HIStalk Interviews William Febbo, CEO, OptimizeRx

William J. “Will” Febbo is CEO of OptimizeRx of Rochester, MI.

Tell me about yourself and the company.

I’m CEO and director of OptimizeRx, going into my seventh year. I’ve been in healthcare technology for about 25 years. Early on, I decided to put myself between industry and healthcare providers and patients and try to use technology and data to make that relationship more seamless. That’s obviously a challenge, but both groups need each other. I’m excited to be part of OptimizeRx because It helps me down my personal journey to get those two groups communicating better with technology and data and doing it all compliantly.

OptimizeRx is a health technology platform that enables digital engagement among our clients, life science organizations, healthcare providers, and patients, particularly at critical junctures through the care journey. We reach about 60% of healthcare providers and millions of their patients through this platform that we’ve built over the years, which we call Digital Point of Care Network. We like to say, as a team and in our culture, that we are helping patients start and stay on their medication.

Pharma marketing used to involve aggressive sales reps and buying lunch for doctors. How has that changed?

Even before the pandemic, acts such as HITECH and Sunshine made it nearly impossible to continue the usual lunches, entertainment, connectivity, and building relationships. Then the pandemic hit and made that even harder. The industry is going through a pretty big change right now. Everyone woke up in January 2020 thinking pretty much the same strategy — we’ve got our reps, conferences, and speaker bureaus and we’re figuring out this digital thing to try to make it all smoother.

Then obviously we all had to stay home. What we saw as a company — and I think my peers did as well after talking to other CEOs and team members – was that all of a sudden there were a lot executives from our clients in meetings around digital enablement of connectivity. How to communicate, how to leverage call centers using technology, and how to communicate at the point of care, the point of dispense, and in the waiting room. Obviously digitally, because we were all staying home.

Then in 2021, we saw a lot of micro trying. Pharma tried, either through agencies or directly, lots of different solutions. OptimizeRx has been in the market for a while. This is our seventh year. We like to say we re-founded the business to have a broader platform to approaching communication between industry and doctors and patients. But the pandemic helped awareness and adoption happen. One of the challenges was that a lot of solutions stepped up. They all sound terrific when they’re presented. When you can’t talk to your clients, you’re going to try anything that’s compliant. 

What we have found lately is that pharma is seeing some terrific digital technology and now wants to see who can scale. They are looking at the whole country and then beyond the states as a way to communicate, and not just micro populations and pilot tests with different solutions. 

The pandemic helped pharma lean into digital more, to put continued pressure on the model of people and gatherings, but certainly didn’t kill it. There are lots of questions every day that doctors have for reps in their territories, especially as we’re seeing so many specialty medications come to market. If you think of how many medications people are on and the type of conflicts those can have, then there are questions. So that infrastructure is needed, but I think we’re going to see a wonderful hybrid of digital enablement and people working together and pharma helping that move as fast as possible.

In a perfect world, pharma marketing would benefit the patient, the prescriber, and the sponsor company more than just blasting ads to increase product use.

That’s right. We focused in on two solutions. TeleRep is a connectivity point in the workflow of EHR that the doctor can click on and connect to their local rep to either email or text a quick question. We found in a newly launched six-month case study, and this happened to be in the autoimmune area, that 89% of the brand reps were contacted. It’s a button in the workflow.

There’s not much hard about that, other than getting it there and making sure the doctors are aware of it, but we saw a 42% increase in the engagement over the baseline. It was relevant, timely engagement and support at a time where people had questions and the reps couldn’t be in the hospital. We think there’s some real benefit that’s coming out of the connectivity, but the key is being in that workflow and being present because doctors are on EHRs a big part of their day.

We also launched a real-world data evidence solution that addresses the lack of interoperability between EHRs. We gather data on a patient cohort from various sources. We then build an algorithm around a mechanism of action so that we can compare a patient in workflow to a set or cohort of patients and trigger the appropriate message to the physician at the right time. Targeted, data-driven, and highly relevant. For our clients, we uncovered a significant opportunity and saw an increase of their addressable physician audience of about 200%.

We hear a lot about the newfound effectiveness of inserting information into the clinician’s workflow. How will companies and organizations avoid the clinical decision support dilemma, where users get so frustrated with unwanted or unhelpful interruptive messages that they tune them out completely?

We work with our partners. Their clients are physicians. Through our Innovation Lab, we partner with these EHRs and hone in on the pain points or friction points that frustrate physicians when in the care journey.

Trying to come up with a platform that tells a doctor what to do clinically is not wise. They can do that. The key is giving them tools that help them get information that is highly relevant. Not tangentially relevant, but directly relevant is the key. We also heard from talking to physicians and our partners — no more clicks, no popups, don’t disrupt the workflow. That’s key to keeping the noise out of that care journey.

People with good intentions have come up with lots of solutions, but there’s always a sentence at the end that says, “They just need to go to this app or just need to go to this website.” That’s the hardest part of those models. Physicians aren’t looking for another app. They’re not looking for another website. They really don’t like working in the EHR, but they have to. The key is focusing in on reducing friction, actually reducing time on the tech, and bringing the right tools and information at the right time. That’s hard to do if you’re not integrated, because otherwise, you’re asking them to go somewhere else, and frankly, they don’t want to.

How can technology support the increasing use of specialty drugs and their associated information burden?

It’s a huge problem. You have awareness prior to prescribing, but then a whole host of problems post-prescribing. Pharma has used specialty pharmacy contracts and also hubs to try to make that better for the patient. We had a partnership with a company called EvinceMed last year, which built technology to give an alert about which specialty pharmacy should go with a prescription. They did some of the prior authorization work between the EHR and the specialty pharmacies and the hubs.

We ended up acquiring that company earlier this year because we saw such a friction point, so much frustration with the doctors and the patients and the hubs, and the whole ecosphere. This was a really elegant technology. A couple of other companies are doing it as well, but it’s a big space with so many new medications that have different distribution channels.

Specialty drugs are expensive and complex and involve a lot of questions. Just calling through the pharmacy is not going to do it 100% of the time. The technology that we acquired and that others have is trying to take that friction out, focused on specialty only, not the general meds or the volume meds through retail. We’re pretty excited about that space. And the same way we help agencies help pharma, we see an opportunity to help the hubs help their clients. Technology is going to be a friend to that problem.

Many digital health companies have taken a hard fall in share price along with layoffs. What factors will determine which ones succeed or even survive?

We and our peers have all taken it on the chin. There’s different reasons for different sectors, but what the pandemic did to the investor base was get them excited about solutions that can help with health. That’s happened in fintech and in the consumer world and it rushed into health. There really aren’t that many public companies that can scale.

You had a real rush of retail and institutional investment. In the exuberance, there were some mergers and acquisitions that frankly just either didn’t make sense or couldn’t sustain what was promised. The investor base, at least the one I talk to, is looking at who has a long-term, sustainable competitive advantage. Who’s your client? Is it pharma? Is it a payer? Is it the government? Is it providers? There’s just so much more awareness now.

As pharma leans more towards digital, they are going to look for clients that scale. That makes it a good opportunity for investors. They can look at companies that are public and private that have true connectivity to an HCP or patient and can improve care and not just be a website.

I’m excited about the space. Most of us get into healthcare to actually make a difference and don’t get too caught up in stock price. That’s what I tell my team. Our culture is not about the stock price. It’s about helping patients start and stay on therapy. If you just delight the client and focus there, you’ll build a great business. We’re all getting over the drop in valuation and are focused more on the clients, doctors, and patients.

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

We are focused on our clients being connected digitally to doctors and patients wherever they are. We want to help patients start and stay on therapy. We want to get rid of friction. We’ve made huge progress in the almost two years since you and I last spoke. We have enhanced the leadership team, won all sorts of really cool awards around that RWD solution, and added some great people in AI and just great team members. The issue of communication has only gotten more challenging. It’s still a fragmented way to get to people. We will not only have the platform to facilitate that, but it will be omnichannel as well. We’ll be able to get to them wherever they are, whether that’s in the hospital setting, at home, on their cell phone, or in the pharmacy.

HIStalk Interviews Matt Roberts, Healthcare Industry Practice Lead, Juniper Networks

Matt Roberts is global practice lead, healthcare industry of Juniper Networks of Sunnyvale, CA.

Tell me about yourself and the company.

I’ve been in healthcare IT for over 20 years. Right out of college, I started working in network closets, doing desktop rollouts as part of an internship with Health Midwest back in 2000. I was supporting one of the first Cerner Millennium projects in Kansas City, which led to them offering me a job that I accepted. I worked for Cerner for 10 years, living in hospitals and clinics. I helped them set up one of the first HIEs at the Tiger Institute at University of Missouri. I had an offer come my way to take my healthcare expertise over to the networking industry and I joined a company called Brocade. I led their healthcare go-to-market for roughly six years before we were acquired.

I’m now at Juniper, which is a pure play networking and security company. We are absolutely focused on delivering simple and secure experiences for those who run the networks, and even more importantly, the patients, the clinicians, and the staff who depend on the network.

What are the biggest network challenges of health systems?

We see a lot of Band-Aided networks. I’m a big fan of treating the cause, not the symptom, so when we  look at what happened through the pandemic, there was a lot of stress. It was a dark place for all of us. We all have our own experiences, but it was tough. Through tough, we find ways to innovate.

During this time, many providers discovered that their network should have, and could have, been a more strategic asset, probably more so than originally perceived. We walk up to a water faucet, we turn it on, and we expect water to come out. That was the perception of the network. Until it goes down, nobody really cares. But we have seen the whole delivery model shift, so we have moved to a more virtual model and distributed model, Everything is Internet of Things.

As things continue to shift, you have to take a look at the network. It has become more important. A healthy network puts the organization in a position to scale, to integrate emergent technologies. The chief nursing officer walks in and says, “I need this technology connected today.” IT has always been a “no” center. It has to become a “yes” center and say, “We are going to be able to accommodate that for you and figure out how to integrate it into the workflows.”

How extensive is the need to re-architect health system networks due to consolidation, where new care venues of all kinds need to be brought into the connectivity fold?

Consolidation and acquisition play a major role in being able to integrate the technology seamlessly. As seamless as some of it sounds, you are also often acquiring organizations that don’t have the same standards that you have. How do you rely on integrating proprietary technologies and the way things have been architected at a technical layer from a topology standpoint? You may have to unwind some things to get that new system on board, whether it happens to be multiple hospitals or multiple clinics. It plays a critical role.

Open standards, or standards-based technologies, are important for this exact purpose. Being able to onboard quickly, to integrate seamlessly, and to provision your networks more efficiently, as opposed to having to wait weeks, months, and even sometimes years when you start to get into the project work.

Is it challenging to bring those new locations and networks up to security standards?

Yes. Security gaps are everywhere. The harsh reality is that no one vendor does it all. When you start to look holistically at the security posture of the organization, we are doing something differently at Juniper. We treat the entire network as an enforcement domain, looking at every connection point that exists within your network. It’s not just next-generation firewall, DLP, or an ATP appliance or software. Cyber criminals are getting smarter, where minutes, much less days and hours, aren’t fast enough. How do you identify and mitigate a threat immediately as it comes in?

I use the analogy of how many locks you have on your door at home. You have deadbolt, a push button, an extra lock, a Ring doorbell, and maybe a German Shepherd behind the door. You have multiple layers of different protection. When you look at your security posture, there’s not a one-all, be-all.

Healthcare is among the top industries, maybe number one, for cyber criminal activities because the information is so rich. You have to look at new ways instead of just throwing a bunch of firewalls out. Protect the entire domain and know what’s going on in the entire domain. Then be able to identify something that looks fishy and shut it down so it doesn’t propagate through the entire network.

What changed during the pandemic?

The network is the lifeblood of the healthcare enterprise, like the vascular system of the human body that pumps our blood to and from the heart. The network is your vascular and immune system. If you don’t have a healthy network, the organization is at risk. The pandemic created gaps. But we see positivity as people understand how strategic the network is. It’s not just watching how the packets pass and getting bits and bytes to their destination without latency. You have to look at the whole thing, the hard and soft costs around the economics. Are you buying the same brand because that’s all you’ve known for the last 20 years? Look at what’s fit for purpose. Look at what molds well to what your organization is trying to do. Are there better organizations out there that are leading edge about trying to help also make you more efficient?

That’s where we come in. We are focused  on experiences. If you’re the IT operator, on the network or help desk teams, or an end user such as a doctor or nurse or a radiologist sitting at home, how can that network work for you? Or how can you not have to pick up the phone and call the help desk if you’ve got a really crappy connection? We are starting to see small, medium, and large entities, from smaller hospitals to larger health systems, looking at the network. It’s exciting because they are looking at newer technologies that are different from what they have done over the past 20 years. 

The industry has evolved so much. It involves AI. It involves a lot of capabilities that have moved beyond the marketing hype that allow you to focus on not only delivering a 24/7/365 experience, but to put you in a position where the network is working for you versus having to dig and spend hours trying to troubleshoot issues. That’s where we can help as well.

How are organizations using indoor location services?

When I talk about location services, everything is built into our access point. Think w-fi. We use what’s called virtual Bluetooth low energy. We have a patented array that sits in the access point. We are the only one in the industry that does that. In the Gartner Magic Quadrant for indoor location services, we are in the leader quadrant far over to the right. We are the only networking vendor in that particular space.

Delivering location services is a journey, to be fair. An organization has to have a strategy around that. It starts at looking at the use case. Maybe you want to greet people as they walk in the front door and offer them a turn-by-turn indoor navigation experience because of late or missed appointments or people getting lost throughout the facility. Maybe you want to track critical medical assets because wheelchairs and pumps are getting lost – studies have found that 20 to 30% of mobile medical equipment is lost or stolen. You can deliver these location services directly off of wi-fi now instead of buying a bunch of different pieces and parts and overlay RTLS systems.

However, we integrate seamlessly with those. We’re an open standards-based company. The value for healthcare is to look at open API strategies, to look at exchanging SDKs and other software defined kits, to integrate into other entities like Stanley and CenTrak so you don’t have to do a rip and replace. Cost preservation is big in healthcare. I’ve been in healthcare 20 years and I want to save healthcare a lot of money and make it more efficient. We seeing an uptick in all the different types of location use cases to get a consumer engagement platform in place. Hospitals and health systems can engage with patients and guests while also helping their staff become more productive.

What about proximity alerts involving visitors or employees?

It is opening more opportunities. It creates this platform for IOT, but it also creates a platform for at least understanding who is coming into your facility. We don’t record PHI. We’re just looking at devices. If you walk in with a  Bluetooth capable or enabled device, such as a phone, it  can be detected. You see this in retail, hospitality, and a lot of different industries. We can get within one to three meters, or even closer to the one-meter mark by using  BT11 devices.

That lets you understand what is happening with your facility’s foot traffic. It came more important in the heat of COVID for proximity tracing and dwell times. If a facility needs to disperse a hot zone, they can push a notification out to everybody who was congregating when they shouldn’t have been. We can do these directly out of our dashboarding capabilities and the integration work that we can do with engagement type devices over mobile.

What healthcare developments will we see in the company and the industry over the next few years?

We literally are changing the game again. The accolades are out there. Everybody can go look and see from a lot of the analyst community and industry recognitions that we truly are improving the end-to-end visibility. Insights into users, devices, and applications creates a fine-tuned experience for clinicians, patients, and the people who are running the networks.

We are dramatically simplifying the operation. Using AI to proactively notify IT when there’s a problem, provide a fix, and automatically open up trouble tickets in ServiceNow or whatever your ticketing system is. Imagine not having to chase a doctor or nurse to ask them to re-create an issue. We are eliminating all of that.

Nobody has seen this in healthcare. It’s a foreign concept, and it sounds too good to be true, but the reality is that we are changing the dynamics of how we make people more efficient. Talk about provisioning all those acquired clinics and hospitals as we mentioned before. We can use the cloud and microservices so that the AP and the switches are ready. As soon as you acquire somebody, and you have plans to basically roll out a new network, with single-click activation it literally can be plugged in as soon as you ship it to that device. Or let’s say that the clinic is two hours away and somebody can’t travel there, you can have somebody do this over distance, reducing the truck rolls, the touches, provisioning networks by 50 to 70% better.

Nobody has seen it in healthcare, and this is where we get excited. This is where I get excited sharing my message with you on what we’re doing. We are at an interesting time where people are coming out of the pandemic and doing digital transformation initiatives. The network should be considered when you start throwing all of these other things on top of it. That’s your foundation, and we want to make sure that you have the most modern foundation that is possible, one that can scale for many, many years.

HIStalk Interviews Diana Nole, EVP/GM, Nuance

Diana Nole, MBA is EVP/GM of the healthcare division of Nuance, a Microsoft Company, of Burlington, MA.

Tell me about yourself and the company.

I’ve been with the company just a little over two years, but I have been around healthcare IT for about 15 years, which makes me a little bit further along than just a novice, I like to say, because it’s such a complex industry. Since we last spoke, Nuance has become a Microsoft company. Nuance is a technology pioneer, focused on conversational AI and ambient intelligence and working on how to put things into the intelligence, into the workflow. We are heavily focused on reducing the administrative burden of clinical documentation. Our offerings are used widely throughout the US and globally.

Microsoft’s Cortana doesn’t have the adoption of competing voice assistants from Amazon, Apple, and Google. Was that part of its interest in acquiring Nuance?

There were probably a few levels of interest. We are heavily into the deep workflow of clinicians and the patient experience. We try to understand heavily with our customers and our partners what’s going on in terms of patient care and this focus on the Quadruple Aim. We have a deep presence. We are in 77% of the US hospitals and I think we were quoted as being in 80% of radiology. In healthcare, it’s about how the technology is being used to actually enhance patient experience, physician experience, et cetera. There was the actual technology that we have, but even more so, the relationships that we have and the clinical care. Then, the deep relationships that we have with our EHR partners and other partnerships were very much of interest to them.

Now that Nuance and Cerner are owned by highly competitive technology giants, how will Nuance’s relationship with Cerner customers work?

We deeply value these relationships, as you can imagine. Our solutions have to work within the workflows that our physicians, nurses, and radiologists use. We have had ongoing conversations with Cerner since the acquisition. Clearly, we are deeply committed. We have continued to advance our solutions, such as DAX integrating with Cerner’s virtual scribes. There’s a lot of opportunity here, and certainly we don’t want to disrupt that.

That has been a very key theme of our conversations with Microsoft, that they value that. They are deeply committed to their partnerships and the systems integrators that they work with. That’s a core backbone of who they are. We continue to advance — whether it’s Cerner, Athenahealth, Epic, et cetera — these relationships, because the only way that we can be efficient in the way that we deploy our technology is to do it with them.

Oracle says that it will use its own voice AI product as the primary user interface to the Cerner clinical systems it now owns. What challenges do you see in that approach?

We obviously always know that there will be competition out there. We have been at this for a long time. Medical technology and terminology is very different from just straight conversation. We have invested deeply over many, many years and have many years of experience. We respect that others will come along, and that’s why we constantly are working on our own technology advancement and why we have moved from our medical technology and things like Dragon Medical, which is used by so many people, into more of the ambient environment, which is even more complex. You have to keep pushing yourself, and competition helps you move along because you need to stay ahead of that if you are going to survive and be effective.

I can’t speak specifically to what Oracle’s plans might be, but certainly for us, we are deeply invested in continuing to advance our Dragon portfolio, our DAX portfolio, and other things with our partnerships that we have and investing in the technology. Now we have a phenomenal owner in Microsoft that can help us advance those solutions while also having the cloud infrastructure and cybersecurity infrastructure that they bring to the table to help complement the first-party applications that we have.

