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.

HIStalk Interviews Bob Katter, President, First Databank

Bob Katter, MBA is president of First Databank of South San Francisco, CA.

Tell me about yourself and the company.

I’ve spent my entire career in healthcare after business school. Some on the services side, but had a couple of startups, including RelayHealth that was part of McKesson. I’ve been at First Databank for 12 years, where I’m fortunate to have served as president for the last couple of years. First Databank has been in this industry, and evolved along with it, from the very beginning. What we do is pivotal. Any workflows having to do with meds — whether that’s ordering them, prescribing them, administering them, dispensing them — First Databank content is driving those processes for many users. We take our job seriously in terms of providing accurate, timely, and increasingly concise information that clinicians and others need.

One thing that I love about working here is that we work with people across the entire industry — the major HIT and EHR vendors, a majority of the nation’s health systems, PBMs, pharmacies, distributors, and the VA and government sector. The entire healthcare delivery system. As a company, we go beyond what we do today to industry challenges or problems where we think our footprint and our expertise can help.

How has interoperability across prescribers, pharmacies, and insurers changed over the past few years and where is it going?

It probably hasn’t changed enough. It is slowly evolving. It has always happened when it has to, but has been challenging.

For example, we have a couple of apps that run on the FHIR standard. That is the latest series of healthcare interoperability standards, at least on the clinical side. It is still more of a custom project as you implement the application with vendors than you would think it would be for the standards. 

There’s not a silver bullet, but we are going to have to get better in terms of interoperability. Some of it has to do with everybody having a silo. Vendors like us, information vendors, have our own proprietary identifiers, et cetera. We are all implicated in creating the system we have. We will have to push more standards, make them work better, and make them work more consistently. Otherwise, we will be regulated into it. But one way or another, it’s going to happen.

The industry has created electronic prescribing networks and entire companies that are built around selling specific technologies for managing prior authorizations and specialty drug orders. Will those offerings consolidate?

You have hit on a couple of important factors. There are a couple of dominant players, in terms of high market share, in a couple of aspects of that. You mentioned the standard NCPDP transactions and the prior auth. We think it should be, from the clinician standpoint, more of a unified workflow. When you prescribe a specialty drug, you have to do three or four things, in many cases, each with different parties. You have to do the standard eligibility and formulary check. Eventually, you have to transmit that prescription, but you’re likely going to do a prior auth. That’s usually a different workflow, and you’re likely going to do what’s called a specialty enrollment, which is yet again a different workflow.

Our vision would be that, from a clinician standpoint, you just order the script and then all those other transactions flow out of the back end of your EHR. You don’t have to go to a separate portal or initiate different workflows to complete all those other steps. That evolved because different things were tackled at different points along the chain. It’s not that any one company wanted to make it that way as much as that’s just the way the industry has evolved. But from a clinician standpoint, it’s not a very easy process.

Are insurers interested in making prior authorizations easier for prescribers?

That’s an age-old question. You can say yes from a simplification standpoint, and no if you believe that there’s a vested interest in having the drugs stall, even though if you look at the overall cost of care, there really isn’t. On balance, I think they have an interest in making it work better. I don’t think that there’s any technological barrier to having it all happen in a more electronic and automated way, not having to have all the phone and fax work. Certainly most if not all of the parties have a rationale in wanting to do that.

How well does the industry manage medication reconciliation and de-prescribing?

I don’t think we do it that well. Particularly among the Medicare population, does everybody’s med list make sense in terms of what they’re on, and in addition, what it says they’re on? I think that most clinicians who serve that population would probably say no. At that point, by definition, we’re not doing a great job. There’s a workflow challenge and a data challenge. You have to have the right people at the right time evaluating the meds that this this person on and what they need to be on holistically.

As far as the data challenge, even companies like ours have created proprietary standards that don’t always interoperate. Every system ought to be able to recognize meds from any other system, and that’s not always the case. There’s a way to solve that. It will have to be the healthcare IT vendors that are doing this, and hopefully they are going to work with terminology companies such as ourselves to make that better.

Some of the prescribing-related technology advancements came about after big drug chains got involved. Will the involvement of technology-savvy companies such as Amazon and Walmart accelerate the use of the technology you mentioned?

I think it could. I’m not sure they are bringing new technology, not at all to diss those companies, but I think they may bring pressure on the industry. If I can get healthcare at my local retail drugstore, and they can do a better job of figuring out which meds I’m on and which meds I shouldn’t be on, maybe that’s pressure on the rest of the industry to do so. I just read in HIStalk that Walmart is using Epic in their first five clinics in Florida. To the extent that shines a light on the rest of the industry that we need to do this better, that’s probably a good thing.

How do startups design their technologies around third-party information databases and services like yours?

We have a lot of startups come to us, along with terminology and  building block companies, but I don’t think they all do. We are doing quite a bit of work with some of the big tech companies now as well, and while this might sound self-serving, there’s a sense from the technology world sometimes that they have it all figured out. They may underappreciate the deep domain and content knowledge that already exists that might help them get to where they want to go faster.

Part of that is probably on us and companies like us. We don’t do a good job explaining what we do because it’s so arcane and domain-heavy. So, I would say we are doing OK. Certainly we get a ton of startups reaching out to us, and I’m always amazed at how much activity and how much innovation there continues to be in this market as new people come into it and trying to solve these age-old problems.

Do those companies understand why evidence-based guidelines aren’t universally followed by providers and that systems that don’t allow deviation from them won’t succeed?

Our company, as well as some of our sister companies within Hearst Health, are big purveyors of evidence-based information. A lot of us believe in that platform. But I think you are seeing a real evolution as traditional evidence-based healthcare collides with so-called real-world evidence. People are coming in from the outside and saying, if the real-world evidence suggests X, then what’s this “traditional evidence-based” thing mean, and how do those two relate?

On top of that, you have people saying that we can create this real-world evidence using AI techniques, derive its meaning, and it can be predictive on what to do. On that, I think clinicians are a little skeptical. They want to know the trail from how you got from A to Z. They’re not willing to just accept what the algorithm says.

If you say that we should return to traditional, peer-reviewed, evidence-based methods, and you’re not open to where the real-world evidence can take us, then you are ignoring a big part of the picture and where we need to go in the future. It’s in flux, but exciting for the industry. Ultimately, it should make it work better.

How much impact is pharmacogenomics and personalized medicine having now and how will it evolve?

I’m kind of chuckling because you could have asked me that question five years ago, and I hope my answer today is more accurate. Precision medicine, the idea that we can provide better guidance about this one patient — and PGX or pharmacogenomics is a big part of that, but not the only factor – is something that we and other companies have been pushing for a number of years, specifically regarding pharmacogenomics. We’re starting to see adoption. We have a partnership with Meditech, one of the major vendors, and they are taking that to market. We are inside several other major EHR providers and we are starting to have customers sign up and even ask for it.

I think we truly are on the cusp. We are two or three years out, I think. A lot of health systems, if they’re not doing something with PGX — particularly around areas like pain management or mental health meds, certain areas where there’s just so much evidence that you should look at that before you just prescribe drugs – I think we will see a lot more adoption. But I might have told you that five years ago and I would have been wrong. It’s a slow adoption curve, but I think it’s starting to happen.

The pandemic pushed providers into telehealth, some of whom lost access to the clinical tools that they were using in their EHRs. How has that evolved now that the telehealth urgency has mostly passed?

First of all, I don’t think telehealth is going back to where it was before the beginning of the pandemic. I’m personally a big believer in it, and that was way back about 20 years ago. The original mission of RelayHealth was telehealth. I think its time has come. I don’t think it’s going back.

I think you make an excellent point, and it depends on what you mean by telehealth. A lot of telehealth is  with your own doctor using the EMR system they use to document office encounters, so they are enjoying those tools. A lot of systems don’t have any of that, which presents two challenges. You may not have the tools themselves built in, so something around a dosing guideline or an interaction check, but those are pretty easy to provide, and people can incorporate those. The bigger challenge is that if you’re not running those tools up against the patient’s record with the fuller set of data, then they aren’t worth that much anyway.

All providers, whether they work for a distinct telehealth system or do video visits tied to the existing EMR, should have access to the patient’s basic record so they can run those tools and do those safety checks.

What factors will be most important to the company’s future over the next three to five years?

This is a great industry we’re in, and in that sense, it’s exciting. I’m grateful all the time to work in an industry that’s so meaningful and can have such a great impact on people’s lives. When you step back and look at what we’ve all just come through with this pandemic, the system did great at some things. I don’t think anyone thought we would have mRNA vaccines within 18 months. At the same time, a lot of issues will come out in terms of inequities, our public health system, and interoperability in how information was exchanged to help with the situation.

As I look at what’s important for our company, that vision you talked about is important. Precision medicine, personalized medicine, pharmacogenomics, pulling data out of the EHR to inform clinical decisions better and more precisely and much better. Not all the noise that clinicians see now, but specifically for this patient with this set of meds and labs, et cetera, what do we do? That’s great. When I combine that with what we experienced in this pandemic — and hopefully we are on the back side of that — that’s the right vision. We’re going to keep pushing that.

The science is advancing. AI is advancing. But we have to make it easier for clinicians to use. The industry, including us, has not done that as well as we could, and we have to make it broadly accessible. Information providers such as ourselves have a role in that, and all of healthcare does, but if we can stay focused on that vision at the same time focus on how we make it work for clinicians and ultimately for patients, that works.

HIStalk Interviews Christopher Molaro, CEO, NeuroFlow

Chris Molaro, MBA is co-founder and CEO of NeuroFlow of Philadelphia, PA.

Tell me about yourself and the company.

I come from healthcare as a patient, first and foremost. I am an Army veteran, a West Point graduate, and went to the Wharton School for an MBA. I met a psychiatry professor there and that’s where NeuroFlow got its start. NeuroFlow is a digital health platform that helps assess and triage a population of behavioral health conditions in non-behavioral health settings, like primary care, and helps patients get to the right level of care, keeping them engaged and measuring outcomes over time.

You were deployed to Iraq as a platoon leader in combat. What is your experience with the military’s system for behavioral care?

A lot of people are probably intimidated about the military, or the government healthcare system, because of lack of knowledge or experience with it. In reality, it’s just a giant integrated delivery network, a giant at-risk payer-provider system. It’s obviously the biggest in terms of resources and so forth. When I was serving from 2006 to 2015, there was a tremendous amount of resources and investment, in particular on the mental health side. We were a number of years into the conflicts in Afghanistan and Iraq. PTSD was well known and it was discussed and talked about. There wasn’t a shortage of investments and resources or the supply of those resources.

The challenge is similar to what you see in the non-government space, which is identifying those issues, getting people with those issues engaged, providing them access, and offering them ongoing support at the right time and at the right place. It’s a challenge, especially because of the stigma that is associated with the mental health space. People are, for whatever reason, ashamed, embarrassed, and maybe concerned about their job security or their ability to succeed professionally, so there was a reluctance to get that care. That was a challenge in the military, but from my NeuroFlow perspective in  working with a lot of commercial partners, we see that same thing transcend into the civilian population.

How can technology help bridge the chasm between physical and mental well-being, which involves different providers and insurance requirements?

In the world today, 40 to 50 million people a year have a behavioral health issue. Looking at claims data, we know that two-thirds of them will never get it treated. That’s a huge problem. Imagine if we said that two-thirds of people with cancer never get it treated. That would be a tragedy. That same thing is happening in mental health today.

The highest prescribers of antidepressants in the country are PCPs. They don’t have that nuanced understanding about where to send someone. Maybe psychiatrists have a long wait time, which is true across the country, so PCPs fill that gap. The problem is that no one ever follows up. There’s no continuity of care.

The good news is that there’s a ton of integrated care models, specifically the psychiatric collaborative care model, whose outcomes and significance has been proven through 80 or more randomized controlled trials. The challenge is that it’s incredibly difficult to scale and it’s incredibly expensive. You hire psychiatrists, you train them, and you integrate them with PCPs or other providers like OB-GYNs and pain management doctors. It adds to the work and the workflow.

