time.

How will financial market conditions that have driven down company valuations impact Tegria’s participation in mergers and acquisitions?

Tegria is totally focused on continuing our growth. We have aspirations to continue to grow not only the service offerings that we provide, but also the geographies in which we provide them. To the extent that he macroeconomic environment changes valuations, we’ll just be there with everyone else looking for opportunities. We’ll continue to grow organically as well. But for us, it really doesn’t change our strategy as much as it continues to support where we want to take the organization.

Where you see the company in the next three or four years?

Tegria is founded on this idea of trying to bring the best technology solutions to our customers. We will continue on that trajectory. We are excited about the next decade of technology and transformation that we think this industry will go through. We want to be there arm-in-arm with our customer base to help them move forward. It’s exciting times in healthcare and will continue to be so for quite a while.