What new capabilities does the cloud bring to healthcare?

We have deeply been invested in cloud. The big reason that we are trying to help our healthcare customers move into the cloud is that, historically, we have had a lot of on-premise solutions. It as always challenging to do upgrades, and you want to get the innovation out there as fast as possible. But we also know healthcare has significant worries about privacy and security. We are evolving at a good pace. Certainly with someone like Microsoft, we have deep investments on that side. Once you get everything in the cloud, then we have a good infrastructure to start to unlock other kinds of use cases for the information that resides within the cloud, under the constraints of doing what we’re supposed to be doing as good stewards of the data.

As we have started to think about the combination of our two companies, we think about analytics, reporting, and how you do communication. A lot of things in healthcare are about getting the communication to the right player and the care team. How do you use communication tools to be able to do that? 

Also, things that help enable different kinds of care settings. I’ve heard people talk about the hospital at home. We certainly have seen virtual care advance during COVID, not just with telehealth, but other types of thinking and capabilities. That is helpful because it tries to get at a better physician experience, a better patient experience, while also hopefully reducing cost and not sacrificing quality at all.

Hospital consolidation that creates larger, more tech savvy health systems has generated ideas around scaling patient engagement, call centers, and other centralized consumer-facing technology. Where do you see that progressing?

I think we learned a lot during COVID about what people would accept. We have a tremendous ways to go with consumerization and what you can do to engage patients while also recognizing that you have to deal with accessibility. Not everybody has access to things such as the internet. We also have learned that, so we have to be careful. We have made advancements in basic blocking and tackling, such as outreach around reminders. As a patient, come in and get your mammogram, get your annual exam, get your preventative care. That makes a huge difference. But other settings are starting to be considered, such as better management of clinical trials with a virtual patient clinical trial cohort.

With regard to the care setting, not just telehealth, what can you do in monitoring a patient with a more chronic condition at home? Maybe that is more integration with med tech, home devices, and things where you can identify if and when a patient needs to come in for a visit or to have follow-up. Always trying to prevent that rising risk of issues with the patient. There are definitely opening thoughts around other areas beyond just the typical reminders and telehealth. more sophisticated things that are going to be coming.

Voice assistants are being enabled to support consumer health needs at home, including remote monitoring. How do you think that will progress?

Voice assistants, definitely. We probably have seen more initially on the roadmaps with physicians. The physicians can use “Hey, Epic” or “Hey, Cerner” or “Hey, Dragon — bring up this, bring up that.” It’s much quicker than clicking, because you can speak faster than you might type or click certain things.

But you are also right that in a conversational way, it is easier for a patient who doesn’t know exactly what they’re supposed to be looking for, or how they get basic information. We’ve had some solutions where it’s just simple things that the patient is looking for, such as, “Remind me about this situation that I should be taking care of,” or “Where is the valet parking at the appointment I’m going to?” Just basic interactions that used to flood the healthcare system with basic conversational questions. Those kinds of things can be done now through easy to use, consumer-oriented types of applications, but specifically for healthcare.

DAX has been out for a couple of years. How is it being used and what work remains?

It has been about two years since DAX was announced during COVID. It almost matches the exact timeline. Definitely we would view it as being at the Slope of Enlightenment, where our customers and partners are proving the benefits and use cases within their organizations. Initially, people would start with groups of 25 physicians. Now we are starting into the hundreds, and we have implementations that are well into the thousands. What they are trying to prove is who the right user for it is and where the most opportunity is.

We started out with certain specialties where we thought it would be easy to use and produce a good ROI. We have seen that family medicine and internal medicine have more of an opportunity to use the system than anywhere else. That is where the burden of clinical documentation creates the highest levels of burnout and where we have a shortage, either already in existence or coming.

We published some great opportunities with our customers on what they are seeing. They get better patient experience input, since the patient feels like the physician is talking to them face to face and focusing on them. They understand what they are supposed to do when they leave a visit. As to the physician experience, they are less burned out. They have more of their own time. They can get home. They can take on more patients if they want. Even though it has been two years, we are still in the early days, but definitely have proved a significant ROI for those who are using it.

What has changed in the months since the acquisition closed and what changes do you expect?

I would say that not a lot has changed. At Nuance and at Microsoft, we continue to remain focused on our customers. We continue to deepen relationships with our EHR partners. We are now part of the Microsoft organization. We are a Microsoft company. What we have done since the close in March is to focus on what our shared vision looks like. Our customers are looking for that. They are optimistic. They realize the big, complex challenges that face healthcare, and they really want to have Nuance and Microsoft look together at how can we enhance the ability of clinicians to care for their patients and deliver better outcomes, where technology helps to enable it instead of getting in the way.

We are focused on that right now, and we are involving customers and partners in those conversations. When you think about the combined power of Nuance and Microsoft, where do you see opportunities, and where do you think we should work on this? That’s what we’re focused on, so that we can begin to unlock some of the opportunity that spans both of our companies over the course of the next year.

Another thing we are excited about at Nuance and Microsoft is a partnership with The Academy around an AI collaborative. It’s early days, just announced recently, but it’s an effort to bring together clinical and operational executives not only from provider organizations, but from payer, med tech, and life sciences. We will create a dedicated sandbox for us to experiment with AI and have them, as users of AI, tell us where it will work or not work to guide some of this collective vision that that we are working on.

HIStalk Interviews Ashwini Zenooz, MD, CEO, Commure

Ashwini Zenooz, MD is president and CEO of Commure of San Francisco, CA.

Tell me about yourself and the company.

I’m a radiologist by background. I’ve been a practicing physician for most of my professional career. I made the switch a few years ago, officially, to government and policy. I worked on Capitol Hill and then moved on to continue my work in government at the Department of Veterans Affairs as an executive, then continued my work from there into tech.

Throughout that entire process, I’ve been an avid lover of what technology can bring to healthcare. From my first days as an attending or fellow, I remember all of the things that you could do to have more efficiencies in healthcare, and technology is at the core of it. I believe in the power of technology and I think we are at a great time at the intersection of tech and healthcare, so I’m excited to be here.

I joined this company because the single theme that I’ve been seeing throughout my career is that we have a lot of point solutions and they are continuing to increase. COVID just blew that out of the water. That’s great, because it brought a lot of access to patients and a lot of great solutions, but it became an even more disconnected system. The premise of this company is, how do we bring all of that health tech disconnect to make it work and empower the healthcare workforce? I love that idea, so I wanted to come here. 

We are building the first health tech operating system. Our goal is to bring in and unify multiple data sets and data services so that it is meaningful for the clinicians during those micro moments of care, help with the performance of the organization through these applications; innovate; and give the tools for the systems that are using us to have a platform for innovation that is unifying. I love that concept. We always talk about interoperability from a technology perspective, not from, how does it impact users and how do we make it work for them?  I love that we are actually bringing action to interoperability.

Who are the company’s competitors in data aggregation and API services?

The first thing I would say is that I don’t view data aggregators and API companies as competitors. In order for us to be a functional platform and operating system, it’s important that we bring multiple vendors and last-mile integration companies together. That’s important for us so we can have the data unified in a single place. That’s the first component.

When you reference data integration and APIs, some of that, especially the data integration, has different components. We don’t do the last mile of data integration. It’s once the data is coming together with all these different sources, how do we provide that unification and the unified view? For those, I would say that you could have platform companies as competitors that are out there, anything from a Microsoft or one of the other companies, but they are also partners for us because we build on top of them. Microsoft, Google, Amazon, et cetera.

I don’t think we are yet in a space where we have a competitor because we are the first health tech operating system that is actually bringing FHIR and non-FHIR data together. We are enabling different data structures and sources, and we have a solution where you can actually build on top. I don’t think that solution exists in the market as a whole. If you break down the individual components that we could have for each category, there’s a competitor.

I’m still not getting a picture of exactly what you sell and to whom. Can you give me an example?

We predominantly work with healthcare systems today. If you think of the healthcare system, they have on average somewhere between 10 to 16 electronic medical records or systems of record. They have radiology, laboratory, their main clinical EHR, and they have other data sources. They also work with multiple third-party point solution vendors. 

A lot of times, the healthcare system has to do the work of continually doing point-to-point integration with these third parties to make them effective with the vendors. By bringing in an operating system in the middle, they have found that they can scale those applications across the board by a single plugin. Once you integrate with Commure or you build a solution on Commure, the data automatically flows to anything that is connected with the Commure operating system.

Think of a switchboard, where multiple plugs are connected in. If you are connected into each other, then the data is set up in a way, structured in a way, where it has a common architecture, where you are able to communicate and have data. You have a clinician who has an EHR, they have patient data coming in from the glucose monitor, and you have third-party data that’s coming in. The system has built an algorithm, let’s say on top of Google Cloud for analytics. We can connect the dots and have a system of action. We can bring the algorithm to life and bring it to the forefront for that provider to make the decisions at that moment of care. We’re a transactional system. It’s not retroactive review of analytics. That’s who’s using us, and that’s one example for clinical.

Another example on the platform is using location services. Think about a nurse who is delivering care where there is violence in the workplace. All she has to do is push a button on the badge and we do the work on the back end, where we connect the dots between her to security and nearby employees so we can say, “Here’s the person that needs help.” We can engage. And all of this happens on the back end on the platform, whereas before, you would have to go to a nursing station, pick up the phone, call somebody, et cetera. We are able to connect the dots between clinical, operational, and financial through any app that is connected into the platform.

How do you bring EHR vendors to the table to make their data available?

For the operating system to be functional, you have to work with partners. EHRs are part of the partner ecosystem. It’s not going to work without working with the EHR partners. We have to be able to bring the data together and we have to make it useful. For us to bring the data sources together and for it to be meaningful, we have to work with the developer ecosystem that is building these incredible point solutions in the digital health market. We have to work with the existing laboratory and pathology systems that a health system might use. We have to work with the EHRs and the HIEs that are out there so that we can actually have this data come and for it to be meaningful.

With the PatientKeeper acquisition, we inherited two decades of great clinical experience and workflows that are adding to our vault of solutions. But the overall Commure operating system is going to require PatientKeeper solutions, other vendor solutions, and Epic and Cerner solutions to come together. To me, it’s all about figuring out how to collaborate and not remove these systems that are in existence and bring more cost to the healthcare system. I don’t think we should be kicking out the EHR because the services and functionality that Commure provides are additive and should be enhancing the EHR and enhancing the operational efficiency of the company.

There are a lot of things that the EHRs don’t do that a health system needs, and that a clinician needs. Those are the areas that we are providing a platform for innovation, where you can say, “You have this data. We have these templates for you.” You as a health system can work with your own team or you can work with third-party developers. You should be able to use a low-code or a no-code platform that we have to spin up the workflow that you need within a matter of weeks that it is integrated and connected to the EHR. You have an enhancement of your EHR. I don’t think we should be dislodging them. They do a great job at what they do, which is being the electronic recordkeeping system.

What will the industry look like in five years as startups build products that use existing health system data?

I think it’s fabulous. No one company can be the end-all, be-all in healthcare. If you have a monopoly in healthcare or you think that the EHR is going to be the source of all of your clinical workflows, all of your operational workflows, and all of your financial workflows, one, that’s going to be difficult.

Two, it’s not going to give the system any flexibility to think about new ways to innovate and work faster. COVID has opened up the ecosystem and has allowed for innovation. Health systems in particular realized that there is so much more that they need for a more efficient, better way to engage their patients and their providers. They saw that when we started shutting down and going to a virtual environment or hybrid environment with healthcare. That accelerated the innovation in healthcare, and I think that’s fabulous.

The only issue with that is that with so many point solutions, the healthcare system has to do the job of integrating all of those to make it meaningful for them to use it. We’re working with a healthcare system now that has over a 100 third-party vendors who provide point solutions, and some redundant solutions are being used across departments. That adds to the cost of the healthcare system, which goes against what we should be trying to do.

This is simplistic example, but if you think about the IOS or the Android ecosystem, they create a way for seamless consumer experience through this core data integration platform. Then they enable an easy app development platform and a robust suite of pre-built, ready-to-launch apps. Apple comes with Apple Maps, Apple Calendar, and Apple Mail, but that doesn’t mean that you can’t download one of the new innovative maps or scheduling apps or Waze or whatever that you want to use as a consumer. It is auto integrated. Just because you use Apple Calendar and Gmail for your email does not mean that those two don’t work together. 

I’d like to see that simplicity. That’s where we are going to head with a platform approach in healthcare, where you can have the best-of-breed solutions available to these health systems. But there’s not going to be the issue where interoperability and tech is a blocker. They will function together to reduce the friction for the user.

Has consolidation into bigger health systems enhanced demand for services like yours, as tech-savvy corporate offices connect systems that came with acquisitions?

The short answer is yes. It’s not just the EHRs when you see system consolidation. As we are moving into a new model of work, you’re going to have a lot of non-health system parties that work with the inpatient system. For example, you’re going to have multiple cardiology practices that refer patients and take care of patients inside of a central healthcare system. They are now part of the system. They don’t use the same EHR or billing or operational systems, but you need to give them the flexibility to work with each other. Solutions where you’re able to help with the network of innovation to bring all of this together so that the patient isn’t bothered when they’re going from their external cardiologist into an internal vendor — that’s where I see a lot of change.

It’s not just at the level of the EHR. It’s between the inpatient systems. How do you provide these seamless experiences for these providers, not just the patients, as they are caring for patients and they are traveling between these outpatient systems that are part of a network into the inpatient system? How do you provide the same flexibility as those providers are interfacing with the insurance companies? How do digital health companies refer in and out of a health system where they don’t belong?

That’s the new age of healthcare. It’s this hybrid model of care, the “click and mortar” system. That’s where the platform innovation is going, and we are going to see a lot more of it. It’s great for us because we truly believe that patients should have the flexibility and clinicians should have the data available when they need it without having friction from technology, which is what we enable.

What are the company’s priorities over the next few years?

Right now, we are really, really focused. You probably don’t see a lot of info from us because we are hyper-focused on working with some of our lighthouse customers. We have defined a few focused customers and we want to make sure that we are learning from them and partnering with them to come up with the best solutions. I don’t foresee us changing much from that course, because we are learning a lot and it’s helping us build our product roadmap and introduce new solutions to the market. I would say that we’re going to continue along that path.

We are seeing a lot of requests for payer-provider collaboration and how we can enable that, so we will think about how to extend our platform and the operating system to help connect the dots, as clinicians are working not only across other healthcare systems or across their networks, but also with the payers in the ecosystem.

I don’t think that there’s a silver bullet in healthcare, “one size fits all” solutions. We have to be open to the approach of collaborating and working together, including multiple EHRs working together and multiple competitive companies working together, to help provide the best care for patients and the best experience for providers.

HIStalk Interviews Kyle Kiser, CEO, Arrive Health

Kyle Kiser is CEO of Arrive Health of Denver, CO.

Tell me about yourself and the company.

I’m CEO of the recently minted Arrive Health, which until a few days ago was known as RxRevu. I’m part of the original team and have been with the company for almost eight years. We have built a network that delivers cost and coverage information into the e-prescribing or ordering workflows of providers and advocate for real-time, patient-specific, location-specific, moment-in-time-specific insights to help connect effectively marketplace information with clinical decision-making at a high level.

We can all share stories about inconvenience and aggravation due to prior authorizations, prescription coverage and cost surprises, and the increased difficulty in shopping prescription prices with the move away from paper prescriptions, none of which can be easily measured except indirectly on provider satisfaction surveys. How do you think that frustration manifests itself?

There are absolutely mountains of anecdotal evidence. The way that we have structurally arranged the system is that on one end, healthcare providers make decisions based on what they perceive, how they have been trained, the clinical guidelines that exist, and maybe some influence based on the system that employs them. On the other end, health plans and PBMs have developed rules that are intended to guide the right decision to a best-cost decision. Those best-cost decisions are usually behind a curtain, to some degree. There’s a lot of mystery or maybe unique intellectual property in how those things happen and are derived.

The net of that is there are rules on one end developed by health plans, there are rules on the other end being adhered to by clinicians, and those two sets of rules are entirely disconnected. We connect those two things into one experience, because in today’s state, it’s up to the patient to manage the in-between. They have to advocate for themselves with their health plan. They have to advocate for themselves with their provider. Ultimately, their trust is with the provider. If you have a question about something that’s health related, if you’ve got a question post-visit about something or you’ve got a question about a med you’ve been prescribed, your first instinct is pick up the phone and call the clinic where you went, where the decision originated. We are empowering that provider who already has the trust and the leveraged relationship to drive the right decisions, to ultimately take the preferences of that individual’s health plan and put it into the hands of a decision-maker who is already making that decision.

As far as measuring the impact and maybe even the size of the problem, we are finding about 20% of the time when we present other options, providers are adhering to that. That’s just with the workflow intervention. That’s not with a care team or a patient intervention. Just by providing this information in a relatively passive way in workflow, providers are accepting those options about 20% of the time, which is meaningful. That means that one out of five patients aren’t having to show up at the pharmacy counter and realize that their claims have been denied. They aren’t having to call their PBM or their health plan to understand if there’s a prior auth required, and if so, how they resolve that prior auth. They aren’t having to call back the clinic and say, “I can’t afford that medication.” All of those things are resolved in that moment in time.

The way the world is moving, there’s just not a future where providers are not going to be considering cost. High-deductible health plans are ubiquitous now, and patients are bearing a price for healthcare that was never intended for them. The in-network negotiated rate was used in a calculation before, but now patients are faced directly with that out-of-pocket expense, first dollar. Clinical decision-making and cost and coverage decision-making are now one and the same. They have to become integrated, clearly not emphasizing cost and coverage over the right clinical choice, but making sure that the clinical choices that you are making are the things the patients can access and afford. Patients are demanding that.

How much inefficiency is involved with the provider making a clinically appropriate decision and then having to redo that decision without compensation for cost reasons, through no fault of their own?

I think the number I saw in a Health Affairs article years ago was 65 million calls a year to provider offices to resolve exactly what you just described. There are three therapeutically equivalent drugs. You chose A, we wanted you to choose C. The provider doesn’t necessarily have a strong opinion on one of those three options. They just don’t have the information they need to understand that choice and how the health plan is contracted to derive that preference. There’s an absolutely strong efficiency argument for provider offices in general. Making the right decision the first time prevents reworking many of them.

Have you seen a comparison of patient satisfaction with the provider when their prescription process goes without a hitch versus when the patient is bounced around as the middleman?

We are just starting to look at that. Our focus to this point has been primarily on provider adoption, because in our belief, everything starts there. If we can’t compel a provider to use the tool consistently and to influence their behavior in an appropriate direction as a result of this intervention, then everything downstream of that becomes impossible. Most of our focus has been on the behavior change aspect of the tool.

That’s where that 20% or so number that I mentioned earlier is really important. It is many times higher than most of the other things happening in the industry. Multiple times higher than other behavior change measures in the industry. It has been a huge part of our focus, and the key to our value is understanding provider engagement and how and why they use the tool. That comes from being an organization that was incubated within the University of Colorado health system and having intentionally worked with health systems as strategic partners to better understand their world, to better understand the problems they’re trying to solve, to better understand how our solution can impact those problems.

Transparency would ordinarily create a more competitive market, perhaps among insurers, PBMs, or pharmacies. Are you seeing an effect on the pharma supply side of having patients know upfront where to get their prescription filed or what alternatives are available?