That’s where we think technology can help. Technology can help automate a lot of the workflow that is required for collaborative care, allowing the providers to operate at the top of their licensure. You can reach more people without needing more resources, scaling something that historically only the best-funded academic medical centers could do. Now you can make it more accessible throughout the healthcare system.

How does the psychiatric collaborative care model work in real life?

A lot of people will say they do integrative care or co-located care. They physically embed a social worker, psychologist, or psychiatrist with the primary care provider. That’s a great first step, but according to the academic model that was first studied and researched at University of Washington, that is not the collaborative care model. 

The collaborative care model is a triangular, team-based approach, where a behavioral healthcare manager works hand-in-hand with a primary care provider, or other medical provider, to help identify patients who have mild or moderate behavioral health issues. Then if appropriate, they keep them in the primary care clinic instead of referring them out. They refer them if they are higher risk or if they need a higher level of care, but then there’s a psychiatric consultant there to help guide the PCP in how and what to prescribe.

This removes the burden placed on the dedicated behavioral health providers who are already in short supply. It gets the highest-risk patients to the dedicated behavioral health providers while keeping the lower-risk people treated within the medical provider, the PCP or otherwise. It’s a better allocation of resources and better continuity of care.

Does the traditional model create a blind spot for PCPs who refer patients who don’t follow up, leaving the PCP unaware that behavioral care never happened and leaving no electronic trace in claims data?

In a lost referral, I’m a PCP, I refer you to a therapist, and after you leave my office, I have no idea if you followed up, if you’re getting the care that you need, and how that’s impacting your other chronic conditions. Think about someone who has hypertension or diabetes. Most of those people have a co-occurring behavioral health issue. They are four times more expensive on an annual basis – they are higher healthcare system utilizers or have higher prescription spend than someone with just the chronic medical condition. 

The collaborative care model tries to close that loop. Without technology, that’s a very manual process. I have to call everyone who is enrolled in the model and do monthly follow-up and assessments. It gets burdensome and time-consuming. Technology allows you to do that in a more automated fashion so that those resources connect over voice or in person only with the people who need that higher level of touch.

Employers bear some of the cost of behavioral health issues in the form of abseentism and lost productivity. Does the market address those people, who are probably insured and may receive behavioral health benefits, from others whose needs are similar but who don’t receive employer or insurer support?

That’s precisely it. If there’s a silver lining of the last two years in the pandemic, it’s that as a society, there’s a light that is shining on this mental health conversation. More than ever, people are acknowledging that there are challenges here. We have all felt them at home, and we’ve seen that in the workplace now. The ability to have this more integrated care model not only helps the cost of care, it improves the outcomes. The interesting thing is that we measure not only improved mental health outcomes, like a decrease in depression or anxiety, but you also see improved A1C levels, pain levels, and outcomes on the physical health side.

On the employer side, NeuroFlow does work, some of which is public, with groups like Aflac and Prudential to support their short-term and long-term disability business. That’s relevant because even if people aren’t in disability for mental health reasons, the mental health aspect of being lonely, away from your work, depressed, or recovering has a huge impact on their productivity and getting them back to work. We help their disability claimants and beneficiaries get better faster with the integrated care model.

Behavioral health is the one inarguable success story of telehealth, where both patient preference and outcomes have been documented as well served. How does telehealth fit into the model you described?

It’s great. It’s the best thing that could have happened in the behavioral health space. It is removing those barriers of adoption, engagement, and access. However, it doesn’t fix the problem that a tele-therapist is still a finite resource. If I’m providing teletherapy, whether it’s over the phone, video, or in-person, I still can only see one patient at a time. I’m still a limited resource.

There’s still the question of getting the right people to the right level of care. Not everybody needs a tele-therapist. Some people would benefit from digital self-service tools alone, working on mindfulness and exercises. It’s still a matter of triaging effectively. 

Telehealth services also don’t help with the identification of these issues in primary care or in other types of settings. While telehealth is an enormous step in the right direction, in terms of improving access and so forth, there’s still a huge component that it doesn’t address, which is the way that we think about behavioral health from a behavioral health integration lens as opposed to just the services.

What developments do you expect to be most important to the company and your niche in the next few years?

For the company, we think of ourselves as an augmentee to the providers. We are a clinical decision support engine, and to use a military term, we are a force multiplier to the system. We’re not competing with the therapy companies. Quite the contrary, we are helping get the right people to them. We’re investing a lot into open API structures, making interoperability easier with appointments and making that user experience more seamless from primary care to therapists and back to primary care. I think that will be a huge trend as we move forward in the industry.

In terms of the industry overall, the jury isn’t even out any more. The data is unequivocal that the impact of physical and mental health combined is astounding. I think you’ll see more value-based care contracts that are aligning the payers and the providers to provide holistic care to the patient, ultimately getting the patient better on both sides of the spectrum and making sure that we are reducing unnecessary utilization and improving costs, which I’m excited about.

HIStalk Interviews Sanjula Jain, PhD, SVP, Trilliant Health

Sanjula Jain, PhD is SVP of market strategy and chief research officer of Trilliant Health of Brentwood, TN.

Tell me about yourself and the company.

I am a health economist by training. I’ve spent my career doing applied research both in academia and supporting provider organizations. I’m chief research officer at a predictive analytics company called Trilliant Health.

Your recent analysis found that telehealth enjoyed a temporary COVID boost that was driven more by provider supply than consumer demand. What will telehealth’s long-term place be?

The supply and demand is pretty telling. Does telehealth have a role going forward? Absolutely. But its use cases as the system is currently designed — for incentive structures, payment models, and the consumers it is reaching — are pretty narrow. We need to zoom out to say, what is the intent of telehealth? We’ve talked about it as an industry as a tool to expand access, but the data is showing that it is expanding access for those individuals who already had access to healthcare. They are your proactive healthcare people who have more resources and are slightly more affluent.

If we want to move the needle in terms of who is using the technology, We have to think about payment parity. Who are the individuals we need to reach, and why are they not using telehealth? Is it a preference thing? A lot of the data right now suggests that they like the in-person interaction with their provider. The exception is behavioral health, which makes sense as a sensitive topic where it might be OK to talk about it with someone on a phone as opposed to in person.

Physician incentive structures and patient preference is a big part and it remains to be seen. Are there patients out there who are not using it today who actually want to use it? Once we start unpacking that, we will expose the market opportunity.

What is the impact of telehealth commoditization, where patients initiate the least-expensive visit with whatever provider is sitting on a couch somewhere waiting to pick up a call?

I’m not a clinician, but wearing my health policy hat, I have concerns that it could create waste in the healthcare system. Where does quality fit? Even if it becomes so ubiquitous the way you described, how do we know if it is actually delivering greater value clinically?

We are seeing cases like the COVID testing analogy, where you had to get the pass or appointment to then go get tested. You are being vetted in an additional step. I would argue that could be a sign of waste if that model applies going forward. It remains to be seen where that utilization comes from and how it’s being used.

From a clinical perspective, how many use cases are actually delivering value? So much of healthcare requires touch and running ancillary services to be able to evaluate a patient. That’s why behavioral health becomes an exception. But even if someone can quickly dial in, what will you be able to get from that interaction beyond a prescription refill or a very limited set of services?

An early concern about telehealth that it would create new costs or, at best, move the same care for the same people to a less-expensive venue. And in the US healthcare system, today’s insurer might be saving a competitor’s future cost of treating an avoidable chronic condition. How do you see telehealth impacting overall healthcare cost?

It is yet to be determined , but the initial data is a little bit skeptical. It goes back to the downstream cost of care looking at that patient longitudinally. What else are the individuals who use telehealth regularly doing in their care patterns? What is the lag time when they go see a specialist? What are their actual broader healthcare behaviors?

The initial signals don’t suggest that it is catching things earlier, therefore leading to early intervention. Behavioral health is once again the exception, and that’s maybe an opportunity to improve outcomes from that perspective. But from a cost savings, it’s hard to see where that proves to be true.

Telehealth has created a business model of healthcare convenience, where startup prescription fulfillment services will throw in a free, rubber-stamped telehealth visit to sell birth control and hair loss products. What does that say about how consumers value clinical evaluation?

There are two pieces to that. On the consumer point, to what you are saying and what our research shows, telehealth is being treated like a commodity good. We are in an era where many of us order our groceries online or do Amazon Prime, We like that instant access and convenience. Consumers, to some extent, want that in their healthcare decisions. Those individuals are not thinking about what that means from a quality of care perspective. They are looking at it from a convenience perspective.

But we see that some consumers make different healthcare decisions. A section of the report covers psychographics, a construct that there are five profiles, and each of us by the age of 18 formulates what that is. That defines how we make decisions. Some people are brand conscious and would drive an extra hour here in the DC area to go to Hopkins and bypass the five-minute drive to Inova or MedStar, because in their psychological profile, they have a different brand perception. Those consumers may be ones who don’t engage in some of these commodity-like services. It remains to be seen whether they perceive the quality of a telehealth visit or something like an Amazon Care service to be on par with a traditional visit.

Every consumer is different. With a grocery store analogy, some consumers shop at Whole Foods versus Kroger or Safeway. Everyone associates a different value to it and the outcomes that are associated with it.

To your second point, there just is no quality data out there yet. Consumers have always struggled to make informed decisions because our system makes that hard, where it’s different from shopping for a healthcare service or finding the price of a service. We are in early innings to expect consumers to think through the advanced quality pieces of that. But we as an industry have not even begun to scratch the service there. That’s going to be the next wave, the downstream implications of this new way of interacting with the care system in being able to call in and get a bunch of prescriptions.

Despite lots of chatter about consumerism, patients aren’t entirely free to make their own decisions because they are limited by insurance or geography. Is consumer preference and satisfaction really becoming more important?

I don’t think it’s that black and white. Consumer preference is certainly important, but the way to think about it is, how do you influence consumer decisions? Assume you have two diabetes patients in a given market. One has consumed information only via text messages and virtual modalities. How a provider or health plan encourages that person to to engage in A, B and C healthy behaviors is very different than with another diabetes patient who is old school and likely to respond to things sent in the mail.

We don’t think about our healthcare patients as people who make decisions, so when I’m talking about decision making, a lot of it is a product of the choices in your market and the financial incentives. But each of us weights factors differently — convenience, price, geography, location, and distance. That’s where some of those opportunities lie. The more you understand those and understand your market of individuals, the better you can cater your offerings to your population.

How do you react to investors putting a lot of money into digital health companies whose business model requires employers to buy their apps, chatbots, or coaching services for their employees in hopes of saving healthcare costs? 

I’m not as deep on the employer market, but looking at what the trends show, the employer market is the opportunity for growth within the telehealth opportunity. We are seeing that with existing players like Teladoc and others who are shifting their model from a direct-to-consumer sale to making it an integrated benefit. That is why we made the point in the study around the margin costs being effectively zero.

The opportunity is within that population, but let’s think about who the employer population represents. It still is your commercially insured, healthcare-proactive individuals, for whom it is just an additional service. Without going too deep in a rabbit hole, I think that will be the opportunity where people are focusing, but once again, who is your market and who was telehealth intended to expand access for? Is it those who have great coverage and have a lot of access to services, or the people who with not as great health outcomes and are not regularly seeing a provider who need to be seen them more?

Compared to typical disruption, how might telehealth change the value of brick-and-mortar healthcare locations that have traditionally provided competitive advantage?

Where that is intertwined is this concept of the digital front door. Particularly for a lot of these retail players, but also traditional players like hospitals and health systems, the operating assumption is that if we have a way to engage with individuals on the front end — whether in a retail store and they come into the health system for more serious conditions or they use a digital front door like telehealth – they are going to come to us. That’s usually the operating premise for making those investments.

Analysis that I’ve done previously looked at health system traffic for what percent of patients in their market engaged with them through a telehealth encounter, then continued by seeking downstream care services at that health system, such as specialty care or other services. It’s not actually that strong of a connection, meaning there is a fair amount of leakage. Consumers want choice and options in hybrid models of care, but the data doesn’t support the extent to which telehealth investment will bring more patients to my brick-and-mortar location.

As a health economist, what technology trends do you follow most closely?

I’m spending more time on home care and some of these ancillary services and therapeutic technologies, at-home testing and things like that. It will be interesting to see whether that changes the practice of care and how that the data coming out of those technologies for treatment changes the whole system.

But ultimately, what I think about from a macro perspective is what I call the healthy tension between technological innovation and the payment model and the policy to meet that where it is. The largest payer of healthcare services is the federal government, and that share is growing. We have a lot of private sector innovation, which is great, but how does the incentive structure and the payment model support that innovation? Where does quality fit in? Where do the outcomes fit in? How do we measure that it is working and are we reaching people? That will be, no matter what the technology, the heart of how we know if it’s transforming the system or not.

HIStalk Interviews Anjum Ahmed, MBBS, Chief Medical Officer, Agfa HealthCare

Anjum Ahmed, MBBS, MBA, MIS is chief medical officer, clinical safety officer, and global director of AI and innovation of Agfa HealthCare of Mortsel, Belgium.

Tell me about yourself and the company.

Agfa HealthCare is a global solution provider of imaging IT solutions. It is part of the Agfa-Gevaert Group, which has been in the industry for over 150 years. Our prime focus over the last year has been transitioning our customers from the traditional PACS approach towards enterprise imaging. That strategy of consolidating imaging service lines has evolved across the industry. We launched our flagship platform for enterprise imaging few years ago. We were first in the industry to build a platform from the ground up. The company has R&D centers across the globe in Canada, Belgium, Austria, and China.

My role with the company is global chief medical officer. I’m also head of the portfolio for innovation, for artificial intelligence, and in making sure that we are successful in rolling out these new innovations to our strategic customers.

What maturity level does enterprise imaging have in the US, and what benefits does it offer?

The rest of the world is looking at what the US is doing. If you look back at how the consolidation of electronic health records started in the US — that transition from paper to digital and from digital to electronic health record – it made CIOs and hospital systems across the US realize that now is the opportunity to think about imaging as a service line. How the consolidation that they did with electronic health records could transform the care that they are delivering to their communities. That’s one of the reasons I would say that the US as a region was one of the early adopters of the enterprise imaging strategy. It made sense because they realized gains from electronic health record consolidation. 

The question was, why not when it comes to imaging? There were multiple approaches that the health centers and health systems in the US took. The initial approach was with vendor-neutral archives that could be a starting point for consolidating imaging from service lines that go beyond traditional radiology and cardiology into oncology, point-of-care ultrasound imaging, mammography, and breast imaging use cases. That was one aspect.

Here in North America, including where I’m based in Canada, there was also another aspect, which was that we have consolidated the imaging records, but our health systems or hospitals are on multiple PACS technologies. How do we go about bringing a uniform viewing layer? That’s where the universal viewing component for enterprise imaging also came about. We have the VNA and we have consolidated the archive of images, but how do you use or visualize that data? Besides VNA, universal viewer also became an important component for not only beginning the journey for consolidation, but also the visual layer in terms of consolidation of imaging and how you view those images.

The US is pretty mature, I would say, in comparison to what’s happening in the rest of the globe, where the enterprise imaging strategy may initially be focused on bringing the new technology into radiology or cardiology, point-of-care ultrasound imaging, and GI endoscopy. Multimedia images related to surgical procedures is also something that is being spoken about.

The next wave in enterprise imaging will be led by digital pathology. If you think about holistic clinical care in terms of oncology, and along with a lot of talk about precision health and precision medicine, bringing in histopathology, digital pathology data, and seamless collaboration with other imaging records is something that we are already hearing about in the US as a region when it comes to enterprise imaging adoption.

A recent KLAS report noted that Europe is leading the adoption of digital pathology. What are the opportunities and challenges of rolling it out in the US?

I have noticed that as well. We saw the rollout of digital pathology for certain use cases in Europe in 2015 or 2016. Obviously there are regulatory challenges when we compare North America to what was done in Europe, but the biggest challenge is that there are no standards that have been adopted for digital pathology, unlike what we had in radiology with DICOM imaging and all those standards.

The other challenge with pathology was the use of scanners to scan the glass slides and convert those glass slides into digital data. That is unlike radiology imaging, where you have modalities that are generating digital data. In pathology, you still use microscopes that are being read manually. Every scanner vendor generates proprietary formats for data ingestion. That was a challenge with some of these labs that were transitioning from glass slides to digital. Should they stick to one scanner vendor, or if they have multiple clinical use cases, they might be in a multiple scanner environment, which means multiple storage solutions for each of those scanners. That is where they started exploring whether a data management strategy would be an entry point into digital pathology with enterprise imaging. That is something that UK also took when these new RFPs or tenders were coming out over the last couple of years.

Data management became a very relevant ask. Rolling out enterprise imaging outside radiology, how would you manage data from these multiple scanners that generate proprietary data in the absence of DICOM standards? That challenge had to be addressed. VNA is vendor-neutral, so there must be a strategic approach in how that data could be managed with digital pathology acquisition.

Besides the data management aspect, there is also the departmental workflow when you go digital with pathology, similar to radiology and cardiology workflows. Pathology has its own requirement in terms of the departmental model. The question was, how are we going to develop these modules within enterprise imaging similar to radiology in the pathology workflow?

The third aspect is the visual layer. Should it be a universal viewing platform? Should it be a radiology desktop kind of a solution for pathology?

This is how the industry evolved. We have seen recently in our regulatory clearances that have been coming out in the US certain use cases to consider for digital pathology. That’s one of the reasons I’m saying that there are lots of lessons learned in how Europe started with their adoption of digital pathology based on certain clinical use cases, data management acquisition, and the visualization layer. Those are the three components that will help drive the adoption of enterprise imaging further into digital pathology.

EHRs made it possible for clinicians to work from anywhere. How is the profession of radiology changing as their work becomes digital and enterprise imaging becomes more prevalent?

We witnessed that during the pandemic. Enterprise imaging is a modular platform. As part of that modular platform, we have the image exchange portfolio. Besides image exchange, there is the federated image exchange network, so that you don’t need to physically move the data. Our customers started asking us when they started working from home how they could access this desktop on their home environment with the all the tools they require. Little did the customers realize that when they invested in that enterprise imaging platform, which brought them image exchange and collaboration capabilities, it took just a click of a button to enable those collaborative workflows.

When I talk about collaboration, I talk about real-time collaboration. One benefit of building that enterprise imagine platform strategy is that you’re not sending data across to external systems, where you could be exposed to someone interfering or accessing that information. Because you have created this secure system with enterprise imaging on a single platform, you are enabling access to your users if they’re at home to leverage the same capabilities with the same viewing platform on a thin client. We have Xero Universal Viewer, which is cleared for diagnostic reading. It has built-in capabilities and real-time chat collaboration similar to WhatsApp. Within this tool, you can see your colleagues who are online, you can share interesting cases with them, and you can share securely, including with other users who may not be part of your enterprise. It generates a secure image exchange kind of a workflow.

Another thing I spoke about was the federated image exchange. Federated image exchange means that you do not need to push and pull images from one storage to another archive. We could  set up Xero universal nodes so that users are able to view our stream images from an external, non-Agfa PACS, for example. That’s one of the benefits that we have seen our customers appreciating — they were able to build these networks of communication and collaboration not only within their Agfa enterprise imaging environment, but also outside Agfa’s enterprise imaging portfolio, so that they can view those images on a common viewing platform.

The clinical community, radiologists in this case, have realized that these tools are actually much more helping and facilitating in terms of how they view cases and how can they be more productive if they are not on premise. From an IT perspective, we have gone live at certain hospitals in the US during the peak of the pandemic in a rollout of the technology that was also managed remotely. That’s where we saw a lot of collaboration, not only from a clinical perspective, but between the IT segment of the community as well with our customers, where our IT and project management got involved with the customer IT to remotely deploy some of these solutions.

The hype a couple of years ago was that AI would replace radiologists, which has moderated into thinking about how AI can support radiologists. What is the most promising use of AI in imaging to improve patient outcomes?

We started working on AI in 2015 and 2016, when there was all this discussion about whether AI would be of any use in medical imaging. We partnered with some early adopters and explored certain clinical use cases. My first question to our customers was, what problem are you trying to solve? Let’s park AI on the side and first identify those clinical challenges that your healthcare organization is trying to address. Then we can decide whether it is AI or whether it is deep learning, machine learning, automation, or pixel intelligence. What kind of technology could we apply in helping you address those clinical challenges?

We identified certain use cases associated with chronic diseases such cancer care, where we thought — and customers agreed with us — that automation could perhaps help to them in early disease detection or even automating some of the manual tasks that radiologists are performing in some of these clinical applications. When we announced our AI strategy, we called it augmented intelligence, the intersection of machine learning and advanced applications where clinical knowledge and medical data converge on a common platform. AI replaces clinical knowledge or clinicians, while augmented intelligence works with the clinical audience and facilitates their work.

We worked with our clinical users and early adopters to say, let’s define KPIs and see what outcomes we are able to improve. At Agfa, we want to focus on the workflow side of the things. We are an enterprise imaging solution provider and our customers would expect us to use AI data from several AI applications that are being developed in the market and leverage that data to do something. Some of those companies that were creating hype around replacing physicians with AI have disappeared from the market because the claims that they were making were not addressed in use cases.

There are 100-plus AI startups out there. We decided to focus on workflow, because in developing our own AI applications, we realized that a lot more needs done than just reading pixels and images. An AI algorithm developer has developed something very nice, so how can we as Agfa utilize it? We developed this framework for AI that we call RUBEE, whose goal is to embed clinical intelligence into the user’s workflow from five perspectives.

Number one is that AI generates a lot of data. How do you utilize that data and how do you visualize it? How do you show it to the clinical user? Instead of having a radiologist or a clinician use multiple applications or viewers, we have embedded those visual findings from AI into the enterprise imaging portfolio, whether it is the desktop or whether it is the Xero Universal Viewer that I spoke about.

The second and third aspects are the workflow orchestration and triage. With workflow orchestration, AI generates abnormality findings, abnormality scores, measurements, or some other aspects. With the RUBEE engine, we are able to orchestrate certain workflows and automate certain tasks that radiologists are spending time today doing.

When we released our AI package to one of our first early customers, they said that reading a particular CT scan went from taking 15 minutes to being finished in seven to eight minutes. With RUBEE, all the tasks that they were doing have been automated. They know that at the top of the list, these are the abnormal cases that they need to start their work with, these are the measurements that the AI algorithm has generated. With RUBEE, they can see where those specific cases are. We can distribute some of those cases to certain groups of radiologists who are concerned about that specific clinical scenario. That’s where the visualization, workflow orchestration, and triage help achieve certain productivity.

The fourth aspect is automation of all hanging protocols. Radiologists spend a lot of time — when they are reading certain exams, currents, priors, and certain cases — going back and looking at certain prior scans in comparison with what they are seeing now. RUBEE, based on AI findings, automates certain hanging protocols so that radiologists do not need to find a relevant prior scan for this particular patient. Early adopters told us that this is useful and they have appreciated the time savings.

The fifth element of our RUBEE strategy is, how do you communicate reports and results? AI is generating visual findings and you are orchestrating and triaging. How can you save me some time in generating reports? That varies in North America versus UK and Europe, where the use cases are different. In the North American region, we have seen customers are using specific reporting solutions, so we can provide a feed from report that is generated by AI to the reporting engine. In Europe, where customers are using the built-in module for reporting with enterprise imaging, we have created structured reporting within radiology, so that we can extract certain drop-down menus within the report itself. It becomes then easy for radiologists to do a one-click signoff to agree with the report or disagree with the report and generate their own findings.

HIStalk Interviews Kevin Field, President, Clearsense

Kevin Field is president of Clearsense of Jacksonville, FL.

Tell me about yourself and the company.