Real-time benefit is a mechanism to communicate the supply-side negotiations that have already happened. PBM and manufacturer have decided on formulary placement and what tier and what reimbursement is appropriate. Real-time benefits allow the mystery that was happening in the background to be provided in a way that makes sense to an end user, to a provider trying to make that decision. It will be some time before having that information at the point of care starts to influence, well downstream, the supply-side negotiations. Because in a lot of ways, we are just communicating something that has already happened between the risk-bearing entity and manufacturers.

But I do think that over time, the fact that this is happening at the point of decision is a massive opportunity to think about these things differently. Maybe future-state thinking about other forms of affordability being communicated at the point of care and maybe even directly to patients. That’s the key to all of this, starting to expand our purview beyond just the point of care, but also to care teams and also to the patient themselves. Making sure that we are leveraging our network — which is focused on driving the right decision the first time, whether that’s a med or something beyond a med — to influence point-of-care decision making, care team decision-making, and patient decision-making, all from a common source of information and one source of truth.

That’s where we can start to change systemic decision-making, but it takes all three legs of that stool to do that well. The impact then will be some of the things you are driving at, which is ultimately that adherence will be massively impacted, the patient experience will be massively impacted, and even ultimately how some of these financial decisions around which med and why will be financially impacted. Because we will have the data end to end, from decision to fill, to understand those things, to identify the cohorts, and to understand outcomes. That’s the groundwork that we are laying, this decision network and then the access network.

How hard is it for prescribers to advise patients, using available electronic information, where their prescription will be cheapest given available pharmacies, manufacturer assistance programs, coupon programs such as GoodRx, and insurance coverage? In the paper prescription days, patients could visit multiple pharmacies for prices, then choose which one to fill it.

Today, that’s a tough thing to do at the point of care. I think your point around empowering consumers is the most relevant one. Ultimately we have to put some of this cost decision – specifically, the decision around location of fulfillment and what methods to drive affordability that patient needs — in the hands of the consumer. E-prescribing 1.0 really limited patients’ ability to have choice and patients’ ability to be an active and informed consumer. 

Real-time benefit and price transparency, like the liquidity of price transparency information more broadly, absolutely represents an opportunity to return to that. We can put these types of insights into the hands of the care team that’s trying to support that patient and the patient themselves to potentially select the lowest-cost pharmacy, to select the lowest-cost path of care in general. For sure, that is the opportunity. That’s the turn we are making as an industry and we are making as a company.

Our transition from RxRevu to Arrive Health is part of that. We see our role expanding, both with stakeholders — so not providers alone, not prescribers alone, but care teams and patients — and also around the types of transactions and services that we are able to impact. It’s not just drugs any more, it’s labs and radiology and all of the shoppable things that are coming because of the No Surprises Act, price transparency regulations that have happened, and even the Cures Act to some degree, Patient data itself is more liquid and we are required by statute to engage patients with. All of those things net out to an environment where patients being empowered to make those decisions now is possible. The technology, for a number of reasons, wasn’t capable of doing it, and that has changed.

How will the lab, pharmacy, and radiology market, as well as the company itself, change once prescribers have access to cost and alternatives information during the ordering process?

Providers care a lot about patient out-of-pocket costs. The ability for a patient to actually afford care is usually motivating for a provider, because ultimately, they can only benefit from care that they can afford and access. In some of these more discrete medical benefit site services, the out-of-pocket impact is not quite the same as drugs. We lose some of the incentive for the provider to engage, because providers care a lot about patient out-of-pocket costs, but it’s much more difficult to get providers to pay attention to, or adhere to, plan cost requirements.

This is not a criticism of providers. It’s just that when you think about the way they are trying to make that decision, it’s ultimately doing the right thing for the patient. The right thing for the patient is, can they afford it? That’s where care teams become really important, the care teams that are doing access work, the care teams that are doing referrals, the care teams that are doing prior authorizations. That’s the opportunity that I see to influence some of that other medical benefit type decision-making that’s just more appropriate workflow. That’s where that work is happening and that’s where I think the value is, in concert with a direct patient outreach. Patients need to understand their options, but it’s heavily a care team utility in that case.

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

The continued capability of health plans to expose price transparency information to their members is really, really important. Critical, even. The continued push for data liquidity as it relates to eligibility, the straight commodity stuff that you need to understand who the patient is. To me, pharmacy eligibility is a good example of that. That should flow freely, because ultimately all you do with pharmacy eligibility is you understand that I, Kyle Kiser, am a part of Health Plan A and Formulary A. That’s more or less like a user credentialing function. 

If you think about an Amazon login, that’s just a ticket to the game. Making that flow freely and as liquid as possible, accessible to any patient who wants it, accessible to anybody working on behalf of that patient that the patient has given permission to. All those things that Cures promises — the progression of that is important because the restriction of that information is a rate limiter to innovation, period. Those two things, from an industry level, are important.

For us, as we look to the future as a company, it’s ultimately how we more tightly integrate point-of-care decision-making, care team decision-making, and the patient themselves making these decisions. How do we create as tight a feedback loop between those stakeholders as possible, so that everybody is informed in the right ways and in ways that drive the right decision the first time? That’s us spending a lot more time in how we are engaging patients and engaging patients in ways that add significant value to the decisions they are trying to make. 

Creating a whole-patient experience for care team workflows. Those are highly fragmented tools right now. If you ask a member of an access team in any health system in America what they use, they’ll give you 30 answers. Really, the truth is those 30 answers are on sticky notes stuck to the monitor, all the websites they have to go to solve these problems — one for prior auth, one for medical benefit prior auth, one for affordabilities content, one for enrollment. Creating a more consistent workflow for that team has a huge amount of value and is low-hanging fruit in the industry. 

Then ultimately, continued focus on point-of-care behavior change. What really drives decision-making in an appropriate way for providers? How do we continue to become value-add to their workflow? Not another alert, not another thing that burdens them, not another of the overwhelming amount of information that we tend to throw at them, but how do you start to drive decision-making in way that is effortless for them to engage with?

Ultimately patients are demanding, and will only continue to demand, that clinical decision-making and marketplace information are considered in one consistent workflow. How do we do that in a way that consistently drives provider engagement and behavior change, and how do we measure all of that? What is our ability to stitch together that complete patient journey from point of care to care team, to patient engagement, all the way to fulfillment? What is the underlying data that allows us to understand when that is working and understand when that is not working?. That’s our future.

HIStalk Interviews Brian Robertson, CEO, VisiQuate

Brian Robertson, MHSA is founder, chairman, and CEO of VisiQuate of Santa Rosa, CA.

Tell me about yourself and the company.

I’m 30 years in and a data geek at the core. I started helping the provider industry achieve yield improvement from the revenue cycle 30 years ago, initially at a consultant that had a boutique. That turned into a company called MedeAnalytics. It was taking the application of what you learned in consulting walking the halls of the hospital. People were interested in visualizing what was going on in the enterprise. MedeAnalytics was focused on that and still is. 

I departed in 2009 and started VisiQuate, fundamentally doing the same thing, although my passion grew from targeted point solutions to a broader data platform for the revenue cycle as opposed to having too many point solutions. We deliver that as a service-enabled technology, because we are doing the data aggregation and processing.

I am trying to the help CFO, the VP of revenue cycle, and their staff do two things. Drive yield improvement, but also those data signals can also tell you where there’s redundancy and where automation — more buzzwords, such as AI, machine learning, RPA, all of those things – create a tremendous opportunity to take waste and process inefficiency out of the revenue cycle. My passion remains. The bots have arrived and we’re helping clients get things done through intelligent bots.

What has changed the most in analytics and technology since you started the company?

There’s a nice tipping point, in my view. Let’s just go back five years. We started our initiative for AI and built a chatbot, essentially Alexa or Siri for the revenue cycle. You could say, “Ana, what’s going on with Medicare bad debt, or what’s going on with Aetna, payer code 1234?” That then evolved to looking at deep data signals on where there is redundancy. Clients would say, “We have to start automating things. We are growing to so many people growing through acquisition. I have 1,200 revenue cycle FTEs, the company is growing, and the CFO wants us to maintain 1,200.”

We started to lean into that. For those years it was pilot projects, proof of concepts, interest. Everybody knew it was something you should do. COVID arrives, we’re all working from home, and you look at getting people at the home. Then some labor shortages, some problems with the sheer volume of accounts that need to be processed every day. The conversation went from “nice to have, we should do that” to “what can we automate?” We are in COVID hangover, but many folks are still at home. Many of our clients tell us, and we see it in the data, that they are having problems. Largely in the back office, where it’s hard to find FTEs that are doing account follow-up call center type activities. The line you hear is, “Target pays more than I can pay the most senior collector.”

We are addressing that shortage by using one lens of insights that is driving yield improvement. Who’s paying and who’s not paying? Where are there under payments? Where are their denials? Those types of things. But now we are training the data signals to also look for redundancy, where any kind of revenue cycle FTE is doing the same thing. Filling out a payer downgrade appeal form, and they do it 15 times in their day. And you say, we have all the data, what if we automate that? Oh yeah, I could work more accounts.

Our approach, instead of pure robotic process automation, is what Gartner and others call intelligent or cognitive process automation. Because we are letting Ana, which is our AI analyst, first go do the discovery, companionate smart people to say, we have a lot of redundancy here, here, and there. They say that qualitatively. Then we say, let’s go look at the data, let’s look for that redundancy, and then let’s do one bot at a time.

We are trying to focus on smart bots, leverage the Pareto principle, get people excited about automation, get them familiar with it, do one and go to the next, and make sure you maintain them. You hear sentiment like “Bots break. Bots are brittle.” Yes, they are. But so is the contract management system, where you have to update tables, profiles, and dictionaries. It just has to be built into the service model.

We are advanced analytics versus BI and reporting. Insights can focus on where to automate. That’s where we are passionate and getting some nice traction.

How does a health system that has revenue cycle opportunities decide whether to bring in outside help, outsource, or invest in technology?

When we are talking to clients, we can walk in and say, “Here’s what we can do, You push the data to us, we’ll take care of all the heavy lifting. You’ll be on the assembly line.” Many clients have already invested in bots and RPA or they are about to, or they’ve got a consultant. We try to be compatible and complimentary in all the things that we do. I hate to use Lego blocks as a metaphor, but I don’t have e better one. Whether it’s APIs or just containers, all the techy stuff, we try to make all of our offerings plug and play. Because half the time it’s fully outsourced to us, and half the time we’re working with a combination of the VP of revenue cycle and CIO and should complement their initiative.

For example, if they have bought or made an investment in UiPath, Automation Anywhere, or tools like that, they have existing licenses. You say, great, let’s leverage them, Our cognitive bot Ana is benefiting from crowdsourced data across many, many clients. That’s the cognitive brain that lets us do that part. For the carpentry of building the bot, if you have programmers and you want to do that, it’s like we’re doing the architecture. We can do carpentry or you can do carpentry. We try to be plug and play friendly, because if you don’t, then you are leaving market opportunity on the table.

How has hospital consolidation into larger health systems impacted the capability for revenue cycle management to scale?

I’m famous for saying that you can end every sentence in healthcare with dot, dot, dot. It depends. We have seen all of the above. Some grow through acquisition, and maybe there’s two-thirds on one platform like Epic. They have robust, capitalized product development dollars. IT shops that have actual software developers, an architect, a true world class DBA are the shops we tend to be complementary to. They have some existing investment. Other shops are resource constrained and are just keeping the lights on in many cases.

People will say things like, they’re an Epic shop, or they’re a Cerner shop. I would say that they have chosen Epic to be their vendor of choice for the HIS and system of record, but they are on Epic, Cerner, Meditech, and Allscripts and they are moving across a five-year journey to centralize Epic. Many times, clients think that we are the bridge. We are still giving a consolidated view of the enterprise, because we take feeds from all those systems and give the CFO, the VP of revenue cycle, and the case manager their dashboards. Everybody gets the intelligence that they need and we normalize that data.

A lot of our advanced analytics is leveraging embedded wisdom across a lot of years. That’s the part we’re always making sure that they take advantage of. I can also sit down with folks if they’re intellectually honest and say, “I know you have invested in licenses and all that, I can show you a TCO calculator, and it would be hard to compete with our benefit of scale. Because we have a massive cloud store, our return on terabyte is going to probably have a benefit of scale that you can’t compete with. We have over 400 hospitals, and we do this every day. Whether it’s the private cloud or it’s running daily ETL, personalizing dashboards — because in healthcare, it’s hard to be a cookie cutter solution, things change too much – we are very malleable in all of our solutions, and to be malleable, you’re supporting them every day.” We tell clients, if you want to do this portion, let’s make sure we’ll consult with you, what’s the maintenance, what’s your maintenance plan. Because these are the hours it takes to keep all the lights on. Data action versus reporting is not for the faint of heart. You have to be a little bit crazy and you have to have done your 10,000 hours.

What do health systems gain from using workforce performance analytics?

One of the most exciting things that I’m passionate about came from a client. The hospital side of the house and the physician side of the house  were very different in how they did incentive compensation. They were using tools out of PeopleSoft and traditional systems like Kronos to not only get time and attendance, but try to have quality performance scores. They would take a random sample of transactions. For example, if you were a patient access clerk, there was a threshold of errors. You can’t miss the Social Security number, the subscriber ID, the really important information required to get a claim paid. It was saying that you have to be at this threshold, and if you’re at this threshold, you’re eligible for points in monthly giveaways in the fishbowl, or you’re eligible in some shops for incentive comp.

It started there, and we started getting deeper into the quality scores, because that particular client got us excited about the notion of gamification. Shops that can’t do incentive pay can do point systems and badges, like a Fitbit. People love bragging rights, to go in the lunchroom and announce, “Hey, did you see I got the badge? I improved my patient accounting collections 3% over last week.” The attaboys and attagirls and things that come from gamification really started to move the needle.

We took time and attendance and added measures of quality that people would usually do through an audit. We automated that audit, so instead of looking at 15 accounts, do a score, and see which threshold they are at, we took all their Boolean logic and automated it. They ended up with something that is similar to RVUs. We called it a PVU, Performance Value Unit. It’s multi-variable calculus on, what does their time and attendance record look like? What does their quality score look like? Some people do things like training, so what is their ongoing training and CEUs? It’s more holistic than grading somebody’s paper on pure time and attendance and leveraging the Hawthorne effect in a positive way.

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

I expect, and we see this in the market, that our revenue mix will shift from 80% insights business and advanced analytics to 80-20 or maybe 60-40, where the 40% will be intelligent process automation. It will be us tackling administrative waste in the revenue cycle in a way that’s compelling and delivers an ROI. Right now we deliver an ROI by improving cash flow, bad debt, and underpayments and the like. I think that because the need is so great, our ROI will now be a combination of analytics and the results of automation, taking out the waste and also upskilling the revenue cycle folks to be directionally headed to being knowledge workers.

HIStalk Interviews Jeff Brandes, CEO, Azara Healthcare

Jeff Brandes is president and CEO of Azara Healthcare of Burlington, MA.

Tell me about yourself and the company.

I am a serial entrepreneur who has dabbled in all sorts of areas of technology. About 10 years ago, I came upon an opportunity in healthcare. At the time, I truly didn’t know the difference between Medicare and Medicaid, but I was heavily schooled by our initial partners as we started Azara. Here we are 12 years later and I can speak the lingo and I actually think I might even have a bit of credibility. Azara provides population health, primarily to safety net clinics, Federally Qualified Health Centers, and others who are serving the underserved.

The argument could be made that value-based care is the superior healthcare delivery model, yet patients are usually part of a federally supported program who are seen as underserved or disadvantaged. What are we learning about value-based care that can change the healthcare system?

The Federally Qualified Health Centers in general, depending of course on the state that they reside in, have mostly been fee-for-service with some shared savings and some upside. But because they are held accountable for quality metrics and improvements to maintain their status with HRSA, they have started to place an infrastructure that looks just like what is needed for value-based care into place. Looking at quality. Looking at high-cost events like readmissions. With both the cost aspect in mind, but clearly if someone’s going back to the hospital, they need more care or they need different kinds of care and it’s all in the effort of improving the patient’s health.

How is technology being used to identify those patients who need the most specific care?

We have learned a lot over the past few years. We started by automating things that we were doing already, in particular, billing. US-based EHRs are all centered around billing for services. But through that, we have collected a vast amount of data on our patients and are now just starting to find ways to unlock that data and make sense of it.

But as we do it, what we are learning is that it doesn’t matter how good the reports are and how good the information on the reports is if you can’t get that information to the right point in the workflow of the clinician or the provider where it’s easy for them to see and digest. You can’t make an impact on the patient. What we are starting to see, and what we will see in the years going forward, is more and more emphasis into how to get the right information that we already have to the right place at the right time.

There’s a significant amount of patient responsibility involved in participating in these programs since they need to be engaged, receptive, and perhaps educated about the concept. Does technology help in that way as well?

Technology helps us identify which patients are complying and are engaging a lot sooner potentially than waiting until they come in their next visit and they’ve gained 10 pounds and say they only take their meds once in a while. Using technology, we can at least identify some of those things. If they’re not picking up their prescriptions, it’s unlikely that they’re taking them. We can use things like that to get a bit ahead of the problem instead of waiting six months or a year, or for an emergency room visit, to realize that the patient is not engaging the way we had hoped or the way we had talked to them about.

They may be skipping doses because they can’t afford the prescription. How do you draw a line around delivering value-based care versus the social services that may be required for the patient to do what they need to do?

There are technology aspects and programmatic aspects of it. Of course, there’s just being in tune with it. The vast majority of our clients, the ones who are in the safety net, are very in tune with the patient’s social needs, screening for those and finding their patients affordable means to get the medications and other services that they need. First is identifying the need and then having access to the programs that can fulfill that need. Definitely medications is an obvious example, and there are programs to get medications in the hands of those who can’t afford it.

But when you start to expand the scope of those needs around housing and access to quality food in caring for patients, all of a sudden you need programs like Medicaid and Medicare to be a little more flexible in how those benefits can be delivered. Because it may not be a drug they need, but enough money to buy high-quality fruits and vegetables instead of processed food. Definitely we are hearing and we are seeing our clients look more and more for that flexibility in caring for the total patient in order to address their medical needs.

Capturing social determinants of health is becoming common, but what is the role of providers to help address them?

My perspective is a little biased because I believe that my customers in the safety net are a good bit ahead on this, but it doesn’t just affect patients at Federally Qualified Health Centers. My first experience with how being in tune with social factors and social determinants of health was an interesting one. In talking to a clinician, they talked about having a flag to tell them that the patient had unstable housing or was homeless. The patient presents themself with a run of the mill tonsillitis or some type of infection that requires antibiotics. Just by knowing and recognizing that that patient is homeless, you’re going to look at the available meds, antibiotics in this case, that you could prescribe. If you know they are homeless, you’re going to choose the one that doesn’t require refrigeration. Even though the refrigerated one may be the best one, you’re going to choose one that you know the patient is capable of hanging onto and taking effectively to cure that infection, versus something if it required refrigeration would get thrown away or likely not provide the intended effect. That was my first experience at how recognizing these factors and working with them could really change the way the clinician and the care team delivered their care to be more effective.

What are the constraints in recommending and arranging those services?

The majority of our customers are in the safety net. They are community health centers, and many of them function in the true nature of the word “community,” where they provide the medical care, but they have long established relationships with food banks, shelters, and social service agencies that can help fill these gaps. Do new challenges present themselves every day? Of course, they do. But I think they’re pretty adept at handling it.

I think what they’re optimistic about is that now that the broader world is recognizing the social factors and some of the disparities and starting to put funding and services in that direction, they are well positioned to be able to align their patients to take advantage of those services better today than they were yesterday.

What is the role of text messaging?

In our experience and with our clients, text messaging is extremely effective in the populations that our clients are serving. I’ll speak for myself. Getting text messages for my doctor is quite effective, and in some cases, maybe a little too effective, where I want to turn them off because there’s so many of them. But when I go back to the kind of programs we run and with our clients using texting, there are a lot of ways you can configure a texting campaign, especially around childhood well visits, immunizations, and cancer screenings that you’re automatically due for when you hit a certain age.

We wanted to work with our partners and our customers to make these things really, really simple to execute. From our perspective as a population health company, we know magically when you turn 45 and you’re due for a colorectal cancer screen. We don’t need someone to generate that list. We can build that list every week of who turned 45 and is due. We can see the record. We can kick off that campaign to message them to schedule an appointment. A week later, we can look and see if they’ve taken that action. If they’ve not, we can send them a second, gentle reminder. In fact, a week later, we can send them a third reminder and ask them if they care to schedule an appointment or if they are going to ignore this, etc. We can get some feedback through texting.

All of this runs in the background. No human has to go pull these lists every week look at who took the action and who didn’t. Every new week there’s a new group of patients that turn 45 and are due. It’s combining the text messaging with effective patient identification and automation to make this stuff just happen in the background so that no one at the practice has to handle it day in and day out.

What impact did the pandemic have on your clients?

I think the number one thing they walked away with, besides the confidence that they know how to treat patients even under some of the worst circumstances and keep things moving forward, is the importance of data and information. We had been in this business long before the pandemic hit, but all of a sudden that need for accurate data and the accuracy of it just bubbled up to the executive suite fast and loudly. We had clients for years whose quality staff and operational staff were engaged with Azara and all all of a sudden we were hearing from executive directors.

We were watching a lot of the disparities that we’ve read about in the pandemic, or as the pandemic unfolded. We were watching it in real data how it disproportionally affected those that were black and brown, and how that compared to the population within the practices that we were already serving. As these practices rolled out telehealth, we saw who had access to telehealth, who took advantage of it, and what those disparities were. It’s one thing to go with anecdotes, whether it’s to the state house, the Feds, or to your payers. It’s another thing to go with real numbers and fact. To come back to your question, it heightened the need for accurate and easily available information.

What will be important to the company over the next few years?

To us, the most important thing is to support our clients on their journey to value-based care. They are in different states and in different spots along that journey. Everyone is concerned about improving quality and making the patient better, and we should never forget that there’s a patient behind every number. No matter how good the data is, if there’s not someone out there to take action with it, it doesn’t make an impact. But getting the data, making it available for that journey, whether it’s quality, cost, or risk utilization. All of them play a part. More and more, the requirements are going to be how to get it to the right place at the right time in the workflow so it’s very easy for that provider to know what to do when they’re with the patient, whatever type of provider it is.

HIStalk Interviews Todd Cozzens, Managing Partner, Transformation Capital

Todd Cozzens is co-founder and managing partner of Transformation Capital of Boston, MA.

Tell me about yourself and what you do.

I built two companies in what we now call the digital health space, which we called healthcare IT back then. Marquette Medical offered cardiology software and the first vestiges of patient monitoring, the first vestiges of the electronic medical record. We bootstrapped that company since we didn’t know any better in those days, built it up, and I took the company public with the founder. We had a great run as a public company, then sold it to GE in the late 1990s, where it became GE’s cardiology software division and remains so to this day. I just went to the founder’s funeral a couple weeks ago, Mike Cudahy out of Milwaukee. He was an incredible inspiration and mentor to me.

Picis was the electronic medical record for high-acuity care — operating room, intensive care unit, and emergency room. We started Picis after the Marquette Medical exit and built it up over the years. We had 2,000 hospitals in 23 countries. We were going to take it public in 2010. Then the Affordable Care Act hit and UnitedHealth Group, at that time, was looking at the ACA with a lot of trepidation, thinking about things like medical loss ratio that could challenge their managed care business. As we all know, United made more money than ever in the ensuing years, but at the time, they were worried about that.

United was basically a rollup of 108 health plans. Every time they acquired a health plan, they got a technology piece, like a claims engine or analytics, and they used to roll that up into the division called Health Services. With the Affordable Care Act, they decided to monetize that group of assets and do a string of pearls in acquisitions. They acquired Picis under the idea that hospitals would just become high-acuity centers and low-acuity services would move out of the hospital into the ambulatory areas. They didn’t want to buy bricks and mortar hospitals, but they wanted to engage in the enabling technologies to make hospitals run more efficiently.

I stayed on after that acquisition and did a couple of things for United. Basically I was on the founding team of what became Optum, which was very exciting at the time because it was just a canvas to paint the future of healthcare with the company with the largest momentum and asset base to be able to build something big. Strategizing on how that would shake out was a really exciting time for those of us that participated in that founding. I ran the first value-based care division, which was dedicated to helping hospitals take on risk. This was early on in the value-based care spectrum and it was interesting figuring out what would work and what wouldn’t. My last job there was mapping out strategy and M&A and helping figure out what their next $3 billion of acquisitions would be.

I left there not long after that and joined Sequoia Capital, which was probably the most successful investment firm in the history of the planet. I was really excited to join them and help them with their emerging healthcare focus. They had not done a lot of healthcare in the past, so they needed someone that knew payer, provider, et cetera. I came on to help co-lead the healthcare investing with a guy named Mike Dixon, a young guy that they had hired who, at the age of 26, got them into MedExpress, the urgent care company, Health Catalyst, et cetera. I went on a couple of those boards. ZirMed, which is now Waystar. Little known fact — we were the first institutional investor in Epic, which is a long story, but interesting.

We had a great run there. My only issue with Sequoia was that healthcare was destined to be about 10 to 15% of what they did. I had the chance to start my own fund in 2016 with Leerink, the largest healthcare-focused investment bank. Leerink wanted to get into more on the tech side, and like many investment banks, wanted to start an asset management principle investing wing of the firm. The first fund that they wanted to do was growth equity digital health, so that fit with me.

I’ve known Jeff Leerink for 10 years and I was able to pull Jared Kesselheim, who’s a doc and MBA from the Harvard Mass General system, but more importantly, eight years very successful digital health investing with Bain Capital Ventures. I was able to pull him out of there. He was leading their healthcare investing at the time. Digital health was just starting to boom and the electronic medical record with the HITECH Act was proliferating, generating a whole bunch of data that caused thousands and thousands of companies to be formed. We were at the beginning of the digital health boom and off and running with a $350 million fund, invested in 15 companies across payer, provider, self-insured employer, and pharma, from a tech perspective. We don’t do therapeutics or diagnostics, but pharma is increasingly using this data to bring products to market quicker, et cetera. Virtual clinical trials, what have you. Self-insured employers were starting to directly try to manage conditions of their employees, not getting what they wanted from their brokers and their third-party administrators. The fifth area was the consumer. When I joined the workforce, there were no co-pays, no deductibles, and now families can be spending $6-7,000 on a deductible before they even touch the insurance, so people are going directly online to take control of their healthcare.

Those are the end user bases that our companies sell to. We were able to raise Fund Two during the pandemic, $500 million. My former partner from Sequoia, Mike Dixon, joined us as our third managing partner, built out the team of people that are just totally focused and experienced in this area with either the clinicians operators or long experience investing in this space. Healthcare is very complex, and to understand the intricacies of the reimbursement system and the labyrinthic payment system, in addition to all the nuances of sales cycles, et cetera, generalist firms generally have a tough time really understanding the space. We felt our focus would be an advantage. We invested in 16 more companies in Fund Two, and then we just raised Fund Three at $800 million and closed that in January of this year. We were heavily oversubscribed and ready to go. I’m glad we raised that when we did. Now we have lots of dry powder as we face this very uncertain future here.

How would you describe, to someone whose memory isn’t long enough to have seen it before, this market in which companies contract, valuations drop, and IPO activity dries up?

We are facing very uncertain times, but all indications are — and they are compiling every day — that we are going to enter into a extended period of inflation. Every time you’ve had full employment and this level of inflation creeping up, the economy has gone into a recession. The likelihood of us going into some sort of recession is high, and geopolitical factors like Ukraine are only adding to that prognosis. In uncertain times, you’ve got to be extremely aware of your circumstances — where your company is in its cycle, where you’re spending, and where you’re going to get revenue. The end result of that is you’re going to need cash runway to be able to survive these uncertain times. This will hit different areas of healthcare in different ways.

I’ve been through four of these in my career. Most of the millennials that we see as founders of companies today from 2010/2011 onward have never seen a down market, have never seen a contraction, have never seen a deep recession. Healthcare can be resilient because people still get sick and still need care, but other factors may not make that as viable as has been in the past. For example, I was on the phone yesterday with the CEO of a pretty large health system. He said, “This is the most challenging time I’ve ever seen in healthcare. We can’t find people to staff our hospitals. We have incredible shortage of caregivers right now. It’s not only the great resignation. The average ICU nurse is something like 48 years old. We already had a shortage of caregivers going into this and now that’s just been exacerbated.” He told me he was $50 million variance to budget on staffing costs already, year to date. Closed 10 ORs in the main hospital, the most revenue-generating part of the hospital.

I don’t think providers are going to escape this. Self-insured employers are going to start analyzing what’s nice to have, what’s got to have. In other words, is this point solution I have for diabetes or hypertension really going to save me money? Musculoskeletal is an area that has huge ROI, if you can help employees avoid surgery and get rehab. Getting into understanding the financial benefit, in terms of return on investment of your product, is going to be absolutely key here. The consumer will have less discretionary money to spend on some of these applications that they’re going directly online to engage in. Payers, maybe with a lower utilization, will continue to be profitable. Maybe they’re the winners in this. Yet to be told. Pharma is investing more and more in analytics to get their products to market quicker. Maybe they keep that spend going, because time-to-market will be essential here for them to keep their revenue streams going.

There will be winners and losers, but overall, we’re cautioning our founder who have not been through this before that if they just avoid all the mistakes I’ve made, they will probably do great. We went through financial downturns, such as when the Clintons first wanted to go to a single payer and healthcare was just frozen for a couple years. Obviously the dot com bubble, that wasn’t really the dot com bubble, and it wasn’t HIPAA or Y2K around the Year 2000. It was the Balanced Budget Act, where hospitals were bleeding money and they would engage these consultants like the Hunter Group that would help them just slash their budgets. Then obviously the 2009 Great Recession was significant because hospitals had put their monies in these mortgage-backed securities and couldn’t get liquidity in the assets that they had.

It’s really a time to hunker down and make sure you’ve got cash runway. I’m telling companies that they have 48 months. You should never be raising money again unless you’ve got 12 months of cash runway, because it will take that long and investors get spooked when you’re running out of cash, and they come in like sharks. Really hunker down on your expenses, watch your spend across the board, and keep your team motivated and focused. Those are some of the things we’re cautioning our companies on right now.

How will the M&A picture look in a situation where companies that either can’t turn quickly from growth to profitability or can’t establish a place in the market find themselves looking for a fire-sale buyer?

M&A will continue to be a big area of focus for some of the bigger companies. Some stuff will be cheap compared to the totally inflated prices over the last couple of years. We were definitely in a bubble. The multiples of forward anticipated revenue were crazy and off the charts, and now it’s time to get back to reality. What’s the real steady state of this business? What’s its gross margin? When does this company get to cash flow break even?

The multiples are already coming way down. They’ve come down on the public companies and we’re starting to see that creep into the later-stage growth companies. That’s going to start to affect all companies. There’s usually a lag there for sure. But still, in order to be acquired, you’re going to have to be a company that has line of sight on cash flow, break even, and profitability because these public companies have to acquire you and have to merge your profitability, or lack of profitability, into theirs and affect their earnings per share. Good businesses will still be acquired for reasonable multiples and there’s probably going to be a ton of fire sales out there, for sure.

Health systems are going beyond spinning companies off into actually creating startups and running their own investment firms. What effect will that have on the market?

It’s a mixed bag on those strategic entities. When I started Picis, there were 6,000 hospitals, and very few of them were in integrated delivery networks. Now there’s basically 500 health systems out there, so the number of customers that you can sell to in the hospital area has gone down to 500 decision makers versus 6,000. They have consolidated, and to their credit, they have strengthened their balance sheets through that consolidation, and that has generated pretty good cash flow for most of them. Many of them went off and set up these strategic venture funds.

Some of them are integrated into the strategy of the health system, where the C-suite and the chief digital officer are completely aligned on what they should be investing in or participating in. Some of them are kind of off on their own, investing in early stage companies that can’t scale for the health system. I think there’s going to be a culling of those. The ones that have been successful over the years and bringing great returns, like Ascension Ventures and Providence, will continue to see funding. The ones that are less integrated, kind of afterthoughts as in, “Hey, this doctor’s really smart and he’s got an MBA – let’s let him go set a venture fund up” are going to go by the wayside. We’ve already seen a few of them not get their next funding round.

How do you see the next few years playing out?

At the end of the day, we still have a incredibly broken health system, which is extremely inefficient. Yes, you may have a staffing issue, you may have fewer nurses than used to have, but you’ve got to make them more efficient and make them spend less time on tedious tasks and more time on automation. I’m still very bullish on the market and I’m happy with reasonable multiples from historic times.

When I sold Picis to United, four times forward revenue was a fantastic number. We did OK for ourselves back then. We don’t have to be 20 times. We don’t need 20X investments to return to our limited partners. We need reasonable exits in great companies.

I’m still very bullish. The need is there, the market is there. We are still in the early innings of this digitization of healthcare. I think it will take 15 years before we’re anywhere near digitized as other industries. We’re definitely more scrutinizing about the spots we pick, the companies we go after, the founders that we want to work with and who get it. We’re not going to be perfect. We’re not going to always pick the outstanding winners. But I think we’ll pick enough of them that hopefully we’ll be successful.

HIStalk Interviews Waqaas Al-Siddiq, CEO, Biotricity

Waqaas Al-Siddiq, PhD, MSc is founder and CEO of Biotricity of Redwood City, CA.

Tell me about yourself and the company.

I’m an engineer by training. I got interested in remote patient monitoring because I did a bunch of work at my grad school in remote monitoring. One of the applications was healthcare. I took a weird road through my career, as I think all entrepreneurs do. But I really felt that the future of healthcare was going to be in remote monitoring. I founded Biotricity and the rest has been history.

How are clinicians using real-time ECG monitoring and how does that compare to old-school Holter monitors?

There’s an application for both areas. We just recently got into the Holter space as well. But our focus has been chronic patients, patients where you have a risk of a heart attack or a stroke and where 87% of patients are asymptomatic. Many of these issues are happening at nighttime while you are sleeping. Traditional solutions are recording your data, but they are not monitoring. It’s called Holter monitoring, but  the “monitoring” name and nomenclature in the industry is misleading. It is recording your data, which you then download later for analysis the week after that report.

If you are sleeping and you have chest pain and wake up in the middle of a heart attack, the real-time monitor is looking at your data continuously and analyzing. It’s a smart monitor. When it detects that you have crossed a threshold, it sends a message with that strip of data to a call center, where we have nurses who know how to read ECGs and who can deal with emergency response. You can solve the problem for high-risk patients where if they are sleeping, you can get them in, you know what’s going on, and and you can treat them.

How do outcomes change with having a clinician on the other end of a real-time monitor versus consumer phone apps, where users have to initiate the reading and then react to vague “call your doctor” warnings when the app sees something resembling atrial fibrillation?

AFib is a good example, because a lot of people have chronic AFib. A clinician on the other side knows if you need to go to the hospital, such as if you’re in heart failure and won’t survive without immediate help. The clinician has enough data and can interrogate the device to get more data. By the time you get into the hospital, they know what’s going on.

Many times with our products, we see the patient’s heart going through pauses, or AFib burden that is increasing. That means that the patient’s heart is going to stop, or they are going to end up having a stroke if the AFib burden is increasing. You get an alert at 2:00 in the morning, the nurse calls the on-call doctor, and they get the patient in. But they already know that the patient is going to stroke out, or they know that patient needs an emergency pacemaker put in. The diagnostic and the treatment has already been concluded before the patient is even there. 

You are saving the patient’s life. But more importantly, you’re avoiding muscle damage. The big part of rehabilitation is that you have a catastrophic event, you survive it, but now you’re debilitated and you have to go through rehabilitation. Or maybe it’s been so catastrophic that you are going to have to live with a worse organ or a worse condition for rest of your life because they treated you, but got there late. This is where smart monitoring can really make a difference.

Patients at home call 911 and wait for first responders to evaluate and transport them. How does the process work when your monitoring center detects a problem?

They patient won’t always even know. We have had cases where patient is taking a nap, something happens and the alert goes in, and the call center looks at it and decides, this patient is going to go into heart failure or have a stroke, so we need to get them in. The doctor is called, looks at the data, and says yes, get the patient in. Usually there’s either an on-call doctor or a prescribing doctor, depending on how they set it up, so some physician is called once the threshold is met. They will say, call the patient’s family and tell them to come to the hospital immediately. Or they will say to call 911, depending on what is happening. The physician is directing it.

Many times you call the family member and tell them to bring the patient in for an emergency intervention and they say, “Oh no, that can’t be. They are taking a nap.” We say that we understand that they are taking a nap, but you need to wake them up and get them to the hospital because they are having an emergency event.

Smart phone atrial fibrillation apps trigger a lot of false alarms and send patients to cardiologists who determine that treatment isn’t necessary. How can that process be improved?

The bare minimum for effective diagnostics in the heart world, in the ECG world, is 24 hours of continuous analysis. Apple Watches and consumer products collect 30 seconds of data. They are not providing a holistic view of the patient, and even 24 hours doesn’t give you a good chance. Holter monitors and mobile telemetry monitors are being used from seven, 21, or 30 days of continuous recording. False positives and warnings about non-issues could just be random occurrences within that 30 seconds, but in the broader spectrum of 20 days of data, it’s a blip. 

We all have these blips, but our core health is solid. Smart monitors can track and watch this, and if the blips hit a threshold, the doctor sees that. Sometimes the doctor will say, this is not an emergency and I’ll see the patient when they come in. The event doesn’t meet the requirement for an emergency intervention, but they are making that call remotely.

That also happens when the device alerts for something, it goes to the call center, and the nurse looks at it and decides that it’s an issue, but not a life-threatening one, so they might not even need to call the doctor. Or they decide that it could be life-threatening, they call the doctor, and the doctor decides that it’s not an emergency and books them an appointment within the next couple of days.

What was the business case for developing the non-prescription Bioheart chest strap monitor that is sold in the competitive consumer market?

What we see is there’s 15 million Americans, maybe 17 million now, who are diagnosed with cardiac issues. We are part of that diagnostic flow. Once they have been diagnosed, it’s a lifelong condition. Whereas diabetics have glucometers, cardiac patients have nothing.

We created Bioheart to take the technology that we use to diagnose patients and provide it in a simplified, non-diagnostic scenario for personal use. It can collect long-term data on that individual so that patients can better manage their lifestyle. It targets individuals who are diagnosed or at risk for cardiovascular issues so that they can get that broader insight, because cardiac issues are intermittent and most patients and individuals are asymptomatic. 

They don’t have any insight. Diabetics can prick a finger, collect their glucose, and now can use continuous glucose monitoring without even doing the prick — it tells you your level and you can make adjustments to your lifestyle to manage that. Cardiac issues are way more complicated because they are intermittent and many patients don’t have symptoms. You have to collect a long amount of data to determine what you should or should not be doing. We introduced the Bioheart because we felt that individuals needed a tool, and in the marketplace, 30-second and one-minute data collections are just not good enough. You really need long-term data, and that’s why we built Bioheart.