I joined Clearsense in 2017. Prior to that, I spent nine years working at Epic as a implementation executive, where I oversaw major EMR implementations here in the US as well as international. It was a fun time helping these healthcare organizations go through the adoption of enterprise systems to help with their medical records and the processes around that.

When I looked at healthcare IT as a whole, I started recognizing that there was a whole lot of data that we were collecting — certainly within the hospital, but also outside — and we weren’t necessarily taking full advantage of everything that we could do with it. Clearsense is focused on being able to intelligently take all of that data that exists within that ecosystem of health and applying it in a meaningful way to change the way that we can operate in healthcare. That can be through operational-type use cases or improvements, clinical, financial, and even population health. We are focused on how we can make it easier to work with all of that data and get it into the right hands to drive change.

What are the most common use cases you are seeing?

Data exists in a lot of areas. People are trying to get to more of that prescriptive medicine and thinking about ways to impact the care itself. But there’s a lot of operational improvement that can be a good starting point. We see a lot of healthcare organizations start with rationalizing their applications. It sounds so simple, and it’s not nearly as enticing as some of the more advanced predictive types of use cases, but it’s a practical one, helping organizations take a look at their current portfolios to be able to offload a lot of that data. We work with them to make sure that they can maintain the integrity of it, because there’s still a whole lot of valuable information that exists when you’re looking at these historical systems. We see a lot of groups starting with being able to shut off some of the historical applications and be able to recoup or avoid some of the costs that come alongside of that. That’s a great starting point for a lot of groups.

As they continue to evolve, though, it’s really as big as you can think. You can start to apply this data for research, to advance the ways that you can get from a data-driven hypothesis to applying that in an operational setting. That could be anything from throughput to advanced heart failure, any sort of use case set that applies to this area. But what we focus on, and where our industry needs to focus first and foremost, is how to build trust in data. Before you can do any sort of analytical work, before you can do any sort of meaningful work, you have to build up that trust. That’s the foundation.

Are health systems struggling to effectively use the data that they capture in their IT systems?

Unfortunately, when healthcare systems were forming and data was being designed, there was no master plan. Every single application that these hospital groups operate has come up with its own way to identify data and be able to aggregate and and organize it. That has left is mounds and mounds of data spread across hundreds if not thousands of applications within these provider groups, but no way for them to create a source of truth. It’s a confusing area when you start to look at this data.

A lot of healthcare provider groups have captured a lot of data, but maybe they don’t exactly know what they can do with it, or how to get it organized. Step 1 is being able to build up data literacy, the ability for people to understand data, understand definitions, understand what’s possible with it, be and able to challenge it and look deeper into it. If you’re able to start to work in that capacity, then you have the ability to create initiatives around normalizing that data or curating that data and starting to develop some level of truth in that data so you can apply it.

How does healthcare stack up to other vertical markets in its performance on data maturity models?

Certainly if you look outside of healthcare, there’s a lot of good literature and good practice of ways to build up that data maturity. A lot of organizations are starting to look at that more seriously. Some maturity models are specific within healthcare as well. Even some of the advanced or healthcare groups that we talk to, if they are being honest with themselves, have pretty low maturity levels.

Much of the time, healthcare organizations are trying to get meaningful information out of reports.  That’s foundational for the rest of the work that takes place. There’s a lot more that is possible when look at that data in a way that is more forward-looking, more universal, or taking into consideration the data that exists in other systems. There’s a lot we can solve for if we put all that data together appropriately and apply the right lens.

Groups are starting to think about how to evaluate themselves on data maturity. Some groups are hiring chief data officers or chief digital officers and starting plans for a data maturity program. But the reality is that data maturity is an evolution. It will be an ongoing cultural shift for these organizations. It’s about building a culture around data for an organization, understanding the value of it, and then building practices around it to continue to evolve and mature. There’s never moment of, “Hey, we’ve reached the top of data maturity and we’re good now.” It’s a constant evolution.

What is the role of data scientists in health systems?

Data science will be critical for the future of healthcare. We’ve seen that in other industries, where they bring data science as a practice and a staple to drive things forward. Healthcare’s challenge is that there’s not a large number of data scientists who are healthcare specific. Even if healthcare organizations can get those individuals into their systems, providing them access to the data in a way that is meaningful is a challenge. The velocity which they can operate is also challenging.

We’re going to see a lot more healthcare organizations becoming interested in data science. The next step for it to be widely adopted is making it more accessible. We’re going to have to work to continue to have technologies and processes come in that allow for data to be more trusted and more centrally available, and also for data science type initiatives to be more approachable. There are some good examples out there if you look up technologies that are starting to evolve and emerge that can be applied in that space. 

That’s going to be what allows us to shift the way that we think about data and healthcare — having people taking a look at it, look for trends, understand what could be coming up or what events are happening, and then ultimately being able to look backwards through that so we understand the drivers so that we can prevent those or catch them earlier. Transparency and trust, again, in data and in the models being created are going to be key for adoption for data science and healthcare.

The challenges I’ve seen are getting information into the hands of frontline decision-makers quickly and avoiding turning the process into a mysterious black box where some IT basement guru manipulates raw information in unknown and potentially unsound ways. How does that fit into the culture of using data and the tools needed to manage it?

A lot of that comes from being able to establish lineage in data, which is critical. When I say lineage in data, by the time you are serving up some insights or results out of a data set or analytical workflow, you have to be able to show exactly where that data came from. If you want somebody to consume it, you have to be able to build that trust up with them and be able to trace that data back to the source. Lineage is absolutely critical and key.

While you’re working on the governance of the data and decision-making on that data, it’s important that the people making decisions on data — what fields are trustworthy and which systems are providing the right information – are making those decisions along with the appropriate data stewards in the healthcare organization. If you are working with a radiology department and radiology data, it’s important that the people from that group have input to understand exactly which data elements are most relevant or which systems are most accurate. By the time you are able to have that output, if you’re not getting those decisions made by some of the true operational owners and the business owners, it makes it challenging for people to trust it.

A lot of orchestration has to take place. Lacking of any sort of black box has to be part of that. Having those IT groups or data scientists who are working in the basement interacting and understanding the data that they’re working with and the people that they’re ultimately serving it up to. If you involve them in the process, there’s a lot better chance for trust and adoption.

What C-system health system roles are being given responsibility for data and analytics?

I’m seeing a couple of flavors. There is a spectrum of CIOs. There are CIOs who are more the traditional type who have come to own a lot of the technologies and applicationse. Maybe that’s the world that they continue to operate in. There is another grouping of CIOs that I’ve noticed recently that have realized or recognized that a lot of the healthcare organization’s data sits within the systems that they own, and they are becoming more strategic and more of that operational driver. I’m seeing chief data officers or chief digital officers typically reporting directly to a CEO or a COO. 

From a data science perspective, organizations are looking at ways to get data scientists more decentralized so that individual business units don’t have to wait in an IT queue to have their initiatives prioritized and to get results. Having access to the appropriate data and technologies to get better or more timely results and to to get those results ongoing as applied to specific areas will be important.

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

We are going to get data into the hands of the people who are using it. We’re going to build up a culture around data literacy and applicability that will change the way that we operate. We operate so frequently on historical information or reports or looking backwards. As technologies catch up and as a culture of working with data catches up, people will be more proactive and more capable of working with data to solve problems.

It was in the 1990s when latex gloves were adopted into healthcare setting as standard practice. That seems almost shockingly recent. When we look back on today from the future, we will recognize that we had the answers to a lot of our most challenging healthcare problems or questions and just needed to apply the appropriate lens. The future is heading to getting that lens on the data to have new perspective on the problems that we have today and coming up with data-driven ways to provide results.

HIStalk Interviews Patty Hayward, VP, Talkdesk

Patty Hayward, MA is VP of strategy, healthcare and life sciences, of Talkdesk of San Francisco, CA.

Tell me about yourself and the company.

I’ve been in healthcare IT for the past 25 years. I’ve worked with several organizations to transform processes and procedures in areas such as medication safety and revenue cycle. I worked at Aetna, helping with the first ACOs. I’ve had a lot of stints in population health. Now I’m working with patient experience.

Talkdesk has been around for 10 years. It offers the first cloud-native contact center as a service. It was born out of a hackathon from Twilio. There was a niche in the market that needed to be worked on. The company has kept over 50% of its employees based in product and R&D, which is a huge commitment to innovation, looking at how we can transform and disrupt different areas.

About a year and a half ago, the decision was made to look at specific verticals, with healthcare being the first. That’s when they brought me and other folks on board. For us, it’s all about how to reimagine that patient experience, reduce friction, and help providers offer a different experience than is typical. We want to make sure that it is synchronized across multiple channels and is personalized and convenient.

How do large health systems tailor their digital health strategies in the face of potential competition, but while operating at capacity and with record profits?

Interesting and unique forces are definitely in play. There’s a lot of change in the market. Large retailers are jumping into the market, bringing their experiences to target areas such as primary care, population health, and chronic disease management. That’s going to give them a lot of ability to steer. Whoever you’re dealing with most — your primary care doc or someone who is working with you to manage your chronic disease — is who you will listen to on where you go. Younger generations are interested in different ways of doing business and thinking about healthcare in a different way. Record profits make it attractive for people to jump in, and you are seeing that.

Amazon has the luxury of catering to a self-selected customer base that is comfortable with an online-only relationship. Do providers have a different challenge in accommodating people who may prefer interacting in person or via telephone?

You are seeing this a lot with Medicare Advantage plans. They are obviously targeting the senior population, but they are tech savvy and tech forward in their approach and are using it in a smart way. They are giving a lot of choice and a lot of opportunity to utilize technology selectively, but also using care guides to guide folks through the system, which is much needed when you think about chronic disease patients in the Medicare population. It is difficult to navigate. They are allowing their members to come to them as they can, or as they would like to, whether that’s via voice or via technology. They are also using technology to make their agents efficient. So there are multiple ways to look at technology and how to implement it. It doesn’t have to be patient- or member-facing.

How are health systems using their contact centers differently?

Health systems are starting to look at their contact center as a strategic asset versus just the cost center it was in the past. It is the front door, typically the first touch that a patient has with their organization. We went the NGPX patient experience conference at the beginning of December and one of the things that struck me was that about 95% of the presentations were on HCAHPS scores. Those are acute focused, inside, did we do these certain things. When I had conversations with a lot of folks, the Mayo of course jumped out and started talking about patient experience in a very different way. They still do HCAHPS, because you have to, but they have jumped over to using Net Promoter Score as a measure of patient satisfaction. That’s unusual in the space.

People are starting to think differently about how they can transform to “how did we make you feel” versus “did we do the right things all the time.” A lot of forward-thinking folks are looking at how to do this differently. You are also seeing CMS start to push member experience as a huge piece of how they reimburse, making that one of the biggest metrics that they are using for star rating.

Providers used then-modern technology such as PBX systems or online contact forms to prevent people who needed help from easily accessing their employees. How are they thinking differently about tailoring communications using someone’s preferred method and personalizing the message?

People are talking about things like digital front door. Health systems, especially those that take risk or have their own plans, want more interaction with their patients in the right way. Being able to do things like send a text reminder that is interactive versus “say yes to confirm or no to cancel.” They want to keep that revenue stream going, because if you miss an appointment, that’s money out the door. They want to continue to have those record profits. There are a lot of ways that you can work through that whole aspect.

During COVID, the volumes that hit their switchboards were unmanageable. I talked to several health systems whose entire phone systems were taken down by the volume. People quickly automated as much as possible, standing up IVRs to give automated answers to quick questions, offering chats, and adding FAQs to their websites. Taking simple things that could be easily answered by automation off their switchboards to give their agents time to answer questions and have good interactions.

Forward-thinking ones are looking at the disruptors that are coming into the space and taking patients off of their books. How can we keep up with them? Amazon Care is going after employers, not necessarily patients themselves. Hilton was their first big one. There’s some big innovation in not only the care that is given, but in how they get patients on their rosters.

Most businesses assign a single customer identity and a defined way to interact with them. How well do health systems coordinate the many reasons they might be communicating with someone – clinical care, marketing, reminders, population health, billing – and give their employees a single view into every one of those communications?

The key is integrating with the system of record. If it’s the EHR, you want to make sure that you’ve got a connection to make the API callout so you can see snippets. You aren’t trying to duplicate the EHR – you want the highlights of things that are of interest. We are completely customizable, so we can build that to the experience that you would like. You may have different groups that need different visions. Someone who is in revenue cycle and billing wants a different look than those who work in patient access or care management.

You would want to be able to see if they started it off with a chat. You would authenticate to have a real conversation, be able to see who they are, and be able to do things like patient scheduling. Then if it is escalated, to be able to bring all of that information to that agent’s workspace so that they can see what’s happening and they don’t have to listen all over again. You see that in other verticals, where when people call in, they start with a discussion with an AI agent and then escalate to a human who says, “Give me a minute to get caught up on what you’ve said.” That’s an important aspect that we don’t tend to have in healthcare as much. It’s important to have that integration into the EHR.

Patient portals used to be viewed as consumer-unfriendly, but suddenly they are the well-received launching point for most interactions with patients. How do they fit into the ideal consumer experience?

Patient portals are not going to be real time. I just had my annual physical and it took a week to get a response from my physician. The patient portal can automate things that make sense for patients to do when they are on their computer, such as scheduling appointments, rescheduling, paying their bill, things like that. But a lot of times, people are on their smartphone and want to be able to start a conversation using the chatbot in the corner of the web page.  

Ideally, it’s all tied together and you can see the history. If there’s an interaction that’s recent, you want to be able to pull that in, create intents, and use AI to determine that the person is calling in because they’ve asked their question three times. You should see that as you’re answering the phone call. It’s important to be able to synchronize all these things, which typically doesn’t happen today. You call in and they have no vision into what you’ve been doing. I’ve been with my primary care provider for 19 years and it’s like I’m brand new every time I call.

Providers used to just hang out a shingle and people lined up, so nobody worked too hard to attract new patients. How are chief digital officers or chief experience officers who come in from other industries working with health systems who aren’t used to having to be consumer-friendly?

They are bringing in all sorts of people for these roles. It’s not just folks who are traditional healthcare. You have people coming in from Disney, Best Buy, the retail sector, and the entertainment sector with a viewpoint of what it could look like. They are bringing a different and unique lens to how you can capture more of the populations and become a destination place where people want to go. Mayo Clinic can dictate the kind of patients it wants, and other systems are, like you said, taking the approach that their shingle is out and people are coming.

Disruptors that are coming into the space are going to peel off those more valuable individuals, those who have more money to spend, and offer additional services that they are willing to pay for. If you look at that Amazon Care video, it’s pretty cool to be able to have a virtual visit, and if they can’t solve it on videoconference, they will send someone to your house or your place of work and then deliver your medications in two hours. There’s this full circle of care that can happen that makes it convenient and easy for you to seek the care you need.

Otherwise, folks will avoid doing that and then end up in a worse position or in the ER, which may be profitable if the ER isn’t taking risk. But if they are taking risk, all of a sudden the cost situation flips. That’s where the change is. Fee-for-service loves that ED visit, but with fee-for-value where you take on risk of the population, it’s a different discussion. We are seeing a lot of push towards fee-for-value. It has been going on for over a decade, but we are seeing more folks jumping in and offering different opportunities to grab onto that fee-for-value area and show value back to the government or to employers who are paying the bill.

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

You will see AI take a bigger role, both in the things that are easy to automate and those that are not. It will take a huge role in helping the agents with their work, so that information is easily accessible and correct so that you can get it done quickly the first time. Agents will be able to spend more time and emphasis on that empathetic journey that you would like to show to your patients, at least those organizations that do it well.

You’re going to see a lot more emphasis on providing what in retail they call a delightful journey. Not too many people would call healthcare’s journey delightful. You typically come there stressed out and having a lot of interactions, so being able to deliver an experience like that is important. As we get folks to take care of themselves in the way that is prescribed, how do we activate the patient? How do we get them to think about how to take care of themselves and make the right choices? All of that will start to come together. Smart watches, devices, and different areas will allow you to get a lot more help and a lot more ability to, when you want, get guidance in real time.

HIStalk Interviews Amihai Neiderman, CEO, Nym

Amihai Neiderman is co-founder and CEO of Nym of New York, NY.

Tell me about yourself and the company.

I’m an engineer by training, in computer science. I did my bachelor’s in math and computer science when I was 14. Later on, I joined the Israeli army and did mostly cyberintelligence. After I left the army, I was influenced by my wife — she’s an MD-PhD ENT surgeon – and I started Nym. We do autonomous medical coding.

How do you distinguish autonomous medical coding from computer-assisted coding?

Computer-assisted coding is a tool that helps coders, giving them suggestions on the most appropriate code to use. It doesn’t make the final decision. Our fully automated solution requires zero human intervention. We code a chart in around two to two and a half seconds on average, then submit it directly to the billing systems in our clients’ facilities without anybody having to review those charts to make sure that the coding is correct. From there, it’s usually being sent directly to the payers. We completely remove the human from the loop.

Do payers trust the system’s consistent coding more than that of humans, where human coders may not all code the same way?

That was one of the reasons that it was hard to do automated coding until now. There was this lack of trust between the payers and providers, for obvious reasons, probably. The unique approach that we took when we started Nym is language understanding into clinical intelligence, what we call today clinical language understanding.

We can generate an audit trail that gives providers an end-to-end explanation of our entire thought process. If one of our clients ever gets a denial, an audit request, or even just during the onboarding process, they can assess and understand how we’re doing our coding. They can review those audit trails. We’re not hiding anything. We’re proud to show our internal thought processes and how we ended up deciding the right codes to use.

Payers who are receiving our audit trails are starting to become more interested in learning more about our solution, because we are not hiding anything and we have full transparency into our logic. They are usually afraid of fraud, waste, and abuse. We can show on the fraud part that we have nothing fraudulent in our process. It addresses that trust issue in a very interesting way.

Do you test in parallel with the customer’s human coders during implementation to measure the impact?

Yes. We know that our clients are moving something that is business critical for them. If we make a mistake, they could be exposed to compliance risk. They could lose revenue. We do a shadowing period, where when we do side-by-side coding for 30 or 45 days, depending on the client and the complexity of the project that we’re doing with them. During this shadowing period, we will have weekly or biweekly meetings with them and let the client choose choose any charts that they wish to review. They have access to our audit trails through a dashboard.

Sometimes they understand for themselves why we code something in a different way than their coders. Sometimes they’ll want to surface it up to us for an explanation of why we coded it this way when they might have done it differently. If we need to, we reconfigure our system based on their standard operating procedures.

How often do payers ask to review the audit trails, both initially and after they become comfortable with the system’s coding?

The payers don’t have direct access to the audit trails. It’s only if our clients decide to submit the audit trails as part of their appeal process if something was denied, or for an audit process that they have with the payers. Our relationships are directly with the providers who are our clients. But we do see from some of our clients in our periodic review that there is a significant drop in denials rates. Mostly because one of the things that we’re striving for is high coding accuracy, following the guidelines to the letter. You won’t see a lot of deviations.

That’s one of the beauties of using software to do coding. It is deterministic. You’re going to get the exact same results every single time. Once you become confident that you know that the results are up to your standard, you’re going to have reproducible results every single time.

Are issues with fraud, waste, and abuse usually caused by improper coding or are the provider’s notes themselves inaccurate?

We only code charts where we are fully comfortable with our understanding of those charts. If we see ambiguity, contradictions, or missing documentation, we drop those charts and let them go through the client’s ordinary process. Coders can reach out to the physicians if they need to. We code charts only when we are 100% certain that we fully understand everything in them. If there is any missing information, or if the chart might have any issues that will lead us to have wrong coding, we will just drop them. We are not taking any risk there.

Do clients implement your system primarily for efficiency or for accuracy?

Every organization has their own reasons for using our system. Sometimes it is speed. Provider groups that take five days to a week and a half to get their charts coded now see it happen in two and a half seconds. That reduces several days from their days in AR, giving them more cash on hand to operate their business.

Sometimes organizations, especially those who have tried outsourcing, usually offshore coding, encounter compliance issues and quality issues. Running an entire operation to try to reduce the compliance risk is expensive and not usually as fruitful as they believe. They are looking for a better solution to help them from a compliance perspective. This is where we come in.

In other cases, it’s reduced cost and improving their overall revenue cycle operations. We show the client that we are not just impacting directly their coding operations, but we will do it much faster than any one coder will do and we’re going to have a reduced number of denials, meaning fewer people that have to do scrubbing and running the appealing process. We affect the entire revenue cycle process downstream from us on the coding side.

Companies, including Google, are using natural language processing to support searching electronic charts and extracting data from free text notes. Will Nym use its experience in extracting chart information to extend beyond billing functions?

Definitely. When we started the company, we took a whole different approach into language understanding. What you see most of the bigger companies doing, almost all of them actually across the board, is using language models or AI solutions that weren’t tailored for healthcare, which has its own unique needs and problems. You gave Google as an example. They have an AI solution that solves their issues for search for understanding websites or news articles, but it’s not necessarily tailored for healthcare.

We built our own. We take a lot of pride in this. We built our own AI stack for language understanding, for clinical language understanding, and for coding that is specific for the healthcare domain. We’re a great coding company, but what we are really good at is capturing clinical narrative. Capturing the true clinical picture of what happened to a patient. Once you understand this, coding is a relatively easy thing to do. Because we built this strong technology and invested a lot of time in doing this, we can expand to other product lines or areas, using this technology to power new products.

Why does Israel produce so many successful entrepreneurs?

The vast majority come from a couple of well-known intelligence units in the army. One is the unit I served in, called 8200. It’s not the army that people envision or what they’ve seen in a movie. You get a lot of responsibility at the age of 18. You can become an officer when you’re 20, commanding soldiers and being tasked with some of the most complex things that could change the course of our history. They encourage you to do whatever it takes. 

There’s a mandatory army service, so people get replaced all the time. You come in, do your three years of service or four or five if you extend it. New ideas are being surfaced all the time. People come in and challenge what people have done before them. You have a huge number of new ideas coming all the time and people are energized to try them. I was lucky enough to serve in a place where I was constantly asked to innovate and was given the backing of my commanders to do it.

What parts of your background have been most relevant to being an entrepreneur? What do you find most challenging?

I was doing cryptoanalysis in the army. When we started the company, we knew that we were going to tackle a challenging problem that some of the largest healthcare key companies have tried and failed to solve for the better part of the last 20 years. We needed some of the best problem solvers in the world to work with us, so a lot of our R&D folks are people who we knew back from the army. My co-founder Adam Rimon and I both served in the cryptoanalysis department, which was a good place to find great problem solvers. That has helped us with the early work of trying to prove that the unique approaches that we took to solve the problem could actually work. We had the right people to do this.

The challenge is that the army doesn’t teach you how to manage a company. The army has a very different management style than what you’ll see anywhere else. I felt pretty relaxed because of the nature of the business that we were doing back there, but it’s still not very similar to what you’ll see in a company. We had to learn a few things the hard way, but we try to fail fast, learn from it, and not repeat the same mistakes again. As long as we have a smart team that can follow the same kind of principle, then it’s OK make mistakes. 

We just run, run quickly. We try to learn as fast as we can. One thing that we want to bring into the company and to the healthcare space is rapid prototyping. See if something works. If it doesn’t, you throw it away. If it does, great, you iterate over it and it creates value almost from Day 1 of the company.

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

We are building great business in the coding space. The quality of our product and our results speak for themselves. We get our clients just from word of mouth, and our clients are highly referenceable. It sometimes amazes me that we are coding several million charts per year. We have three coders right now on the team who are serving as subject matter experts, but are not doing the coding itself. We are building a great coding company, bringing in work, adding to the client base, and expanding our footprint. We are going to be the top coding company in that area.