Your website mentions pain management, which is fascinating since pain is monitored as subjective patient perception rather than a physiologic measurement, with limitations that can lead to undertreatment or addiction. How do you see your cardiac issue model applying to pain management?

Exactly right, pain is very subjective. One of the reason we started looking at pain and some of those issues is because pain can manifest itself with an elevated heart rate or elevated temperature. It will show up in certain metrics, including how you are moving. With our Bioheart product and how we are moving in terms of remote monitoring, we looked at how can we quantify and align pain.

The other thing with pain is that everybody’s concept of pain is different. One person’s pain level of seven might be a pain level of two to someone else. How debilitating it is subjective. One way to contextualize that and provide some objectivity to it – it will still have to be individualized — is to look at their biometrics. Someone may have a pain of seven, another a pain level of two, but both of them have elevated heart rates. One person has a natural tendency to deal with a certain kind of pain better than another. Another thing is the types of pain that individuals have. Some people can handle throbbing pain, other people can handle sharp pain. It’s all over the map. 

Our focus is to try to provide objectivity and link it to remote monitoring so that we can use data to support and provide insight to individuals so that they can better manage their conditions.

How do you see pain monitoring evolving into a business?

As we grow and as we continue to make inroads from a business perspective, it’s a service that we are providing to bring in that objectivity. We are not really focused on the nuts and bolts of revenue, rather that we have the technology, it’s helpful, and let’s make it available and we will provide it at free of cost. 

Long term, how it will transform into a business is that a lot of pain docs need a data point that individuals are engaged with. If they can do that, then they can bring that as a part of their way of managing pain for those patients. The commercialization, the business, will align pain specialists and make it a part of their assets and toolkit to help manage individuals’ pain. In that regard, we can create reporting and ink that to reimbursement. If we can achieve the goal and show outcomes that this tool is effective and offers objectivity that makes sense, then that is something that will become commercialized with insurance and we will have a commercialization pathway.

What are the company’s goals over the next three or four years?

One is to build our diagnostic product. We have multiple products coming out with the Bioheart and with the Holter solution. The next year or 18 months is about transforming into a platform company and building the entire cardiac ecosystem so we can track a cardiac patient from diagnostic all the way to disease management and have multiple touch points with them through their cardiac journey. We are with them every step of the way, and so building that brand.

Then 18 months after that, to democratize cardiac care and delivery across the United States. There aren’t many cardiologists — 70 million people at risk, 17 million diagnosed, and 25,000 cardiologists. It’s just too many patients. Many of these individuals have no access. In the smaller suburbs and rural areas, your access to the specialist is limited at best. We create time if we can make cardiologists who use our platform and technology more efficient. It allows them to focus on the patients that matter and the patients that are stable. We enable them with the tools to manage their conditions and we create time. Creating time and efficiency for cardiologists allows us to improve access. We can use digital help and virtual care to do remote diagnostics and deliver care across the spectrum. That’s our goal and our vision.

In three or four years, you will see a very different company. We are laying the groundwork today. I always joke with my team internally and my reps that everybody thinks Biotricity is playing checkers, but we are playing chess. We are releasing components of a broader picture that will create a domino effect three or four years from now, where we provide accessibility to cardiac solutions and cardiologists in an easy way by big technology, as a conduit for not only those individuals who are stable, but also to create efficiencies so that access is improved.

HIStalk Interviews Ed Marx, CEO, Divurgent

Ed Marx, MS is CEO of Divurgent of Virginia Beach, VA.

Tell me about yourself and the company.

We’re a consulting, design, and services firm. I have been in healthcare for 30 plus years in a variety of roles, initially, as a janitor in a healthcare facility, a combat medic, an anesthesia tech, and eventually chief information officer. I led digital strategy for a few global healthcare organizations, and now find myself as CEO of this consulting firm. It has been quite a ride, and I have to give complete thanks to all my teams and organizations that helped shape who I am that allowed me this opportunity.

Divurgent has been around as a virtual company since its inception 15 years ago. It has grown year over year at a quite fantastic pace. We are privately held, which has many, many advantages, and that certainly was one of the reasons that I was interested in taking this position. We have several hundred W-2 consultants, and we purposely have made many of our consultants W-2 because we think it makes it more of a family-type atmosphere. Depending on the projects that we are undertaking, it could grow to a thousand or 1,500, but those are typically 1099 or traditional consulting roles that we add. It’s a fairly sizable, I would say mid-sized, company, but growing. It’s at a sweet spot right now, but we have quite aggressive opportunity to continue our growth.

As a first-time CEO, how do you assess and manage the company’s culture, especially since you are taking over from a founder?

It’s a very humbling opportunity. One of the things that drew me to Divurgent is the fact that they are very strong in their values, and they live them. What I love is that at the beginning of every meeting, we talk about one of the five what we call ELITE values – excellence, learning, innovation, trust, and enthusiasm — and someone volunteers to give an example of how someone on the team demonstrated those values since the last time that team met. It’s great storytelling, so that the culture continues to be embedded in the fabric of the organization.

My task is simple in that I don’t want to be the one to change that culture. I want to help that culture continue to rise to the challenge. There is a strong basis for culture. There’s a lot of storytelling involved in that culture. It’s not like I have to come in and help create or shape culture. The challenging task ahead for me, as well as the entire organization, is how do we maintain that culture as we double in size? Retaining that culture is always a tremendous challenge for organizations that grow. Because of the foundation that has been set, I think we’ll manage it, but it will definitely be a challenge.

As someone who has spent most of their career working for non-profit health systems, does it feel different running a for-profit company that provides services to health systems?

It’s different, for sure. But what I like about it is that I can bring that mindset of the C-suite of the provider side. Divurgent was already pretty much there in terms of the partnership approach that we took with clients and prospects. Given my experience, the one thing that I am bringing to the table is that I know how the C-suites analyze and determine who they want to partner with. Bringing that thinking over to the supplier side or the consulting side can really meld well. Now it’s a matter of bringing that thinking and experience that I have, understanding the provider side, but also leveraging the team I already have that is expert in consulting, creating this unique partnership and unique capability. We are bringing those two strengths together, the experience of having been in the C-suite as well as the consultative experience, and that will be our sweet spot and one of our key differentiators

How did consulting change since the pandemic started and how will it look over the next few years?

The good news for Divurgent is that it actually thrived during the pandemic. One of the reasons is that because of the agile nature of Divurgent, and being that mid-sized company and privately held, enabled Divurgent to continue with these close relationships and be super flexible on everything when it comes to terms, the nuances of contracts, sensitivity to payments, and things of that nature. Some companies that might be more traditional or more beholden to stakeholders have to go by sometimes bureaucratic methodologies that don’t allow them that sort of flexibility. It hurt them a little bit being unable to respond quite as intimately with their customers. With Divurgent, we’re just continuing in that fashion of being agile in terms of understanding the customer and working with them in whatever unique terms they have. There’s no cookie cutter approach.

That comes out in the way that we work as well. We don’t bring best practices. A lot of companies pride themselves on bringing best practices to bear, but we don’t bring best practices. We co-create best practices with those organizations that are as unique to them as the solution itself. Going back to the size and being privately held, we can take this unique, customized approach. I’ve been on this side before, where I would have presentations done for us as a C-suite member, and it was a standard slide deck that you know they used last week with some other health system, and sometimes there would still be the old name of whoever the particular consultants pitched to last time. We just don’t do that.

During the pandemic, those relationships were solidified. Our customers started to recognize the fact that we’re not doing cookie cutter, we’re not bringing other people’s best practices and forcing them on them, but we will truly co-create with them. That’s the feedback I got before I took this position. I did my homework, just like Divurgent did their homework on my myself and checking references. I called some of their references, some of my peers who I knew were Divurgent customers, and some other knowledge bases that would have some information. One of the common themes is that the way Divurgent worked — and I’m not trying to sound like a commercial, I really am not — was unique in that it was customized. That really showed itself during the pandemic and helped the company to grow during the pandemic. That’s one of the attributes or differentiators that we want to continue with.

How would you describe the key elements of digital transformation in healthcare?

It’s one of those terms now that is almost meaningless. What we’ve been talking about is not digital transformation so much as digital acceleration. Everyone is using the term digital transformation, but when you look at what’s been done in the last few years — other than the majority of healthcare organizations moving to electronic health records and some outliers with virtual care and move to the cloud — we haven’t reached the scale of transformation that we might have hoped for five years ago or even 10 years ago. I’m focused, and we are focused as a firm, on digital acceleration.

One of the basic building blocks that’s still missing — and I’ve done personal surveys with CHIME members and I’ve seen other more formal surveys — is that the majority of organizations don’t even have a strategy in place. If not a strategy, certainly not a roadmap. What we saw through the pandemic — and this was happening before the pandemic, but was really exacerbated during the pandemic – is a lot of what I would call pockets of brilliance. There would be an immediate problem, standing up virtual care would be a great example, and then you look at it now and wow, this great thing was done to help patients, help save lives, and help with clinicians. That’s a pocket of brilliance. But what we want to do now with digital acceleration is take these organizations from pockets of brilliance to enterprises of excellence. It’s not just one area that you need to be good at when it comes to digital transformation, but it’s everything, all the different services that we do.

Beginning with a strategy, having a strategy, having a roadmap that basically says, what’s your baseline, and measure it. A lot of times we talk about progress, but no one takes a baseline. It’s like, no, let’s take a snapshot now. Let’s take a baseline. Let’s find out, where do you want to go? It’s pretty simple what I’m describing, but yet less than 10% of organizations have a written, codified, approved strategy. Let’s do this baseline, let’s benchmark so we have a general understanding where you are as an organization, and then where do you want to go? Then you have a natural gap analysis that’s done.

Then you can determine not 100 different things to do, because you know what happens when you do that — nothing gets done, or a bunch of things get done with a bunch of mediocrity. Let’s take 10. The magic number is different for every organization, but let’s just say the average is 10. Let’s do 10 things that help to move the needle on that gap, so that in three years you can say, we did digital acceleration. We were here in 2022, now it’s 2025, and we measure it. And of course you are measuring all along the way so that you can make adjustments and hold the organization and the leadership accountable. It sounds simple, and it actually is, but few organizations have the resource or focus to do it. 

That’s one thing that we are emphasizing with digital acceleration. Then of course, we can help with those things that might be needed to fill the gap, whether it’s a virtual care implementation or strategy or help with movement to the cloud or helping with robotic process automation, all these different elements that would be included in a digital transformation acceleration, but just aren’t being done. Or like I said, if they’re done, they’re being done in pockets of brilliance, but not enterprises of excellence. Ultimately, to get to what we’re all striving for, this amazing patient and consumer and member experience, as well as the corollary, which would be clinician experience. Oftentimes we just talk about patient experience, which is super important, but I’m a big believer in, patients come second. It’s the clinicians. It’s the staff. We have to make sure that they are not burned out so they can take care of patients, and that way, everyone wins. It’s that whole gamut from the strategy roadmap, all the way to things around virtual care, but ultimately to the consumer, member, patient, and clinician experience.

Health system CIOs commonly rose through the healthcare ranks and then took responsibility for everything that was related to technology. Health systems are now creating new C-level roles, sometimes filled by people from outside of healthcare, that have technology responsibilities. How is that changing the CIO role?

It has been a huge wake-up call in the ranks of the CIOs. To your point, a lot of CIOs were raised exclusively within healthcare. HR job descriptions would insist and reinforce this old way of thinking — you had to have 20 years of healthcare experience to become a director in a healthcare IT organization. CIOs were people within the ranks, and as a result, we got insular and accidentally shielded ourselves from all the great transformation things that were happening in other industries. 

It hurt us. The response by hospital CEOs and hospital boards was, oh my gosh, we do not have the internal talent to take us to transformation and acceleration and execution. We need to go outside. We need to go to Disney. We need to go to Microsoft. We need to go to AWS. We need to go to Walmart, to CVS, to Rent-a-Center, to you name it. These are real examples that I’ve just given you. These chief digital officers who had all this experience in retail, finance, and entertainment came in, and most of them have done an amazing job. In one way, I look at it as a sad thing, because many of my peers have the skills and can reequip themselves to better understand digital in these other sectors and bring that thinking and leadership to bear. But in many cases, they haven’t, and outside influences came in.

Overall for the patient, I think it’s a net win, because at the end of the day, it’s really about the patient care and patient experience, consumer and member experience, and the clinician experience. It’s a good thing to have this external view, external influence into healthcare. I think it makes us stronger. We could have been a little bit more thoughtful about how it all happened, but it happened, and I think it’s good. I always prided myself on having at least one team member who came from outside of healthcare. I had someone from entertainment, military, or finance because it always made us stronger. The argument that they have to be in healthcare because healthcare is unique and special is not true. While we are unique and special, other people can come in from unique and special verticals and learn healthcare. We all had to learn healthcare at one point. 

It’s good to have these outside influences, and like I said, it has been a net-net gain for everyone. We’ve learned so much from these individuals and these leaders that came from other industries. CIOs who are maybe more traditional should take note of this and take steps now to benefit their organization, and to benefit themselves, to make sure that they are not left out in this next wave or the current wave. Hang out with individuals from other industries, study other industries, learn more about what’s being done, and bring that to their organizations.

The pandemic allowed big health systems to get bigger by acquiring weaker community hospitals, and the remaining standalone facilities are also facing publicly traded competitors who are anxious to cherry-pick their profitable services. Can the traditional community hospital survive?

My heart and soul still are with community care. Divurgent wants to help hospitals of all kinds to not only survive, but to thrive in this new digital era. We want to help everyone. It is really important. I call it “survival of the digital-est.” It’s critical that all these hospitals, including smaller critical access hospitals and community hospitals, grab hold of this whole digital revolution that’s taking place and take action.

I’m afraid that some organizations have not moved quickly enough, or think that they might be insulated because of their location. If they are insulated today, it won’t be for very long. In the digital era, you need to embrace digital tools and all the things we already talked about related to consumerism, the clinician experience, and modern technologies to not only to deliver the highest quality of care, but do it in such an efficient way that you can afford to survive. We really want to help these organizations. 

That’s part of the reason that we wrote the book on digital transformation and have another one coming out on patient experience with Mayo Clinic, Cris Ross. It’s all aimed at trying to help these organizations survive and to move from survival to thrive. It’s incumbent upon the boards of these organizations and the leadership of these organizations to understand what’s going on and take demonstrable action.

How will the company change over the next few years?

At Divurgent, we expect to double in size, but our metric is not currency. When you talk to a lot of companies, they talk about growth that they measure it in dollars and cents. Like, we are going to go from $100 million to $200 million. We are measuring our growth in the number of clients served. We want to double the number of clients served. We believe that if we serve clients and we serve them with excellence, the currency and all the other metrics will follow. Not really fixated on that, but fixated on the growth of clients. How we do that is continuing with excellence. When I did my homework and looked at KLAS ratings and talked to Divurgent customers, 100% are referenceable accounts.That’s a meaningful metric that we’re proud of and will continue with.

Another is to look at new services. We already do advisory and services, but incorporating design, and what I mean by that is this human-centric design, in everything we do. In the past, a lot of consulting and a lot of services were process-oriented, which is good, and built on technology. But what we found are shortcomings. You come in there as a consultant or advisory and you leave and you don’t really ever experience and find out later why none of the initiatives had long-lasting impact. Incorporating the sense of human centricity, human-centered design, is another differentiator that we’re bringing to the table that will help drive growth.

Digital acceleration and that whole model includes the governance piece that was never really solved by many organizations, how they prioritize and how they make effective decisions. It never included what I would call value creation and the concept of, we are going to hold not only ourselves accountable, but let’s hold, or help organizations hold, themselves accountable to doing 360-degree, closed loop investment analysis. I serve on the board of Summa Health in Akron just had the same conversation with the CFO about ensuring that with all these projects, initiatives, and use of consultants, we do these 360, closed loop value realization exercises. That basically means that a year after you came here and you said you’re going to do X, Y, Z, what was the actual performance? It doesn’t have to be with a consulting organization, but since we’re talking about Divurgent, that’s just another sense of differentiation, that we are going to hold ourselves accountable to what we partnered with the organization on.

We’re seeing a lot of M&A in the consulting business. You’re seeing some health systems buying consulting consulting firms, and you’re seeing big tech acquiring firms like Tech Mahindra with HCI. You see mid-sized players exiting the market and I think you’ll see a little bit more of that, which will provide more clarity for those who are left in that market. There’s going to be a lot of changes coming in the next several years, in terms of the number of firms that stay in the market and focus on delivering this level of value that I’m speaking about to their clients.

HIStalk Interviews Justin Sims, President, CareMesh

Justin Sims is president and COO of CareMesh of Reston, VA.

Tell me about yourself and the company.

The business of CareMesh is all about helping healthcare organizations break down communication barriers so they can better coordinate patient care. We do this by helping them solve a number of related problems. Firstly, finding the providers that they want to engage with, then exchanging patient information with them, and then coordinating actions and decisions, both within the organization and between organizations. I guess if you wanted to give us a label, I would call it care coordination.

As to me, I’ve been doing this with CareMesh for the past five years since we started the company, but I’ve worked on a number of similar problems in other health tech companies over the last 20 years. Before that, I did about 15 or 20 years in the telecom industry. But I can tell you for a fact this is a lot more fun.

How well do health systems communicate with their local, community-based physicians?

The truth is that the dominant form of unstructured communication in healthcare today is still stuck in 19th century technology. And I meant it when I said 19th century technology. The first fax, if I’ve got my history right, was sent by Alexander Bain in 1843. That technology is still the dominant form of communication in healthcare.

A lot of people incorrectly think that Direct Secure Messaging is the answer to that, but it isn’t, for a couple of pretty big reasons. The first is a practical one. Only about half of physicians in the community have Direct addresses and can technically use that form of communication. But the second reason is more a structural one, and that is that the standards for Direct messaging focused on exchanging CCDAs, structured patient records, and they didn’t focus on unstructured communications, which is where a massive flow of communications actually takes place. That’s why communication with community providers is still pretty challenging.

It is inevitable that healthcare is scorned for being behind other industries, but isn’t part of the reason that it is more limited by HIPAA and privacy concerns that preclude using the usual consumer-grade tools?

I think that’s right. We are not like others, for a couple of reasons. One is the privacy concerns, although I would say a fax is not exactly the most secure form of communication in the world from a HIPAA perspective. It was one of those things grandfathered. But the other thing that I think makes healthcare communications complicated is that a patient record doesn’t fit into a PowerPoint, an Excel spreadsheet, a Word document, or a PDF document, which is how other industries often exchange information and data. A patient record itself is uniquely structured. 

That’s why it’s important to give credit where due. The government’s efforts around interoperability and getting unique forms of patient record exchange established are important. But again, I come back to these unstructured communications, these things that are so important to coordinating patient care. Not everything fits into a CDA. Not everything fits into a patient record when you’re coordinating a referral or a discharge. Sure, you can send structured patient record information, but that’s only a small part of what needs to be done to properly coordinate with an outside provider. That’s where HIPAA and the lack of a common messaging standard for plain old communications make certain types of communication difficult in healthcare.

Unlike hospitals, most community-based practices don’t have big capital budgets, training and technical support teams, and a commonly used brand of EHR. Does that make communication with them harder?

Yes. It also needs to take into account the workflow within a practice, that there are as many different workflows as there are practices. Some community providers are organized centrally, with a coordinator taking care of everything coming in and protecting the doctor from information overload. Others are organized with perhaps a nurse practitioner or a clinical assistant helping the doctor. Others are organized where the doctor really wants to take care of things themselves.

One of the challenges is that hospitals often attempt to impose their solution to clinical communications on the provider in the community without actually taking account of the fact that they are organized differently. They have different information needs, and they certainly have different workflows. All of that needs to be taken into account when designing a communication strategy, for example, with a hospital and its community providers.

What does a hospital user see and do differently when their organization’s Epic or Cerner system is integrated with CareMesh via APIs?

There are a couple of key things that both the hospital and the community providers get out of that integration. From a hospital perspective, we literally take care of all communications from and between community providers. The hospital doesn’t need to worry about maintaining a directory, dealing with message failures, or having gaps in who they can communicate with.

Our delivery rate is pretty astounding. Only in one out of every 300 communications that the hospital gives us to deliver do we have to go back to the hospital and explain that we can’t deliver it for a particular reason. Very often, that’s because the practitioner has retired or moved out of state or something of that nature. The first thing that the CareMesh solution does is solve or address the problem of the administrative side of communication.

But from a community provider perspective, we don’t force any particular solution on the community provider. We give them multiple options. If they want certain communications delivered by fax or by Direct Secure Messaging, or they want to log into a portal to look at information, they can choose that. If they want information sent centrally or to a delegate of the doctor or to the doctor themselves, they can choose that. We have created a system that allows the community providers themselves to say that if you’re sending a referral, don’t send it to me, send it to this person instead, and I’d actually like it delivered by fax. But every now and then, I’d like to go to a portal and download the patient record. We give as much flexibility to the community providers as possible so that the communications are relevant to them.

Direct addresses were never as simple as they seemed given that a provider can have multiple employers, multiple roles within an employer, and may change employers where some messages should remain within the original practice. Is there a better way to manage the use of the Direct address system?

It’s certainly still a challenge. DirectTrust has done a great job at consolidating a directory of Direct addresses, but the information is only as good as the sources. There’s a chain, if you like, to get the information into the DirectTrust directory. It starts with the organization that employs the doctors and other healthcare professionals and then moves to the HISPs, the health information service providers that run the Direct messaging platform. Then it moves to the DirectTrust directory. That chain can and does break, so often Direct addresses are out of date or they’re not complete.

There are about a million doctors in the country, and we’ve been able to match Direct addresses with a little less than 50% of those. Some of those Direct addresses come from DirectTrust, some from hospital systems, and some from NPPES, which is now collecting that information. We get the data from a variety of sources. But there’s still half of the doctors in the country that don’t have a published Direct address. That represents a fairly big challenge when relying on Direct for communication purposes, in particular, CDA exchange.

One benefit of a fax number is that the receiving organization receives everything that is sent, then intelligently routes each message appropriately. Is there an electronic messaging equivalent?

There are certainly tools around Direct to support that within a number of EHRs. EHRs are able to route messages according to particular rules. One of the things that those of us that are close to healthcare communications would advocate for is Direct working a little bit more like POP email. But that’s really dependent upon the EHR vendors adding more sophistication to their messaging platforms.

In the longer term, there is a strategy that the government is advocating for to create what are called FHIR endpoints. These are essentially web addresses that would allow one healthcare organization to post information into the EHR of another healthcare organization. That could be used for structured communications, like exchanging patient records, or unstructured communications as well. So there is a long-term strategy that could over time close some of the gaps, but it really is a pretty long-term strategy. A lot has to happen for that to solve all of the problems that we’ve been talking about.

What are the challenges involved with maintaining a provider directory?

Maintaining a directory of about 5 million people is a labor of love, but it’s also a big data challenge, and it’s a constantly moving feat. Let’s even narrow that down to just a million doctors. If each of those doctors change a piece of information within their profile every two or three years, such as a change in a location or a communication endpoint, you’re dealing with hundreds of updates that need to take place every day. That’s not something that can conceivably be done manually alone. We heavily rely on big data technologies to pull together the most comprehensive and best view we possibly can of that provider, and we use all sorts of specialized techniques. There’s a concept called master data management that we use to make sure that we present the best possible information possible.

We have also realized that it’s important to design a directory for all, not just some, use cases. We have insurance customers. We have state and local health department customers. We have hospital customers. We have HIEs. We feel that ultimately a single resource that can support many, many different use cases is the only way that anyone is ever going to be able to maintain a strong directory. It’s got to be scaled. It’s got to be heavily utilized by many others. It’s through some of the methods that we talked about that you can gradually get to something that is fit for purpose. It will never be perfect. Anything in big data with 5 million records in it, 5 million providers in it, is never going to be perfect. But it should be good enough to meet the basic needs of registering patients, sending communications, and so on.

How do you see the company’s business changing over the next three or four years?

I think our business is going to evolve as the industry addresses and improves generically on some of the challenges that we’ve talked about. But the foundation of what we do is our directory business, which we brand Search. But a directory on its own is going to be quite limiting in terms of what it can do if it’s not integrated with a communications capability. As we discussed, we augment EHRs and other systems and their native communications capabilities by making it possible to communicate with anyone and everyone.

But the area that is perhaps most interesting as it expands and evolves into a new line of business for us is that once people can find each other and can communicate with them, they then need project management tools and workflow tools to help them manage the patient journey through their particular healthcare condition. It’s those project management tools that we’re providing today, we brand them Navigate, that I think stand the greatest chance of developing into scalable solutions to solve these care coordination challenges that we’ve been talking about.

HIStalk Interviews Kevin Coloton, CEO, Curation Health

Kevin Coloton, MBA, MPT is founder and CEO of Curation Health of Annapolis, MD.

Tell me about yourself and the company.

We formed Curation Health in 2018. The primary objective is that the recognition that value-based care is extremely complex, and often a more difficult transition for organizations to take migrating from fee-for-service than many expect. It is particularly challenging for the providers at the front line of care delivery. 

We are obsessed with solving for the experiences that our end users need. In our case, that’s the providers and the support they need to have sustainable success in value-based care. We recognize who they are and what they need, and we design tools and solutions to make it easier for providers to do the right thing when engaged in value-based care activities.

The end result of that is we have built a clinical decision support platform that facilitates provider workflow with the goal of elevating care delivery and receiving the appropriate clinical and financial outcomes for good work being performed.

I’ve had the great privilege of working in the healthcare industry for the past 25 years in various roles. Specifically, in patient care as a physical therapist, hospital administrator, management consultant, technology executive, and entrepreneur. I’m also fortunate that we have been able to assemble a team at Curation Health of industry veterans that have served organizations in health technology, consulting, and value-based care for a long time. They hail from organizations like Evolent, Optum, and The Advisory Board Company in Clinovations. In many cases, I’ve had the great privilege of working with a host of my colleagues for a very long time.

We’ve heard for years that value-based care is just around the corner, but most providers continue to make most of their revenue and profit from fee-for-service. How will that change?

The evolution of value-based care is slower than many expected, but is making progress. One of the most interesting, catalyzing events has been COVID and the pandemic. If patient volumes decrease in a purely fee-for-service environment, the clinical and financial implications of care for patients is pretty significantly impacted. Many organizations have recognized the need, despite the fact that they have a primary focus on fee-for-service. A balanced portfolio across fee-for-service and value-based care makes good sense to allow organizations to have sustained success.

We are seeing the march to value-based care taking a dramatic turn in the last nine months, where organizations are seeing appropriately that they need to start building the infrastructure and participating in value-based care. In some cases in their regional and local markets, the health plan and provider collaborations have greatly encouraged migration to more value-based care. It’s an important effort for almost all organizations, regardless of their payer mix, to have begun investing in value-based care infrastructure, capabilities, and knowledge.

How do the clinical decision needs of providers change as they start to see patients under a value-based care arrangement?

When you reflect on what’s different between fee-for-service and value-based care, most organizations today — unless they are purpose-built for value-based care — rely on a fee-for-service infrastructure. Their operations, their scheduling process, their patient contact. Even the clinical operations themselves of registration, check in, rooming the patient, seeing the patient, and allocating time for visits are all very different if you’re in a fee-for-service environment versus value-based care. 

The provider challenge is that they are attempting to have more intensive, longer value-based care interactions with patients where they are reviewing the complete chart and trying to prioritize, what is the clinical focus for our time today? They are balancing that with fee-for-service interactions, which are typically 10 minutes or less and focused on the reason for the visit. Why is the patient here today? Certainly they take care of other healthcare priorities as well, but it’s a very different mindset and operational approach.

Our goal is to simplify, to take some of that cognitive load away from identifying which patient is in front of me today. Which plan are they associated with? If they are in a value-based care arrangement, what should be my clinical priorities to address today for this patient, oriented to the highest clinical impact? If I only have time to do one thing today, what’s the most important thing for me to do? Or, what are the top two priorities I should focus on to achieve with this patient today?

The other big transitional difference is that value-based care is managing thousands of patients over a calendar year. Fee-for-service is typically prioritized and focused on, what are the priorities for the 30 patients I have scheduled tomorrow or the patients I have scheduled across the next few days? It’s a pitching and catching delta, where value-based care is a strategic approach across the calendar year and fee-for-service has a tendency to be more reactive, where patients are coming to the clinic, in the home, or in a telemedicine visit with a particular urgent or emergent need or acute need. Those are very different operational approaches. We aim to simplify that.

The technology requirements of that “feet in two boats” situation, where a given patient may be covered by fee-for-service or a value-based care arrangement, must be complex.

Massively complex. The attribution of patients alone is a massively complex undertaking. Which patients in my care are mapped to which value-based care program? We have some clients that have four, five, or six different value-based care contracts with different health plans. That complexity is massive.

Our goal is to greatly simplify that by having the provider focus on one simple workflow, and have that workflow be agnostic to whatever plan they’re mapped to. We focus our technology to simplify, to say that “this patient has these priorities that would benefit from being addressed in this interaction for the provider” instead of the provider trying to figure out which health plan it is, and of that plan, which subset a VBC contract is aligned with that. What have I already taken care of this calendar year? We seek to greatly simplify it by producing insights that are prioritized by clinical impact and greatly simplified into the handful of items that the provider can take care of to maximize the health of the patient.

In some cases, they are not even aware of which value-based care contract that patient is mapped to, because they don’t need to be. Their focus is on rendering awesome clinical care for the patient. Having one simple workflow enables them to focus on what matters, which is, this patient needs my help in these areas.

The healthcare technology industry has a tendency to focus on what we describe as data maximalism, which is this mindset that bigger is better. It’s really the identification of massive amounts of data that holds limitless potential value, and it’s candidly the easiest and most exciting approach to take. You can use incredibly modern and precise technologies to harvest a tremendous amount of data at a patient level or across your whole community of patients you’re serving. 

When we launched Curation Health in 2018, we learned the hard lesson of having a data maximalism approach. The problem is that when you’re analyzing a massive amount of data — and in our case, we also compile this dataset with human review to find more and more items of opportunity — the results we found were counterintuitive. The more accurate and voluminous the data that we found and sent to providers, the less they acted on it. 

We quickly learned that the value is not on the potential of this information and what it could do to transform provider success. The only thing that matters is what information they are going to use when managing a patient’s health. Therefore, we came to this realization that value-based care, healthcare technology analytics and reporting, and clinical decision support are not really technology problems to solve. It needs to be a clinical workflow problem to solve. How do you make it easier for the provider to do the right thing?

We evolved this concept of data minimalism, which in our mind is the minimum dataset required for a provider to use to enhance the health of their patient. Instead of bigger is better, which is the data maximalism approach, data minimalism is that less is more. Once we prioritized and contextualized the information that we were sending to physicians, we saw adoption and use skyrocket. It was a really powerful lesson for us. It revolutionized the way we design our technology platform, how we build our user interface, and how we choose the information that we are serving. It made it simpler for providers to act. We learned more and more of the power of simplicity and the direct correlation with provider adoption and use.

How much detail and complexity is contained in a provider’s value-based care contract that is translated into plan-specific clinical decision support?

The contracts themselves are incredibly complex. They are very different from agreement to agreement. Some prioritize risk adjustment performance HCCs and related measures, RAF particularly. Some prioritize quality, HEDIS, and Stars. It is very dependent on the region, the health plan, and the provider partnership. Because of that, we spend a lot of time with our clients helping demystify the agreement that they are participating in. What would be the analysis of the return on investment clinically and financially for the organization? What are the KPIs that the provider group needs to focus on to achieve the results they’re hoping to achieve? If they have limited time, where would they emphasize their focus and dedicate their attention to serving particular metrics, measures, or activities that help everybody win in this equation?

The premise with this equation is that if we can prospectively manage the patient’s health and outcomes, then we can improve their health, and everyone wins in this model. The health plan, the provider organization, and ultimately the patient. The goal is to also understand that this particular value-based care contract prioritizes certain investments of energy and time and making sure that everybody is aware of those and keeping appropriate attention on those items.

How does the pre-visit review differ under a value-based care arrangement?

I had the great privilege of running ambulatory clinics for a period of time in a predominantly fee-for-service environment, so I have a good sense of how that works. The value-based care pre-visit activities are dedicated to figuring out ahead of a clinical interaction, what are the top clinical priorities that this patient is challenged by? Then, focusing the provider attention on those priorities.

In the traditional model, physicians would quickly scan the chart and go into the room, if it’s a clinic setting, and ask the patient something along the lines of, “What brings you to see me today?” to make sure that they are aligning what they see as the priorities with what the patient priorities are. That’s good practice.

In a value-based care world, it’s a little more complex, because you have to understand what you’ve already done that calendar year. What items remain to be managed? Also, what are the priorities that you haven’t yet covered with the patient that would greatly improve their health and wellness? 

That concept of pre-visit is leveraging good technology to discern clinical opportunities from the thousands and thousands of lab values, radiology reports, HIE data sets, EMR data, and claims data and narrow it down to a specific set of high priority items that the patient would benefit from having managed. In some cases, the pre-visit review also involves a human reviewing the output of the technology or the reports to further refine the data that gets to the physician. Ultimately, the goal is that when the physician enters the room with the patient, they are well aware of the clinical priorities that need to be addressed, but they also have the context as to why these are priorities.

One of the big challenges of working in a fee-for-service and a value-based care world is that providers are challenged by capacity, time, and resources in most cases. They have limited time with the patient. They may not have a lot of technology tools or humans to participate in that pre-visit analysis. So when they review the clinical opportunity while sitting in front of the patient, they often don’t have enough time to validate them, to go through the EMR and understand when this lab value is drawn and what this comorbidity and this medication might lead to. The goal with pre-visit is to take all of that clinical administrative research and have most of it conducted before the patient is being seen by the provide so that the provider is able to focus their attention on validation and action rather than just pure research.

Do patients know that they are being covered by a value-based care arrangement? Do they need to be educated about their role in it?

It varies. In some cases, patients are well aware of the program that they are participating in. They are able to make determinations of which network they want to participate in or who the provider group they want to have administering their care. In other cases, it’s more of an administrative function that happens in the background, and patients may or may not be aware of it or have much information or insight into what it means and the potential delta of how the physician may be managing their clinical interaction.

I think Medicare Advantage has become the largest area of focus in the value-based care realm. A lot of patients are becoming more understanding of why it’s important to have more of a prospective care approach than a retrospective care approach or a fee-for-service, real-time engagement. 

It definitely varies by region, by plan, and by other elements. But I have seen many cases where patients are very aware of it. I think you’re right, though, that the onus is on the provider, the practice, the organization, or the health plan to educate the patient as to the change in the model of care being delivered. From the feedback we hear, patients have appreciated the value-based care approach, because it feels like their care is being holistically managed and sometimes a bit ahead of time. We are biased, but we believe it’s a better model of care delivery where you’re trying to anticipate future need by focusing on current challenges and engaging the patient in that journey more directly.

What factors do you see impacting the company’s strategy in the next three or four years?

Several elements are going to be impacting our strategy. We highlighted one of them at the beginning of our conversation, which is how quickly organizations are adopting value-based care. Some organizations are in the early phase of their journey, while others have been doing this for some time. That progress directly impacts our ability to serve and elevate performance for those organizations. The ever-changing nature of the value-based care design model and contracts definitely are impacting how we do what we do. Every year we are constantly scanning regulatory changes. Compliance is a huge priority for us. Our clients are relying on us to greatly focus on that. We need to be very current, and the only constant in the value-based care structure to date has been change.

The other element is care model delivery has been greatly changing. We’re having a real increase of organizations focused on in-home primary care, in-home specialty care, and virtual care. How all of those align with value-based care models has been interesting and fun for us to design and partner with. I think that will keep us busy for some time.

HIStalk Interviews Mariann Yeager, CEO, The Sequoia Project

Mariann Yeager is CEO of The Sequoia Project of Vienna, VA.

Tell me about yourself and the organization.

I’ve been in health IT virtually my entire career. I got my start years ago working for an insurance company, then a clearinghouse, and have been in health IT ever since. I got into the interoperability space, working with the ONC on the Nationwide Health Information Network project, which led to the formation of this particular project 10 years ago. We were formed as a non-profit, public-private collaborative. We are solely focused on advancing interoperability for the public good and working in collaboration with government to offset the burden of what they’re trying to accomplish.

Is the lack of interoperability a technical problem or a business problem?

All of the above. There are policy, business, and technical issues that impede the ability for information to flow seamlessly. That’s where we focus our energies at The Sequoia Project, identifying the issues that are impeding progress and systematically addressing them one at a time.

What other industries provide a model for competing organizations exchanging information about their shared customers?

Certainly we can learn a lot from financial services, telecom, and banking. In fact, as we were exploring and preparing to launch Carequality in 2014, we researched how things operate in the ATM and ACH world, where they have a non-profit that brings together different stakeholders to develop rules of the road so that ACH networks interconnect. Carequality was modeled after that type of activity. There’s a lot we can learn, but in some ways, what we’re dealing with is a far more complicated transaction than a banking transaction, so there are a lot more issues to unpack.

Arguments have been made that healthcare participants should be paid for sharing data instead of being penalized when they don’t. Is the sharing model yet to be determined?

From where we sit, there needs to be a baseline of technical and policy capabilities in place to interconnect our ecosystem.Then there needs to be a value to exchange and then an impetus to exchange. The value to the exchange usually comes from the value of the information and whether it offsets some administrative burden. Is there a return on investment, for instance, or does it somehow contribute to some other good? That’s the first thing to look at and explore — the value of exchange.

Then the impetus to exchange is, how do you get people to use the capabilities that exist? Again, it’s really derived from value. You can have opportunities to have better information more readily accessible and that makes the clinician’s life easier, makes supporting value-based arrangements easier. The impetus to change can also come from governmental mandates. What we are seeing in our space now is a combination of all the above, which creates an exciting opportunity to advance the ball within interoperability, because the stars are aligning in terms of all these things coming together.

How will ONC’s information blocking review work under a complaint-based system where it’s often a big health system that isn’t sharing patient data?

We’ve seen tremendous progress in healthcare organizations interconnecting for treatment purposes, of course, starting with health systems. There’s a tremendous volume of information being exchanged between health systems and now increasingly across the continuum of care. 

We have to take into account the maturity of the platforms that these other care settings are using to support their clinical environment, and then the other actors that have a need for health information but that aren’t even participating in the network. It makes it a lot more difficult if you’re trying to approach point-to-point arrangements versus if you’re a public health agency, a health plan, or a small physician practice. If you’re able to connect to a health information network, that is the mechanism that allows you to access information. Then of course if that network interconnects with other networks like to Carequality or an ONC-endorsed TEFCA framework, that’s where we’re going to see the seamlessness. I think it’s a reflection of, in part, the maturation of those capabilities, the ability to participate in networks and along that life cycle. 