While we are doing this, we are also maturing our core technology. Our CLU engine gets better all the time. The more clients that we’re seeing, the more edge cases that we’re seeing, the better it gets and the smarter it gets. This allows us to take this unique core technology that we built and apply it in other areas that we’re still exploring. Coding is interesting because it sits between the clinical side and the revenue cycle side. We have the opportunity to influence the clinical side, to assist physicians both in the documentation side of the house and the revenue cycle process downstream from us.

HIStalk Interviews Brian Yarnell, President, Bluestream Health

Brian Yarnell is founder and president of Bluestream Health of New York, NY.

Tell me about yourself and the company.

I got started in healthcare 10 years ago. Prior to that, I worked in digital media, consumer behavior, and data-driven analysis for retail, manufacturing, marketing, and sales. I have quite a bit of background dealing with consumers and big data. I sold my first health tech company about seven years ago to Hillrom. That was a business called Starling, where we built a replacement for a nurse call system that routed out throughout the hospital and used intelligent workflows.

We shifted gears and founded Bluestream after that, with the idea of figuring out a better way to bring real people, through video, to a patient’s bedside. At the time, we didn’t really anticipate what was going to happen outside the hospital. We were thinking through how we could better provision these relationships between a remote provider and a patient.

Providers rushed to offer telehealth services via whatever video platform was quick and easy to roll out, but the novelty of interacting with patients by video has worn off. What virtual health platform capabilities are needed to provide a good patient and clinician experience?

Things have evolved fairly quickly. I think of it as a continuum. Those technologies that you mentioned were effectively video, which is a commodity at this point. Beyond the basic video connection, things have evolved from telehealth all the way to what I would call virtual-first healthcare. If you think of it in that context, the video piece is the last mile, but it’s really about opening up front doors for patients and meeting them where they are and how they want to be engaged.

The idea of patient portals and downloadable apps has generally not succeeded. The big things that people ought to be focusing on for virtual care is, how do you get in front of a patient, wherever that patient is, and however that patient feels like engaging? Then for clinicians, starting to take some of these brick-and-mortar workflows and make them virtual so that you can do all the great things that you might do in person, but do them remotely.

What elements of a virtual visit most strongly affect patient satisfaction?

We recently added Net Promoter Score, thinking about my marketing background prior to healthcare, to the platform. We know specifically what impacts patient satisfaction. It’s not just the bedside manner of the clinician. It’s what happens when somebody shows up a day early, an hour early, or 20 minutes early for an appointment. You can’t leave people in limbo. You have to be “consumery” in terms of how you engage folks and walk them through this process, even if they show up at the wrong time.

Making experiences that feel like a consumer-driven website. Give people information, expectations, and tools to engage, even if they are not necessarily at the front door at the right time. Then, post-visit, what happens when you wrap up with a clinician? What happens when something goes off the rails and you have to reconnect? All along the way, from showing up early or showing up on time to the visit, dropping the visit, concluding the visit, providing a real framework that still hand-holds the patient and has that consumery feel without being overly technical, overly burdened with lots of bells and whistles.

What virtual options can be offered to patients who have limited technology or bandwidth?

One of the things that we’ve seen as being successful is getting folks like MAs and assistants to tee up the call for physicians. You certainly don’t want the physician troubleshooting cameras, networks, and things like that. But you can have lower-cost, higher-availability resources work with the patient first and do a handoff.

But as you said, some folks aren’t going to get there in terms of tech. What we’ve seen be successful is automation to reconnect these people, to literally point out where you have to click to accept camera permissions. But some folks, like my mom, will never get there, and in those cases, you have to be willing to work with telephones. We’ve seen people doing emergency medicine consults , ET3 [emergency triage, treat, and transport] programs where the reality is that a large portion of the population is going to pick up a phone and dial it. You have to be able to route those visits in with the same attention and same priority as the people who are fully into the smartphones and video.

Health systems initially saw virtual visits as a distraction that should be turfed off to third-party companies that provided not only the platform, but the providers. Now that virtual visits are here to stay, are they treating them more like a full-fledged, branded patient experience?

Absolutely. You hit on a really important point. If you gave a hospital a $1.5 billion a year and a half or two years ago, they would have built a new wing. Now, they have to be thinking about how to build virtual experiences.

These vendors that you talked about that offered a lifeline of virtual visits with the provider network behind it will compete for those patient relationships with the hospitals as the world shifts towards more consumer-facing, on-demand care. The hospitals need to think about how to implement these programs to prevent their vendors from cannibalizing their core business. That becomes important in a transition into a value-based framework.

How does virtual health avoid becoming commoditized, where consumers see all encounters as equal and just choose the cheapest or first-available provider?

Consumers expect it immediately and pervasively. What you’re talking about is this preponderance of front doors that appear to come from all different places.

We and other vendors are starting to equip health systems and traditional healthcare delivery platforms with the ability to cast this wide net. Even though you may come through an insurance company’s website, a phone number on the back of your insurance card, a kiosk in a homeless shelter — very different experiences and a different type of front door — you’re going to start funneling those visits into a common pool provider. People like Teladoc have done that for years. The difference is that health systems are getting smarter about getting in that game and funneling visits from non-traditional places into their provider group.

Healthcare didn’t follow other businesses in looking at the lifetime value of acquiring and retaining a customer. Is that changing?

Absolutely. We have customers all across the spectrum, from people who just pay the bills of ambulatory visits to those who fully participate in these risk-based programs. The more sophisticated folks are looking at the cost of acquisition and  the cost of attrition.

What happens when a non-traditional player, such as Walmart, CVS, or Amazon, gets your patient? They’re not coming back. When you get into this modality where you are getting compensated for the cost of keeping the patient healthy, the lifetime value of patients goes up substantially. Smarter health systems, more strategic entities like some of the pay-viders, are playing that game of, how do you capture as many relationships as you can and keep them? Because you want to be on the winning side of that equation of people who are getting paid to manage a population effectively.

How does a health system’s marketing strategy change when those relationships are established during virtual visits and that involve consumers who may not require a health system’s services for a long time?

We’re seeing more sophisticated health systems, even the traditional ones, get smarter about using tools that let them take the providers they already have. A lot of them are large physician employers, and they have a pool of providers. What they don’t have is access to a patient until that patient has a heart attack or gets hit by a car. To empower those providers to get in front of patient, they are establishing commercial partnerships with large, self-insured employers, with insurance companies, and with municipalities that need healthcare coverage in housing projects and homeless shelters. Establishing lots of diverse front doors — whether it’s a walk-in clinic in the inner city or a health clinic in a Federally Qualified Health Center — and proactively identifying.

They cast a wide net to get patients. The branding might not even be their own, but they’ve got to be funneling those patients to the providers that they are already paying to be on the bench.

Are we in the early days of virtualizing the clinician workforce, where most of them already prefer to live in urban areas?

The hub-and-spoke model is a real thing, being able to have centers of excellence and making them accessible to remote communities, whether it’s because they are socioeconomically disadvantaged or because they are physically remote. The big risk is brain drain. You don’t want to be in a situation where you have no local providers who have expertise any more, because if somebody walks into a hospital and needs follow-up care, they want to have a good experience with a local community member. You’ll start seeing some of that shift into more urban hubs or more centralized hubs, and it’s a little bit of a risk.

Most people would be happy if virtual primary could deliver results equivalent to in-person visits. Are areas that can deliver arguably superior outcomes, such as behavioral health and chronic condition monitoring, drawing equally enthusiastic interest?

We do a lot of behavioral health. We do it inside acute settings, like emergency rooms and inpatient units, and we do it outside of acute settings. The big difference is, are you trying to keep someone out of the hospital and from incurring healthcare costs, or are you trying to adequately address somebody’s needs when they set foot in the door? Either case is a big one, low-hanging fruit with an event that has the potential to cost a lot of money and cause a lot of headaches if you don’t address it up front.

Behavioral health is a good one. We see the measurable impact with our customers and our partners. We can bring in a behavioral health expert, such as a clinical psychiatrist, to write an order for a patient in well under an hour, when in an ED, it might otherwise be a one-day or a three-day wait. It’s a big difference.

Outside the hospital, I would lump in behavioral health with access to things like emergency medicine, these mission-critical things that cause people to go to a hospital or to incur additional costs. We have 911 and ET3 programs that drive down the number of visits by 50%. It’s a big deal, and there’s a reason people are focusing there.

Are health systems interested in having their providers virtually help paramedics, long-term care, and home health providers who otherwise don’t have many options except to send the patient to the hospital’s ED?

Definitely, and even more so as you think about the systemic cost of care delivery. New York City Health + Hospitals is one of our customers. They tie directly into the 911 system. They deliver their services down into SNFs. They tie into first responder devices in ambulances and fire trucks. 

The underlying theme there is that they don’t want people going to the hospital. So when you dial 911 and it’s not life-threatening, they are going to get you in front of a clinician. If you need a paramedic, they’re going to try to get you virtually in front of a clinician. Even when you show up in person, they don’t want transport you, because the systemic cost of moving someone from a SNF back to the hospital is somewhere in the range of $10,000. You can absolutely prevent that from happening if you have the right safety net in place in terms of clinicians and folks like that.

What changes do you expect to see in the virtual visit concept and in the company’s business over the next few years?

What will drive the evolution of our business as a platform provider, and probably more importantly the business of traditional health systems and payers, is this shift towards value-based care and on-demand access to care. That’s just ubiquitous, and it will be painful for health systems to adapt to do that, because they are used to filling beds and physically getting their hands on people.

There are a lot of new folks coming into the market. Amazon and Walmert are better equipped to present consumers with what they want, when they want it. A lot of work will go into equipping these traditional providers with the tools to rise to meet consumers where they are. The mantra of the American consumer is that “I know what I want, and I want it now.” This notion of trying to make a better patient portal and that type of thing is never going to succeed. You have to give people what they want and then work out how to route these things intelligently and drive critical outcomes from them.

HIStalk Interviews Matt Scantland, CEO, AndHealth

Matt Scantland is founder and CEO of AndHealth of Columbus, OH.

Tell me about yourself and the company.

AndHealth is a digital health company that is focused on helping people reverse chronic illnesses. We started with migraine and are seeing patients for that now. We are soon launching for some of the most common and disruptive autoimmune conditions.

I’ve made a career of combining technology and healthcare. I started college thinking that I would be a doctor and ended up being a programmer, so I combined these two things in my career. Probably the biggest advantage that I have had is to have worked alongside an incredible team for my entire career, in some cases, literally going back to my internship in college. Many of these folks helped us build our last company, CoverMyMeds. They have been joined at AndHealth by a new group of telehealth experts and clinicians.

Each of us have our own “why” that we are at AndHealth. For me, I knew I had to do something like this because my own doctor helped me realize that I needed to participate in my healthcare. That was back in 2011, when my first son was born. At the time, I was busy with CoverMyMeds, but I knew that if I ever had a chance to do another company, I wanted it to be a company that helps support patients to participate in their own healthcare. That leads us to where we are today.

You intentionally use the term “disease reversal” as opposed to “disease management.” How do you distinguish those?

For many years now in our industry, we have focused on this idea of disease management, which is to try to tamp down the progression of cost and disease escalation. We now know that many chronic illnesses can be brought into remission if we can get the patient to change the behavior that is responsible for about 80% of our health. Once we understand that reversal is possible, the key question is, how do you achieve it? The answer is that you need to engage patients in a course of change. We have built a disease reversal company. We have built the whole business around how to support patients in making that change.

How does the approach differ from traditional office-based encounters?

The big idea is that we can get to reversal when we can get patients to participate. The core question then is, how do you get people to participate? We’ve built the company around what we’re calling a digital center of excellence that helps to make that participation easier. One important element of it is moving from delivery of care of that’s episodic and on-premise to one that is continuous and virtual.