Then we can’t even begin to speculate how ONC might and OIG may be approaching compliance. With respect to the different actors, health information networks, health IT developers, healthcare provider organizations, et cetera, that really remains to be seen from where we sit. It boils down the very practical issues that are impeding exchange — different interpretations of law, different interpretations of policy, different interpretations of what is even treatment-based exchange, care coordination treatment. We’re getting greater clarity around that. For us, it’s much more nuanced

What efforts are you seeing to connect public health to the healthcare system?

It’s pretty ad hoc right now, for the most part. Everyone realized that in the midst of a pandemic is not the time to try to create an interconnected health IT ecosystem that the public health is plugged into. But there are tremendous opportunities to leverage existing infrastructure for that purpose. Naturally there are regional statewide HIEs and others that are doing interesting things to support public health and make it easier for public health agencies to get the information that they need.

Electronic case reporting is getting significant uptake and being supported both within nationwide networks and with others across and between networks. That is just an example that if you have a discrete use case and you have a trust framework in which to support it, that capability exists. This is an area where we think that TEFCA is going to play an important role in advancing this in a much more robust way for more public health capabilities.

Can you describe in simple terms the impact that TEFCA and Qualified Health Information Networks might have on consumers and providers?

The 21st Century Cures Act was passed into law in December 2016. It directed ONC to develop and support a Trusted Exchange Framework and Common Agreement, TEFCA, to support the exchange of information between different, disparate health information networks. ONC has been working since then to develop key elements to enable that to occur. They were given the ability to work with a private sector organization to help them implement the different components of TEFCA to operationalize it. The Sequoia Project was selected to serve as that private sector organization, an official designation as being a Recognized Coordinating Entity. We are working with ONC to develop the agreements, the implementation guides, and the onboarding process that would enable networks that want to receive special government endorsed designation as a TEFCA Qualified Health Information Network, or QHIN, where we would work to facilitate that process and do the onboarding and designation for those that comply.

How do the various elements of trust fit in with the ability to exchange information, including one provider not trusting another’s data?

It’s a policy issue, and there is a technical element and workflow element as well. The idea of having trust agreements and trust frameworks is so that a participant — a healthcare organization or participant or actor in one network — can rely on the information they’re getting from someone else. That it comes from a trusted source, that they’re abiding by the same rules of the road, and that the information is only going to be requested in accordance with certain rules of engagement. It will be appropriately protected. That is very foundational before someone would even be willing to share information at all.

The other part of that is, can you trust the information itself? Does the information have value? Is it semantically valid? We are doing a lot of work on that at The Sequoia Project through our data usability work group, which includes a group of subject matter experts, guests from across many different stakeholder groups, to try to define in a more clear way how data should be codified to improve the value and meaning of the information when it’s exchanged.

Is a national patient identifier essential to the process?

The issue around the national patient identifier is multifaceted. Some believe that it would be the linchpin to solving interoperability, while others say that it really has value for a small portion of identities that we can’t match through other means. At Sequoia, we tend to be practically oriented about what can we do today to improve matched results and increase it over time. We publish white papers to that effect and refresh and update white papers we published years ago. The use of secondary identifiers, and adding that onto the other identity traits used for matching, can be quite effective. We think that there’s a lot of value in continuing to look at methodologies like that. We tend to meet the market where it is and set our sights on what we can do to incrementally improve progress over time. A unique health identifier has its place, but there are also things we can do today to make tremendous progress. We look at that very carefully,

People often misunderstand HIPAA or misrepresent it to support what they want to do. Is the 1990s-era rule a barrier to what you would like to accomplish?

In some cases, HIPAA is very much an enabler, because it is a standard for privacy and security that we can leverage and it is well understood and established. In other cases, HIPAA predated most of the digitization of healthcare, and there are aspects of it that are, as you said, misunderstood or misinterpreted. Maybe it is an area that needs further clarification.

A good example that we saw in the pandemic was that healthcare organizations were reluctant to share summaries of patient records with public health agencies. They worried about exceeding minimum necessary. OCR issued guidance clarifying that if you receive a request from a public health official, you can trust that it’s for the information that they need. It was still an impediment that was more of a policy interpretation and a risk tolerance. It was more of an impediment in terms of interpretation and understanding. Trying to get that kind of clarity in the midst of a pandemic is quite challenging.

People who read about FHIR and interoperability APIs may think we’ve solved the problem, but many of us still have personal experience where a new provider is starting with a blank slate. Is consumer education needed to set expectations for information sharing and blocking in a complaint-based system?

FHIR, APIs, and the emerging role that apps will play in enabling consumers to access their health information are all tools in the toolkit. If you think about it from the perspective of individual access, you have obligations now to share information with individuals. It’s an imperative. We are working on how to operationalize that.

A good example of that is the work that we are doing with the ONC on TEFCA and those organizations that participate in TEFCA, others as a QHIN itself or as a participant or someone connected to QHIN itself. There’s an obligation that if someone requests their information and if you have information about that person, you must share it unless you are not permitted by law to do so, or somehow breach privacy or security.

We look at not so much information blocking as a compliance paradigm, which it certainly is, but if you turn it on its head, it’s an information exchange paradigm that TEFCA and other activities can reinforce. The more we address impediments to information exchange, the more we get down to the brass tacks of how to make this work seamlessly. Individual access is an excellent example, because we can support that on a wide scale basis today using the very standards and protocols that have existed for a long time and using new standards and protocols such as FHIR. The issues often boil down to policy. That’s really what we’re trying to unpack with respect to our work on TEFCA.

ADT notification is a lightly heralded success that took a lot of effort. Are you seeing significant uptake?

ADT notification is a great example of capabilities that were born out of market need and demand organically. You see so many health information networks supporting those capabilities, and have that reflected in regulation as well, as a way to demonstrate meeting certain measures with CMS. It’s an exciting paradigm to witness. We hope that the work that we foster here in the private sector can be pointed to in other ways. That’s why we work very much at Sequoia with boots on the ground, trying to resolve issues that have practical implication and get some traction that hopefully reinforces and supports policy goals.

What will be the most important interoperability issue over the next two or three years?

I would like to see us move beyond the sharing of information for treatment purposes. We’ve seen tremendous progress and very much take pride in what we, as a collective industry, have done in that regard. We can expand that to support other use cases, such as the exchange of information for payment, for healthcare operations, to individuals, and for public health purposes. I am very positive about our ability to reach that. We have good momentum. We are getting good traction. I think we will start to see some real progress in that respect.

Do you have any final thoughts?

I would like to reflect on the past 10 years and our journey here at Sequoia. We started in back in 2012 with the idea that there would be a need for an organization like us — a non-profit, public good-oriented organization; public-private; working to advance the ball on interoperability by solving practically oriented issues. We have seen the ability to make strides not by going it alone, but by having a broader community of stakeholders working with us side by side. We attribute the progress and our ability to have incubated and launched these initiatives and the work we’ve done with interoperability matters in TEFCA to the tremendous support that we’ve had from stakeholders. I just wanted to acknowledge and be thankful of that.

HIStalk Interviews Carina Edwards, CEO, Quil Health

Carina Edwards, MBA is CEO of Quil Health of Philadelphia, PA.

Tell me about yourself and the company.

I have spent more than 25 years in healthcare technology. I have dedicated my focus and career on delivering experiences that delight customers and drive value and success in digital health. It has been fun being the CEO from the inception of Quil.

Quil is a digital health joint venture between Comcast NBCUniversal and Independence Blue Cross. We help people organize and navigate their health lives in partnership with their providers, their health plans, and their loved ones. We have two solutions. Quil Engage is the care engagement platform that delivers intelligently individualized care journeys to support patients during every step of their care, prescribed by providers and sold to provider organizations. We now have Quil Assure, the connected home platform sold direct to consumer, that helps seniors enjoy greater independence with exercising their preference for aging in place and strengthening that support between the family and friends serving as caregivers.

Seniors say they will accept some kinds of caregiver monitoring technology, such as fall detection and movement tracking, but draw the line at being monitored constantly by audio or video. How does that affect the ways in which monitoring can be performed?

In all of our research, we confirmed the same findings. We have 54 million unpaid caregivers in the country. There is a booming silver tsunami of seniors, and all of them want to live in their home as long as possible. When you start thinking about that dynamic, we need more technologies to help them live independently, but we need those technologies to be invisible to them. To support the caregiver, but also support the senior.

In our research, we focused on ambient sensing. We are leveraging some of the foundations that we know very well from the Comcast side of this joint venture, which is that connected home with motion sensors, door detectors, and connected hub. Being able to take machine learning and the bots that we’ve written to detect anomalies in daily patterns of living and notify on those anomalies. Then, also connect into the broader Internet of Things ecosystem that people have adopted across all ages.

With COVID, you are now seeing the 65-plus community being way more technology receptive. Being able to connect to their Apple Watch if they’re tech savvy. Being able to connect to their Alexa ecosystem for their weekly grocery orders. Having that open platform, but the importance being how the caregiver can verify that everything is OK. Did Mom get up on time? Are things going well? Has she been to the kitchen three times a day like normal? What going on that is abnormal? Did she leave the house for an extended period of time? All of those things to support the senior so that if they need help, it’s there.

How can technology address the key concerns of falls, wandering, and accidentally creating dangerous situations with normal household equipment such as stoves and bathtubs?

A lot of it is sleep quality, which is interesting. Are they getting around the house doing activities of daily living? Are they going to the kitchen? Are they not going to the kitchen? Are their bathroom patterns changing? In early trials, we’ve detected UTIs and other things because of just pattern anomalies. Temperature sensing is a huge one. We’ve had some seniors in the trial where they didn’t want to bother the caregiver, so when their heat went out, they just didn’t say anything. But then the system alerts when it’s turning to 55 in the room.

“Set it and forget it” ambient technologies don’t make them feel like they’re being watched. They’re not being actively probed. They don’t want to interact with the technology if they don’t have to. But then when it’s there, leveraging the pattern button, personal emergency response activation, or even if they’re connecting in the IoT ecosystem, “Hey Alexa, call Quil,” we can be there 24/7 to respond to those things. Sensors and triggers let us see certain patterns that would indicate a big abnormality, so we will start calling down the caregiver circle to make sure they’re checking in on Mom.

The old-school technology is to call the person daily to ask how they are doing and listen for anything concerning in their response or their voice. Do any technologies simulate that phone call type of monitoring?

We are doing insights in the app. The caregiver gets push notifications, text messages, and phone calls. They can see that Mom’s up and about and it looks like a great day. Those type of insights are coming back to the caregiver’s phone. The nice thing is if Mom is technically savvy, she also gets that same view. 

The interesting part is what we’ve learned from the caregivers. There’s this relationship that they are trying to form and it gets stressed when, every time you call, it’s about their health. There’s this fine balance between, “I know I’m aging and I know I have challenges, but don’t remind me of it all the time” and the caregivers saying, “I love being there for you, but it’s sometimes a little bit exhausting and I’m really worried that you’re not OK.” Bridging that relationship with insights that keep everybody on the same page — how things are going, any tasks and appointments coming up, medication reminders — and leveraging that technology to set those reminders so that Mom can acknowledge with their voice that they have taken that medication.

How does technology address those folks who are mobile and can run errands or visit a friend and the caregiver wants to make sure they get home when expected?

We detect when they leave the house, because then there’s no motion in the house and we have the door sensor. This is a learning system, so we learn their patterns over time. The caregiver can also set that they are on vacation or doing something abnormal. It isn’t sensing and triggering, but we are learning, “Looks like bridge club on Tuesdays, normal event. No worries, Mom comes back around 5:00 PM.” Those are the things that we are constantly fine tuning to make sure that we’re understanding the value that those insights provide. And respecting so that the senior in all of this knows what’s being shared, why it’s being shared, and how it’s helping with technology on their terms.

Big players like Best Buy and now Amazon, with Alexa Together, are involved in selling monitoring equipment and services directly to consumers. In Amazon’s case, it is powered by the same Echo devices that a competitor might use and is tied into third-party sensors such as fall detectors. How is the market evolving?

It’s the race to the connected home. I’m excited that we have a head start with Comcast. Then on the population basis, it’s that connectivity and receptivity of seniors to technology. As I mentioned earlier, I think that COVID has accelerated that comfort level with technology. I manage, or as I love to say, I love four people over 78 in my life. It’s hysterical that when I talk to them, if I’m not on FaceTime, there’s an issue – “Why aren’t you on FaceTime? I can’t see you.” Before the pandemic, that was never a thing. 

As we’re seeing this change in receptivity and now this race to the home, I’m also excited about the other side of our joint venture with Independence Blue Cross and the Medicare Advantage population. We see the joint venture through two very connected lenses. One being that we have “prescribed by provider” with Quil Engage. We have now the connected home. We are thinking about models of risk, pulling this all together to say, that’s what we mean by convergence with the home and health at home in a new way. 

It’s a really exciting time with lots of great players in this space. The question is, what level of depth in healthcare will each of the organizations go into? We’ve seen some early acquisitions that are indicators, but a lot more to come. I never dismiss Amazon ever, or Best Buy. Everyone is in this market.

Does the business model require running a 24/7 call center, or can companies provide just the technology without that escalation capability?

This goes back to what populations you’re serving for the level of escalation. We are looking at the market where safety protocols and emergency support are critical for a certain segment of the population. We think about this as a connected care circle, not just your daughter or your daughter’s husband, but even a neighbor just to check in. As we’re thinking about this, the setup and the onboarding process is critical to figure out and evolve with the senior and their patterns. Start with them. Call the house, “Hey mom, how’s it going? Everything OK?” I’m noticing some pattern detection. No answer, call the first person on the call tree, and then go down the list.

If we find something critical, we will absolutely send EMS, but we think about that person’s community and how they want to be escalated. We want to give them independence. With technology, we have so many different ways to turn on and off alerts and escalations based on their desire.

I worked at Philips years ago, and when we bought Lifeline, I got it for my grandmother. She was in an apartment building in Florida and had to do her laundry in the basement. She was taking a basket of towels down to the basement and she hit the button accidentally. EMS came and she was mortified, mortified. That button never went around her neck ever again – it sat in the basket by her bed. Unfortunately, she did have a fall in the house. Couldn’t get to the button. Thank goodness that she lives in the apartment building, because her neighbors checked in on her. It was her neighbor that found her three hours later.

We have learned so much about the sensitivity of the community, about what they want. Targeting their wishes. Do you want EMS to be initially protocoled or not?

The Echo devices have an option to connect with other devices in the neighborhood. Is there any movement to use that to create groups who can keep an eye on each other instead of going from zero to 60 in dispatching EMS?

We have that in the care circle pieces, where they can invite anybody they want, friends or family. They can designate who they are, what they can see, what they can’t see. You hit it spot on that there is a range between zero to 60, and the world of personalization matters to this generation. They want it on their terms. As we are fine tuning all of this, giving that control to the senior who could literally just turn off whoever they want, to turn off any time on their own device, because they’re seeing the same things that the care circle is seeing.

How do you contrast selling directly to consumers instead of to insurers or employers?

The fun part about this being a joint venture is that we get those great best practices from both parent organizations. Our direct to consumer approach was heavily influenced by best practices that Xfinity has done quite at scale with Comcast. Same with Independence. We’ve learned about routes to market for different populations and payers and self-insured employers and how they interact with companies. We’ve built models aligned with those best practices, and that’s allowing us the time to start this conversion piece and be different than some of the more traditionally funded companies. There’s always pros and cons for joint ventures, and this is one of the pros.

When you look at the entire market for remote patient monitoring and other work your company is involved with, how do you see the market evolving over the next few years?

The question that is so critical here is, what does convergence to the home actually look like? We keep on calling it the home like it’s a physical thing. I look at the home now in two different pieces, the digital home and the physical home, or homes plural in populations of different segments and demographics. 

As we start blurring these lines and we start seeing risk shift in different ways, this is where the models get really interesting. Whether it’s hospital  at home, in a risk-based sharing agreement with new signals from the home that are extended for this population as a benefit, wow, that’s an interesting model. If it’s, “I just had a health event, now the person that’s recovering is no longer steady and needs extra eyes,” there’s a referral model. Then there’s the direct to consumer model.

I dislike the word consumerism because really it does come down to, where is the risk, who’s the buyer, and what is the value being derived? How do you make sure you stay clear on that ROI to each of the parties? In a way, you start becoming this B2B to C2C connectivity arm that’s converging on the physical and digital home.

HIStalk Interviews Steve McDonald, President, Interbit Data

Steve McDonald, MBA is president of Interbit Data of Natick, MA.

Tell me about yourself and the company.

I’ve enjoyed a rewarding 30-year career in healthcare IT, where I’ve worked with some of the largest EMR vendors and some of the greatest minds, such as Neil Pappalardo and Neal Patterson. I also worked with two leading consulting companies.

A lot of your followers have seen significant progress made in the industry. I’m encouraged by the advancements in digital health and move to the cloud. Even AI is showing some promise. CMS is putting teeth around their policies with bundled payments and value-based care and it looks like commercial payers are following suit. I was naturally attracted to the opportunity to join Interbit because we help hospitals that are dealing with some of those challenges

What are the benefits of having a report delivery system that is driven by rules?

We’re a subscription-based service, we’ve been around 25 years, and we have about 500 clients. We simplify communications by being able to send information out to a variety of people on the care team with value-based care contracts. We’re able to send information based on their preference. If a doctor wants to receive abnormal results via text message, we can send it that way. We can send by Direct message. This is all of the care teams. If a skilled nursing facility wants to receive emails or secure texts via an API, we could send things out via FHIR. The value is broad distribution of information to the care team in whatever format that they want to receive it in.

That’s one of our solutions, but the bulk of our value that we drive is on the care continuity side, in being able to provide information at the point of care for situations where the EMR is not available. Things like your EMAR, labs, radiology, pharmacy, and census open orders. If the EMR is not available, we have a snapshot of that information that can be readily available for care teams to access that information to provide care continuity.

Patient engagement uses the word “omnichannel” in giving people information in whatever form they prefer. When you look at the big picture of interoperability, what is the role of those different channels, where people may have legitimate reasons to prefer information sent by fax or PDF?

Healthcare is individual preference, and one size does not fit all. To the extent that a person or a provider wants to receive their faxes or a secure text message — let’s say for abnormal results, which is a great example — we can send it that way. It’s critical that we’re able to accommodate the wishes of our providers. Care teams are expanding with value-based care and bundled payments. You have physical therapists and skilled nursing facilities. They all want to receive it in different formats.

We allow the hospitals to send it to us and then we’ll take care of the distribution. Obviously if we need to put in HL7 or FHIR, we can send it to CommonWell and Carequality to push it out that way. But what we specialize in is operational communications, where we can pull it out of the EMR and then push it out in whatever format that the care teams want it.

How should a downtime solution work to support the continued provision of safe care while mission-critical applications are offline?

That is our sweet spot. If you have a scheduled or unscheduled downtime, you have the luxury of pre-planning for it and identifying the kinds of reports that should be made available. Your med administration record, labs, NPI, nursing, open orders, forms, even your employee contact list should be available house-wide in your hospital.

We have two varieties. One is a server that, during a planned or unplanned downtime, can still be on your network. We would be able to parse the EMR data and send the EMARs up to 2 West and to the pharmacy to allow for documentation, in the case of the EMR not being down. If it’s a full-blown cyberattack, we have an air gap server off your trusted network that contains that same type of information, but it is secure behind a firewall. It would only be accessed in a break-the-glass situation to allow for care continuity even in a case of a cyberattack.

Do hospitals anticipate these needs, or are prospects people who have had an incident that needs to be prevented in the future?