For example, one of our early patients suffered from chronic migraine. She had moved around our healthcare system for years and years, never able to get to a state of disease remission and never able to figure out exactly, in the moment of a migraine, how to cope with the situation other than going to the emergency room. By moving this care to something that is continuous, we were able to dramatically shorten the feedback loop between trying a particular healthcare step and seeing whether it worked, to the point that we were able to optimize her acute medication and also identify the root cause of her migraine.

When we optimized the acute medication that kept her out of the emergency room, we had time then to work on actually reversing the disease. Her root cause ended up being a food intolerance issue that, despite many years in our healthcare system, had never been found. Once we were able to identify that food intolerance issue, we had moved this diffuse idea that we have around behavior such as “eat better” to the equivalent of a shellfish allergy, where just this one step was the difference between illness and health.

The tightness of that feedback loop makes it such that people with shellfish allergies almost never are eating shellfish. But compare that to someone with a cardiometabolic disease, where sticking to a nutritional program is hard. The only difference is how clear that feedback loop is. By moving to this style of care, we are able to shorten that feedback loop.

When we do that, we help the patient achieve a high return on effort. We don’t need to turn the patient into an Olympic athlete when we know the precise root cause of their illness. We just need to address that particular root cause. When we combine that with focusing on diseases that patients are highly motivated to solve, typically because of pain and disruption, then we are able to achieve a higher level of engagement than has ordinarily been seen in these digital health services, which have tended to focus on diseases that, while important, are pretty difficult to engage patients in early in the progression of the disease.

That’s why we started with migraine and autoimmune conditions. They share common root causes with these other illnesses. We can engage the patient in something they care about today because of the pain and disruption, but because of the shared root causes, we end up solving these other issues as a side effect.

Some of the app-focused programs assume that patients will change if offered education videos, scripted coaching, and reminders to modify their lifestyle. How much of your program will be based on psychology rather than technology?

We have built the DNA of the company around the science of how behavior happens. The more we have learned about that science, the more we have learned how big the opportunity is to do better. We do that by understanding the difference between health aspirations and health behaviors. The biggest lever that we have in our healthcare system to create behaviors that support health is to make them easier to do what we call create ability. For many people, we can create ability by making something that used to be time-consuming and expensive quick and inexpensive or free.

That psychology, building around the behavior design, is super important and is a through line in the company, from our technology to our business model and to the actual healthcare delivery. One important distinction between what we are doing at AndHealth and a lot of what has happened before is that we are actually the patient’s doctor rather than a wellness app. When we are the patient’s doctor, we are able to harness the credibility that comes with that.

Patients have shown our healthcare system that what they want is the most specialized expert care that they can get for their particular condition. Each of our reversal centers of excellence is staffed by experts in that therapeutic area, who take on the patient in the practice of healthcare so that we can manage medications, do labs, and have the whole set of healthcare services at our fingertips.

No one disputes that a percent of a patient’s health is behavior. The question is, do people believe that it’s possible to help them change? A core idea that we have at the company that comes from my own life and the life of the people here is that everyone can change if we give them the support to do so, and if we ask them to make a change that they care about.  That’s why we focused on these areas and why we think this delivery model can help support people. It’s tougher to engage people with the garden variety app that counts steps. That’s not solving a problem that patients care about. That’s why we think this is different.

How does a patient’s primary care doctor participate?

That collaboration is such an important idea that we named the company AndHealth to reflect the idea that we can’t do this alone. We see ourselves as part of what I think will be a transformation in our healthcare system that we do mostly outside of the company, rather than inside. While we become the patient’s headache specialist, there are about 40 million migraine sufferers in the United States and only 2,000 headache specialists. This is one of the key challenges that we are helping patients solve, the problem of access. Even if you have good health insurance, the ability to get into a care team that understands how to treat migraine is hard.

By moving this care to a model that is more accessible and is available continuously, we are able to make a big difference in the lives of these patients. You can think of us as a referral from a patient’s primary care doctor or from their employer, because we are an employer-sponsored health benefit that helps complement the healthcare that the employer is providing to their employee.

How hard is it to convince employers and health plans to pay for your service?

Ultimately, we need to prove that we are achieving life-changing results for patients. If we can do that in this area, it will be an important new way that patients get access to care.

One of the reasons that we started with migraine is that leading employers are starting to recognize it as a silent issue, lurking just beneath the surface, much like how the best employers started to recognize mental health five years ago. It had historically been dismissed. It had historically not had great treatment options. It wasn’t generating the claims that caused it to get on anyone’s radar. It was a chicken-egg issue. If there wasn’t good access to care, there weren’t many claims, so it didn’t get onto the radar of employers. 

But we now know that migraine is the leading cause of short-term disability for most employers. It’s a huge contributor to turnover. Because it disproportionately impacts women and people of color, it’s a lever against diversity, equity, and inclusion objectives for employers. We think that a proposition that is focused around increasing access to super high-quality care in a therapeutic area that impacts many of these employers, 20% of the employee base, and is actionable because patients are engaged around this disease, will be taken up by many employers. We are seeing that so far in the market.

Can you survey employees or look at company records to identify the opportunity, unlike wellness apps where employers may get some non-specific value from helping their employees with weight, exercise, or stress?

Exactly. It’s rare that we’re in a meeting with an employer where someone in that meeting doesn’t say, “I have migraines. That has been an incredibly difficult part of my life that has made it difficult for me to show up in the way that I want to at work.” Because it’s common, and historically patients haven’t seen a lot of good treatment options, we are hearing from employers that this is important to solve. Now that we know that it is solvable, there’s a lot of interest in engaging.

It’s similar in autoimmune conditions, although what’s a little different in autoimmune is it has gotten a lot of employer attention because the costs are so high. For the conditions that we are treating, simplifying a little bit, there’s about $40,000 in costs per employee, per year for those who suffer from the conditions. A good bit of it is pharmacy cost, but there’s also significant healthcare cost. That has gotten more attention, but migraine employees are expensive from a claims perspective and especially from a productivity perspective.

AndHealth isn’t primary care, where we need to be able to treat a patient who shows up with anything, and where we have a relatively diffuse cost or value proposition to an employer. This is something that’s targeted at the disease states that, one, are the most expensive and disruptive, and two, by narrowing, give us an opportunity to have a learning system that gets better really fast.

One of the underappreciated elements of digital health is the degree to which when we narrow and then run this through software where we’re force-multiplying the expertise of clinicians, we move to a learning system that is improving quickly. We have a credible chance to move in these therapeutic areas from a new company to the foremost expert quickly by narrowing. That makes achieving results for patients dramatically easier than if we tried to see a patient who shows up with any condition.

What are the most important lessons you learned from starting, growing, and selling CoverMyMeds?

The biggest lesson was to find a way to collaborate with the healthcare system. Because if we want to do something big, we need the help of the people that are already here. We can be transformative without being disruptive. That idea is so important. That’s why we called the company AndHealth rather than OrHealth. That’s a really important one.

The other is the idea of people first, putting not just the patient first in everything we do, but winning through our employees. We ended up being on Glassdoor as one of the top 20 employers in the country in the past. While we think the tactics that will get us there are different, because the world is different than it was 10 years ago, we are focused on being a place where clinicians and technologists can come to build something that makes a big impact for patients, but also makes a big impact in their career. Those two things are core DNA in the company.

What would you like to see happen with the company in the next few years?

We have already shown that we can produce what we think are life-changing outcomes. In our first study in migraine, we were able to get to a 60% remission rate for patients. What we want to do in the next couple of years is show that we can do that at scale for employers and in a way that generates a value proposition that makes this part of the benefits package for the leading employers. It’s about showing that we can create those life-changing outcomes with patients, in collaboration with employers, at a scale that ends up making a difference for the world. If we can do that, that is success.

HIStalk Interviews Gidi Stein, MD, PhD, CEO, MedAware

Gidi Stein, MD, PhD is co-founder and CEO of MedAware of Ra’anana, Israel.

Tell me about yourself and the company.

I started my career as a software engineer many years ago. I was a VP of research and development and the CTO of several startups in the early 1990s. At some point, I vowed never to do startups again, changed my career course, and went to medical school. I was the oldest medical student in Tel Aviv University. I graduated, specializing in internal medicine, did a PhD in computational biology, and held executive roles in one of Israel’s leading hospitals. MedAware is a software company that uses artificial intelligence and smart algorithms to identify medication-related risks and save lives.

What points in the process of ordering and administering medications are most likely to introduce patient harm that existing systems won’t detect?

The flow that begins with the prescriber ordering the medication, the pharmacy approving it, and then administering it or having the patient visit an outpatient pharmacy — all of these situations are basically covered, in some way, by existing systems. But after the patient is already on the meds, after they are  home or are already admitted, things can go wrong. Laboratory abnormalities are found. Vital signs change. Patients can deteriorate into shock or have acute renal failure or anemia. These changes impact the risk that is inflicted on them by their meds, and some have drug events that are related to the medications that they are receiving. Current solutions are usually not good at tracking this, monitoring these patients, and picking up those risks in the post-prescribing, post-dispensing period. Most of the problems we find are there.

What are the alerting challenges that are unique to smart infusion pumps?

Smart infusion pumps are IV pumps that “know” the medications that are being provided to the patient by that pump. The nurses program these pumps in terms of the medication to be administered, the patient’s weight, the rate, the dose, how long the infusion should take, etc. In each of these steps, there can be a typo, a click of the wrong button, or mis-programming. The current systems are similar to the electronic medical record in being not very good at identifying these risks. The alerts that they generate are mostly false alarms, which drive alert fatigue. It’s similar to what we do with electronic medical records — we know how to identify pump programming errors and do this through our partnership with Baxter.

How do you identify an exception to normal practice to generate an alert?

We assume that nurses, physicians, and pharmacists know their jobs. They don’t need MedAware or any of us to teach them how to practice. But you can be the best poet in the world and still have typos that a spellchecker will find. You can be the best doctor in the world and still need that intelligent spellchecker to identify these typos in prescriptions or the programming of pumps. This is where the outlier piece is more relevant.

We published research two years ago with Sheba Medical Center, a large hospital here in Israel, in which we analyzed the errors that physicians make when they’re tired, overworked, or don’t have specific experience with the medications they are prescribing. Two times, three times, eight times as many errors are made when physicians are tired, overworked, working in an overcrowded ER, and especially when they are prescribing medications that they are not used to prescribing. We’ve seen that more and more with COVID in the last two years.

How does the technology coexist with an EHR to reduce alert burden?

What is unique about our system is that the alert burden is very, very low. Current systems can generate alerts in about 20% of medications or medical orders. We provide less than 2%, almost 1%, of the alert burden. The accuracy of the alerts we provide is very high, more than 85% as compared to less than 5% in the current solutions. In most of the cases, physicians — and we monitor this continuously — change their order following our intervention. Instead of applying rules like current systems, we do something more intelligent in applying more sophisticated algorithms to understand the prescription patterns in each hospital, in each care setting, and identify the outlier behavior as a potential error. These are usually consistent with the physician saying, “Oh, I didn’t mean to do that. I’m going to change that.” We see that every day

Are the EHR alerts suppressed by replacing them with yours?

It depends on the client. It depends on the workflow. In some cases, we completely replace the current systems and we are able to generate very few alerts and change the whole experience of providers. In other cases, we focus more on the pharmacy, where all the medical orders are funneled to, so we’re able to surface the catastrophic problems for the pharmacy to focus on. Our engine can be applied in different settings and in different workflows. It really depends on the client and the setting, even inside infusion pumps.

Does the alerting intelligence use the clinician’s individual patterns, or does it look only at their facility’s collective experience?

It’s more detailed than that. It’s at the level not only of the institution, but of the specific department and boiling down to specific prescribing patterns. It really depends on the amount of data that we have in each institution and our ability to model the “normal” behavior based on this data. The more data we have, the more accurate we can be. We can drill down to more refined accuracy and resolution.

How does an organization analyze their alerting patterns to determine that your system can help?