Cyberattacks doubled last year despite all the great efforts in trying to prevent them. The bad guys still get in. Hospitals request a way to have that critical information available even during an attack. We developed that solution about a year ago, to allow for access to that critical information so that they can at least have some level of care continuity. Ours is not a full-blown disaster backup plan,but is a safety net until the systems get restored. Nurses have visibility into a patient’s latest lab tests, for example.

Do hospitals recognize the clinical problems that are caused by that downtime gap even when it is shortened by good technology planning?

Most hospitals go to a paper-based backup in case of a full-blown cyberattack. That’s manual, and affects patient safety. We also see a lot of lost charges occur in that scenario. We are automating that solution to minimize the amount of effort when you reconcile back and your system’s up and running, to sync up all of that information that occurred during the downtime period.

What factors will be important in the company’s future?

The biggest factor we have is the ability to focus in on the human element of delivering care. People get caught up in all these technologies. Our focus is on simplifying operational communication, pushing that information out to the caregivers in the format that they can digest. Because at the end of the day, this is about the sanctity of the relationship between the doctors and the providers and the patient, that human element. We want to continue to deliver information in a format that they can use to deliver care.

A lot of people will say, “Healthcare IT will solve this.” Healthcare IT is great, but it’s not a substitute for that human intervention. Our operational communications approach is still at the ground level of delivering care. We also support the mobile user. We can push information out so that people who aren’t tethered to the internet have information available to make intelligent decisions in the care delivery process. Then once they are back online, we can help sync up to the major EMR system that they are using. 

I’m excited about the industry. I have a deep passion for it. It has been my entire life’s mission to try to improve healthcare by leveraging technologies, and I’m excited that the industry is getting an incredible amount of external capital as Wall Street is taking notice. We are a privately held, cash flow positive company and we don’t necessarily need any of that outside capital, but it’s great that the industry is progressing to help bend the cost curve and deliver higher quality care.

HIStalk Interviews Ashley Glover, CEO, WebPT

Ashley Glover, MBA is CEO of WebPT of Phoenix, AZ.

Tell me about yourself and the company.

I started this job in November 2021, so I’m a few months in. I spent the last 15 years in real estate software with a company called RealPage that is similar to WebPT, in that we wanted to be a vertical software provider providing all solutions to people who largely owned and managed department communities. We grew RealPage from about a $30 million company to about a $1.3 billion revenue company and it sold a year ago for a little over $10 billion. I was president of that company at the time.

That gave me an opportunity to look at something new, and I got very interested in WebPT’s story. WebPT is the number one provider of outpatient rehab software, covering physical therapy, occupational therapy, and speech therapy solutions. Most of our clients are in the outpatient space, although we have a large and growing business in what I would call integrated businesses, like hospital systems that have PT clinics, that sort of thing. 

WebPT has a little over 800 employees and over $150 million of revenues. We recently bought Clinicient and Keet, which were also leading edge providers of similar software in our space. In the last couple of months, we’ve been integrating the companies.

What challenges of outpatient rehab therapy providers can technology address?

Two cases drive most of the reasons people go to rehab. One is that they are recovering from an incident. That could be an injury. Athletes or weekend warriors often need rehab, or they’re coming in related to surgical recovery. The other thing that drives a lot of our patients is it age-related conditions, or other health conditions that drive the need for rehab to support people’s mobility.

From a software perspective, we started out as focused on allowing the clinician to provide leading edge documentation, plan of care, and monitoring of recovery through the plan of care. Ensuring that it is compliant, a best-in-class way to document, and easy to bill. Over the last several years, we’ve added additional solutions, like billing software. That facilitates billing and collections and software that enables the front office to better serve the patient largely through digital solutions. Think digital patient intake, electronic benefit verification, and marketing type solutions that manage communications with the patient.

Is the measuring of outcomes and patient satisfaction more pure than in a health system, where the care environment is less focused?

Absolutely. It’s pure in the sense that people really do want to know that they are delivering good outcomes. One of our biggest issues is that patients drop out of therapy at three or four visits, when they might really need 12 visits. So we talk about the need for patient engagement solutions, which is to keep them engaged through the plan of care, which ensures a better outcome, and frankly measuring the outcomes themselves.

Early in our business, we bought a company and integrated it into our solution that allowed us to manage patient engagement and increase the probability that they would move through their plan of care through better engagement with them digitally. We did not own an outcomes solution, but through this acquisition with Clinicient, we have picked up an solution called Keet that a lot of our members used and that we integrated with, but now we own.

What’s great about Keet is it’s in the musculoskeletal program and it’s a Qualified Clinical Data Registry, or QCDR. That allows for the Medicare reporting, but we think there’s a broader opportunity in using it as an outcomes tool to manage quality of outcomes and promoting that use case within the businesses, because obviously not everybody’s getting Medicare. Often the payers want to know if people are receiving better outcomes as well, and Keet will facilitate that.

What are the main reasons that so many patients don’t complete their course of therapy?

There are two things that just kill us, and if we could solve for it, our clients could make a lot more money and people would have better outcomes. One is that there’s a lot of evidence that people who should get PT are not getting PT at all, or OT or speech therapy. That’s an issue with a gap with people’s awareness of how effective PT, OT, and speech therapy can be in lieu of surgery or drugs, for example. Often, it’s not the first place even a doctor will send people.

I’m a great example of this. I’ve had an autoimmune arthritic condition for years and have had the best of care. Initially, it was misdiagnosed and I was sent in for knee surgery, which turns out that didn’t fix it, and then I got put on probably a three- to four-year cycle of trying to find the right drug. We did find a really good drug, but it was only after I fell off a horse and broke six bones. I’m a horse person, and when I went into PT to deal with my horse injury, my PT told me, “By the way, I can help you with your arthritis.”

I still go to PT even though I fell off that horse almost a year and a half ago. It has wound up being more effective than all the other courses of care I’ve had. I’ve had doctors, but there’s a blind spot to it, in the patient population and medical provider population, that it can be a way to go in lieu of other options. We have an initiative we call Get PT. Our advocacy group, APTQI, is working to increase awareness of people trying PT as a solution in lieu of some other solutions. 

Our second issue is that people will enter PT and not want to continue a course of care because they feel better, or it’s a hassle.

I believe, and many people in our industry believe, that the true evolving model is going to wind up as a hybrid model. It is not going to be all virtual and it’s not going to be all in-person. People are playing around with models and our software supports this, where you might have an initial in-person evaluation and maybe a couple of courses of care, then you might have the option to do home exercises or a virtual visit where that’s tracked through the application, and then come back for periodic check-ins. You’re not having to get in the car, go to the clinic, do your course for 12 sessions. Maybe you’re only doing four or five in-person, but you’re doing some virtually.

I think personally that’s the future to ensure that people stick with a course of care, because you’ve got to reduce the hassle factor and you’ve got to make every visit meaningful when they do have to come in for that in-person visit. The key to that is having software that supports the hybrid model. We have that and we think we can better enable it. The key is RTM code billability, which we’re making sure that virtual visits are billable. Then the key is also monitoring outcomes, because we need to be able to measure that the outcomes in these situations are as good or better than if people came into that in-person care.

The hottest thing years ago was companies that were using Xbox and other consumer gaming consoles to show patients how to do exercises at home and then to monitor whether they were doing them correctly. Do you still see that or other technologies, such as video, that support at-home treatments?

It’s more than video, and we are looking very hard at RTM codes right now. I’m not a lawyer and I’m less than six months into this industry, so I’m not an authority and I am consulting with outside advisors. But there are rules around what defines a medical device. Does the stuff that we are providing qualify as a medical device? We don’t want to go awry on the compliance perspective, as you can imagine.

Remote therapeutic monitoring could be a virtual visit, but it also could be something as simple as people having check-ins through software that measures their current parameters or conditions. It can literally be self-monitoring your condition, working with your provider, checking in, and providing measurements along the way. RTM can be defined in a lot of ways. Before we release anything that does this, we want to make sure that we’re doing it right and that we are supporting all the possible use cases. During COVID, virtual visits were billable, then they weren’t, and now they are saying that they are billable in some cases. This is an area where even the payer and Medicaid rules change frequently.

What does the therapy practice landscape look like? Does it have similar M&A activity that we see in hospitals and medical practices and are private equity firms involved?

There is absolutely a consolidation activity in this space, and that has been going on for a long time. We think of the industry distribution looking like a barbell. There’s a lot of small practices, then there’s quite a bit of consolidation in the top 20-to-50 providers on the larger side, and the middle market is getting smaller. The middle market is getting smaller obviously because these private equity consolidations love to buy larger 10- to 30-practice middle market providers that consolidate into their several hundred practice larger company. If you are doing a consolidation exercise, it’s easier to buy somebody who is managing 10 to 30 clinics versus one clinic.

The middle market is ripe for consolidation activity, so we’ve seen it getting smaller over the years. But there are also, and this is good, a lot of new therapists coming out into business. Many of them are starting out as solo or small group practitioners. There’s also constantly new therapists coming into market and feeding that small business side.

There’s a very large small market side, where one to five people are running a practice together, and then there’s a very large what we would call enterprise, where there’s hundreds of clinics. They’ve negotiated national deals with payers and they’re running more like you a large corporate entity. Their needs are different. In the small practice, the clinician is doing everything. They’re managing patient intake, they’re getting their insurance, they’re diagnosing them, they’re managing their course of care, and they’re billing insurance. We need to provide that all-in-one solution to them.

The larger enterprise area is more specialized. The therapist who is touching the patient isn’t having to worry about the front office activity, the billing activity, compliance, or the financials. They are focused on the course of care. But that means your software has to be able to specialize and handle all the different roles in those organizations effectively. We’ve been working to make sure our software meets the needs of both segments, but they’re very different.

What communication is involved with making and accepting a patient referral and then reporting back the therapy outcomes, especially if there’s a value-based component?

Historically, the practices would build relationships with doctors who would refer patients in for care, either surgeons or general practitioners, all the different reasons why people might come in. You build relationships. If you think about a small practice, that could be local relationships. The larger practices get, the more likely they are to build referral relationships with local hospital systems, local payers, or even unions. We’ve seen people build relationships with unions or other groups that handle populations.

The trend towards value-based care and payment on outcomes is slower in PT and OT than it has been in other industries, but we see that trend still coming. It will still come our way. The models now are more experimental, but there’s a high demand for tighter integration in the referral network for us to be able to automate the receiving of the patient referral, which even in today’s environment is largely manual intake, and automate pushing back what the plan of care is and what the outcomes are.

We are trying to drive a lot more interoperability in the industry with this two-way integration so that we can better monitor the course of care. That’s one place that we’re seeing our business grow. We’re going to continue to push is making sure that we have that tight integration with that broader ecosystem that the patient exists in. Historically, we thought of the patient only in the lens of the person who was treating them in our business, the physical therapist or the occupational therapist, for example. But increasingly we are aware that patients are actually receiving care from multiple providers and there’s a need to see how their outcomes are being managed holistically. Our goal is to support that.

What is the strategy for the company over the next 3-5 years?

This industry is ripe for a more integrated model from a technology perspective. A lot of point solutions were built in the last 15 years and they solved individual problems. If you look at our practices that are buying the software, they are now assembling all these point solutions and trying to integrate them together to get to the answer they need. But no one solution is doing everything or even 80% of what they need to do as a practice, so it’s hard. Imagine that you’re managing a practice, you’ve got your physical therapy degree, and now you’re running a business and you have to be an IT person. That’s just not sustainable. The winners in this model will sit in the captain’s chair as if they were one of these company leaders — whether they were small, mid-market, or enterprise — and think about where people are having their broadest challenges from an integrated solution perspective. Then they will solve those challenges.

I’m not saying I have to be the only provider of software to these companies, but I think there’s ample room to integrate more pieces of the solution so that we take some of the burden off of our customers. Where I saw a lot of innovation in my last business, and I see now sparks of innovation that we can push forward, is how do we fully automate that patient experience? Imagine that our patient went to their general practitioner, they got diagnosed with a problem, they wound up in a hospital, and maybe they had surgery. Then they have to get therapy, medication, et cetera. But in today’s environment, the patient is managing all those interactions disparately because those systems don’t talk to each other and the patient is deciding if the outcomes are coming together.

My goal is that we integrate that patient experience and make it easy for them to cross through all the providers that they need to access. It allows those providers to easily communicate with each other as to what’s going on with that patient. Not the case, but the patient. They key to the value-based care model is making sure that we are looking across all of the modes of treating the patient and ensuring that we are optimizing them. The company that nails that will get a lot of traction.

Our goal is to be part of that ecosystem, to have a high degree of interoperability with the hospital network or the systems that the doctors might be using and make it easy for overall monitoring of the patient and not that individual problem that the therapist is trying to solve, because it exists generally in the scope of more problems. Our business is unique in that very rarely is that problem an isolated problem. Most of the time, we’re treating someone in the context of a larger course of treatment. Our industry has a huge opportunity to connect better to the broader course of treatment, and that’s where I think the future will go. You are integrating that from the patient perspective and you are integrating that from the clinician perspective.

HIStalk Interviews Christopher McCann, CEO, Current Health

Christopher “Chris” McCann, MBChB is co-founder and CEO of Current Health of Boston, MA.

Tell me about yourself and the company.

I’m originally from the west coast of Scotland, now based in Boston. My background is in computer science and medicine. I started Current Health in 2015 based on the experiences of my grandmother. She was repeatedly hospitalized for things that could have and should have been managed at home. Current Health was built to be a one-stop partner for any healthcare organization to deliver care in the home, using our technology platform, our services, and our knowledge and operational models.

What financial models support hospital-at-home and remote monitoring services?

The biggest thing holding back care at home, care outside the hospital, is the financial model across the industry. It’s just too immature and nascent. The CMS acute care at home waiver has obviously been very relevant to our business. That is just a waiver. It is due to expire when the public health emergency expires. There is a bill in the Senate right now to extend that and we’ve been working hard to see that bill passed.

We are reimbursed under Medicare RPM codes. But to be honest, we don’t see many hospital systems that see that as a driver of delivering more care at home. They’re more focused on using us for total cost of care reduction within alternative payment model populations that maybe they set up locally with a payer or on the post-discharge side, helping to improve patient flow and manage capacity, particularly when they’ve been capacity-constrained over the last 18 months between staffing shortages and, in some cases, capacity with COVID patients inside the hospital.

Does the market offer enough FDA-cleared sensors to give clinicians an adequate view of a patient at home?

Yes, absolutely. Not only do I not believe that there is a monitoring gap any more, I think the data that we see from hospital-at-home programs that we manage shows that patients are achieving, in some cases, better safety outcomes in home than they do in hospital. There is not a monitoring gap at the moment. That isn’t the problem that exists in the market.

In terms of scalability, is proprietary expertise involved in identifying the relevant information from a constant stream of home monitoring device data so that a clinician can get involved when needed?

There is. That’s partly why I would say that we are not a remote patient monitoring company, because simply getting monitoring data and dumping that on the physician is not helpful to anyone, particularly when you are managing a multi-thousand patient population. 

The key thing is actionability. How can you identify that one patient, or that group of patients, who require an intervention and get that actionable insight to the right person at the right time? That is, to be honest, even more important than capturing the monitoring data in the first place.

The staffing crisis is probably the biggest issue we have in healthcare right now. We don’t have enough registered nurses. We don’t have enough doctors. So we have to be able to help those staff that we do have — who are already overworked, who are already burned out – and help them focus on the patients who need them most and make their lives easier

How can the industry address the last-mile problem of patients who are being monitored at home who require blood draws or other in-person services?

As a company, we have made it clear that we don’t see ourselves as an RPM company. Remote monitoring is a feature of how care is delivered in the home, but it doesn’t actually, on its own, solve any particular problem. Because as you just said, you need that ability to go out into the home and do something about a patient who needs action or intervention. Even before that, for some patients, you need the ability to go out to set those patients up and help deal with technical support problems. Many of the patients we deal with are seniors. Half of them don’t have internet access and half of them don’t have smartphones.

We need to resolve that, firstly to partner with ancillary in-home services for things like labs and pharmacy and new delivery. We orchestrate that. We have our own clinical command center to provide virtual RN and MD services to support our clients in particular shifts, overnights, or on weekends. We can also do across the threshold logistics and technical support. Combining the technology with those services is, in our view, part of what is needed to solve the market problem.

An important part of in-hospital care is asking the patient how they are feeling or observing their level of discomfort, and that happens by people popping into their room at all hours. Can patient-reported outcomes and E-diaries adequately capture the patient’s perceptions?

EPRO symptom reporting, the capturing of contextual data like that, is critical. Many times patients readmit or come to the ER for things that are difficult to measure through biometric data. Pain is quite a good example of that. Pain is subjective, and in some cases, doesn’t measure on any biometric reading. But pain can absolutely bring someone back to the ER and absolutely massively affect quality of life. Being able to capture that is critical, and we incorporate that into our alarming system.

We also have to make sure that there is an accessible presence from an RN or a physician. It is certainly part of the acute care home waiver that patients need to be able to access a physician or RN if they need to.

I’ll say one other thing, which is that this is one of the reasons we were attracted to the Best Buy acquisition of Current Health. They have the caring centers. While Current Health focuses on the clinical side, the caring centers focus on the social side. They have social workers. They look more holistically at the individual and provide a wider range of social support. That is going to be important to how healthcare at home programs develop in the future.

How do you see Best Buy proceeding in healthcare and how will your company change under its ownership?

I’ve sat with the Best Buy Health senior leadership team and I report to the president of Best Buy Health. Our strategy is split into three parts, and this is all in the latest standings call. The first one is consumer health, which is, let’s get every health and wellness device into Best Buy’s flows and on Bestbuy.com. Interestingly, Best Buy is a larger channel for some devices than anywhere else. The second one is active aging, which was the acquisition of GreatCall. That’s more about how we help seniors age in their own home and a place of their own choosing. The last one is virtual care, and that’s where Current Health sits.

Best Buy is using its capabilities — such as Geek Squad, access to consumer and medical health devices installs and online, the caring centers that I mentioned before — to offer services to hospital systems and healthcare organizations to help them deliver care through the home. Best Buy is not trying to be, and never will be, a healthcare provider. That’s not what they want to do. They are there to help hospitals and healthcare provider organizations deliver healthcare to the home.

What technologies and services could change how life sciences research is performed via home-based clinical trials and monitoring?

Pharma has exactly the same issue as hospital systems. They want to move more clinical research into the home. They want to better the level of drugs and therapies in the home over the long term and do so with better outcomes for their patients. They want to be able to better measure how those therapies are actually doing for those patients, both clinically and from a quality of life perspective.

That last one has become important to regulators and payers. That’s where an organization like ours comes in. We enable better data capture in the home to understand how a patient is doing on a drug and what their quality of life is while taking it. But we also allow them to deliver drugs in new ways, taking drugs that would have been delivered in the hospital and delivering them in the home instead, at lower cost and with greater and greater access.

I would it sum up in saying that in the same way that we are seeing this decentralization of clinical care away from the tertiary bricks and mortar facilities, we’re also seeing a decentralization of clinical research. That  is fundamentally a good thing, because we can deliver better care if we can look at that patient longitudinally across a normal segment of their life when they are at home.

How do you see the market and the company’s role in it changing over the next few years?

Care at home will be the biggest area of strategic growth within healthcare over the next three or four years. Everyone has identified it as a strategic priority. Few organizations really know how to get there yet. To your point at the start, the financial model is still a little bit opaque. Current Health is trying to help make that financial model more transparent, and operationally and technically, make it turnkey for a hospital to stand up a program like this for any population. I hope, and I expect, that we can continue to be a major part of doing that across the US.