It’s common knowledge. We don’t have to persuade the customers that the current alert burden is too high and that they are ignoring most of the alerts. The challenge is to persuade them that it’s not necessary — they could do it differently and it could be a different experience for the provider. They find that hard to believe. One of the things that we do in most of our clients is take a little bit of historical data and show them what we find. This is the “aha” moment, because with most of the stuff that we find, they were not aware that it is happening in their own back yard. That easily triggers the “OK, I want this.”

How much of the capability that your system has was made possible by advances in AI, and where do you see AI finding a place in healthcare?

Our solution uses many type of algorithms, from the simplest statistical analysis to really robust AI with deep learning, neural networks, and all the buzzwords that come with it. We use the most sophisticated part of AI for specific use cases, one of them being to identify cases in which the patient receives the wrong meds. Either the physician clicked on the wrong patient or drug was given to the wrong patient.

Understanding the clinical context of the patient and the relevance of this specific medication to that patient’s profile is an extremely hard task to do. We’ve been able, for several years now, to identify and to classify the medication as, is this relevant for this patient, or is this not relevant for this patient? It doesn’t have to be even something dangerous. It could be a two-year-old male child who is ordered birth control pills. It wouldn’t kill him, but he definitely doesn’t need it and it’s a complete outlier for that child. This is an extreme case, but there are a lot of more simpler ones that are hard to detect by anything else than using sophisticated AI. Our point is that we would rather use the simplest methodology to fix the problem, but in some cases, you need something that is more complex.

The use of AI in healthcare will find its place. It’s still struggling. W see very nice solutions in the imaging world where companies identify risks in CTs or MRIs and surface them up to the clinicians that hey, you have pulmonary emboli, CVA, or a critical event that you have missed –put it on top of the file.

The fine line is understanding and comprehending that we are not here to replace the clinicians. We are here to help them make better decisions. We are not here to teach them medicine. We are not here to tell them what to do. Just being that safety net to make sure that they don’t type the wrong thing. This approach can grow into more helping with diagnosis and procedures and providing a better prescribing and platform for clinicians, as long as we don’t even think or say that we can replace them or do their job, because that just doesn’t make any sense,

Where do you see the company in the next few years and the use of technology like yours in healthcare?

We have developed a unique engine that can be applied in different places in the industry. Our strategy on the business front is to partner with larger companies that have embedded solutions — in medical devices, decision support, or anything in the medication delivery space — where we can make their data smarter. We can make their systems and devices perform better. This is the path of growth to the company going forward. Baxter is one example. We have more that are coming and the future is looking good.

HIStalk Interviews Clay Ritchey, CEO, Verato

Clay Ritchey, MBA is CEO of Verato of McLean, VA.

Tell me about yourself and the company.

At Verato, we are identity experts that enable better care everywhere by solving the problem that we believe drives everything else, which is knowing who is who. Our mission is to be the single source of truth for identity that provides healthcare a complete and trusted 360-degree, longitudinal view of the people that they serve. I’ve spent the last 20 years in healthcare technology, with a passion for helping people leverage technology to deliver better care, better outcomes, and better patient experiences. I’m excited about Verato’s ability to do just that with identity resolution.

What is the extent of mismatched patient records in an average health system?

It is not atypical to have 8% to 10% of medical records be mismatched, either as  duplicate medical records or overlays. That’s very common. That problem has been exacerbated as we move into digital health. The ecosystem is more complex and the information is even more inaccurate as you try to aggregate that data and those identities across not just one or more EHRs, but over 20 to 30 different inputs or data sources that are collecting data on patients.

Is patient identity harder to manage with hospital acquisitions and increased interoperability?

Yes. Unfortunately, we’re still in a world where most health systems are thinking about how to drive interoperability inside their own physical enterprise and virtual enterprise. Even in that scenario, mergers and acquisitions create a challenge with how you take a patient census that is sitting in different EHRs and combine them into one so that the patient experience isn’t harmed or important information is missing so that I can’t treat the whole patient. That’s a key driver as health systems think about expanding and need to welcome these new patients and deliver the service they expect.

How well do EHRs detect patient matching problems, especially now that using Social Security number as an identifier has been eliminated?

There’s two significant challenges with the EHR’s ability to prevent identity mismatching. One is the fact that most EHRs only have visibility into the data that they house themselves. As you start thinking about all these additional channels of data and data sources outside of the EHR, they don’t have the ability to reconcile those data sets from an enterprise perspective.

The second challenge is that the typical EHR identity matching technology is driven by probabilistic matching or algorithms, looking at information that you have physically about the patient. We think a better approach is using referential matching, where we have data that might not be sitting in the EHR about that person and we can connect the data points and fill in the gaps with that information to provide better matching.

Have you seen interest in uniquely identifying people who aren’t necessarily patients, such as public health organizations that try to match vaccination data to their medical records?

The pandemic drove a lot of wonderful things for the future of healthcare. One of the most important is that it created a reimbursement model for telehealth. We are seeing 38 times as many telehealth visits as we had before, and it is stabilizing at around 17% to 20% of all outpatients. With that is a change in the mindset around how consumers want to be treated. Consumers who plan to make an important purchase go online 85% of the time to find information first. In a post-pandemic world, healthcare is seeing that number upwards of 90%, where people consult online resources about their symptoms before they talk to their doctor.

Because of all these different channels and digital engagement around the consumer, health systems have to understand who is who. How can I create a 360-degree view of all those interactions to create an experience for that patient, showing them that I know who they are, I have empathy for them, and I can solve their problem holistically?

What are the competitive advantages of accurate patient identification?

Forward-looking health systems are committed to offering a patient experience that is based on a simple premise – you have to show them that you know them. They are using an identity management platform to create and curate an experience for the consumer who is thinking about consuming a service from them. It might be somebody doing research about a knee or hip knee replacement. You need to understand who they are and be able to tailor your communications with them, so that as they continue to interact with the health system, that health system already knows that they have been on the website, downloaded a white paper on hip replacement, and are now calling in. Can I help you find a doctor who can help you answer questions around those types of things? Accelerating the acquisition of patients requires understanding the identity of the patient and then being able to deliver better care.

Finally, as health systems are moving from fee-for-service to fee-for-value, population health, and social determinants of health — and being able to manage both in-hospital and out-of-hospital concerns — it becomes critical to understand the patient identity, to proactively identify them as having risk factors, and to proactively give them a care plan to prevent a chronic condition or to better manage their chronic condition. All of those things contribute to happier customers, happier patients, lower cost of treatment, and overall better outcomes.

Outside of healthcare, customers uniquely identify themselves via a loyalty card or a website login that allows a business to then understand their behaviors. Can we learn from those industries?

Yes. Healthcare doesn’t have to look far at all to figure out how to delight the patient and deliver an exceptional patient experience. Loyalty programs, being able to know who you are as you’ve logged into their website, and from there to present them with information that is relevant to what we know about them. If we know that you are a cancer survivor, we should be delivering content to you that can help with your journey.

There are many examples across other industries that you can draw from. One of my favorite airlines is Delta Airlines. They seem to be able to anticipate my needs as a traveler even before I have them. If there’s a delayed flight, they are already thinking ahead about giving me options for rescheduling. We are starting to see forward-looking healthcare systems think about embracing consumerism and applying these types of technologies. Over 50% of millennials today don’t have a primary care provider, so they will be looking for experiences similar to how they buy something from Walmart or Amazon. To do that, we have to transform the way that we engage them.

Health systems experimented years ago with patient loyalty cards that also allowed medical records lookup. Why hasn’t that been adopted more widely?

The reporting from a year go on Ascension and Google Health showed a lot of privacy concerns that exist in America with respect to healthcare, our privacy rights, and protecting information about our health. I believe those basic concerns around privacy are pervasive. There’s a lot of conversations going on about universal patient identifier. That would be helpful and necessary, but we don’t believe that it alone will ever be sufficient. There’s just so many ways for patients to engage with the health system and so many front doors they come in, whether physical or digital. The idea that that patient will always have that identifier with them and present it in a confirmed way is challenging.

That’s where you’re seeing this pervasive, long-term need for additional technologies on the back end that continue to piece together these stories and be able to help us identify them. That being said, I do believe that we’re going to see the industry move towards a more trusted identifier. That may be through a trusted private sector opportunity versus the government. We have to work through how to get something that is safe, secure, and trusted before we can break those barriers.

What problems would arise or remain unsolved with the implementation of a universal patient identifier?

You mentioned Social Security number. Isn’t it already a universal patient identifier? Why hasn’t that been sufficient? The idea of using a universal identifier as a key into a lock that it gets you access to a health system, your health records, and information about yourself has a lot of goodness, but you’ll still find that it’s not practical to have a key that can be trusted and validated everywhere it would be used. Our own experience on the consumer side is that we have to find ways to create that experience that don’t rely on that type of unique key. I believe that a universal patient identifier will move forward, but while it is necessary, it won’t be sufficient for delivering the value proposition that we all hope for.

Where do you see the company in three to five years?

We see Verato continuing to enable this idea of better care everywhere by focusing on enabling the interoperability of digital health and the digital health transformation that is happening across the health system. Today, it’s health systems themselves. Tomorrow, it’s going to be across the care continuum. Being able to make that information portable, so that a patient can visit a health system in Pennsylvania and then while traveling on vacation to Florida and being able to visit the health system there, having that type of interoperability across health systems. I believe that Verato will be a part of that transformation as we move from interoperability within a health system to interoperability across the care continuum.

We’re also working on partnerships. We believe that having a common view across the care continuum — pharmacy, pharmaceuticals and biotech, medical devices, HIEs, providers, and payers – that trusted, protected, secure common view will help us eventually get to liquidity of data so that it gets to the right place at the right time to deliver a better outcome.

HIStalk Interviews Kyle Silvestro, CEO, SyTrue

Kyle Silvestro is founder, president, and CEO of SyTrue of Stateline, NV.

Tell me about yourself and the company.

I’ve been in the world of clinical natural language processing for almost the last 17 years. I started SyTrue a little over nine years ago, thinking about how to solve challenges around archaic workflows where we still require humans to read medical documents, especially from the perspective of CMS. And, how we automate a number of processes by eliminating inefficiencies within the system.

How has the need and the ability to automatically extract information from medical records changed over the years?

The need has been there for more than a decade. The awareness is coming to the forefront. We are truly understanding the value in information. The advances in AI and ML have highlighted that. Most of those advancements have been more around structured data and what is possible. Looking forward, organizations are understanding the value of the unstructured clinical note that still comprises the majority of information created in healthcare today. We process more than a billion pages of these notes annually, and that’s just scratching the surface. That would be on data created within the last 12 months. The majority of information is still in this format.

It depends on where you are in the process from the point of care to the point of need. At the point of care, maybe you can get high quality data quickly, but most organizations are not. They are downstream of that information, and it’s packaged up more often than not in a PDF. It’s not even unstructured data — it’s an image. That image is shared with organizations and data is often needed 20 ways downstream. If you don’t have a way to create this exponential uplift, then you can’t start addressing the challenges we see in the system. This problem has been here for a while and there are truly no good solutions addressing it that have a critical level of adoption.

Do PDFs usually come from outside facilities, meaning that it’s an interoperability problem, or are they self-generated because the source system doesn’t capture the data discretely?

It’s a combination. More often not, this is a byproduct of a record release process. Thousands of people go on site to facilities every day to get data from hospitals or provider offices. There are some electronic exchanges now, with CCDAs being sent across the wire, but that’s really the two ways that they are getting this data. It’s definitely an interoperability issue, but it’s more of a misalignment of incentives that is potentially preventing wider adoption.

What are payers and CMS doing with the data?

We have a unique challenge within the payer market. So much of what they get is an image, a PDF that can be thousands or tens of thousands of pages long. The only answer before SyTrue was to assign a nurse to read the document, go through the 4,000 pages, and find the eight or 10 pieces of information that answer the question. But more often than not, the 5,000 other data points that are in that PDF document that could be driving exponential uplift within an enterprise are left behind. They’re saved as an image, so they are being lost. The knowledge that is in front of them is gone. Our solution addresses the efficiency challenge, but we can also liberate all of that information to drive exponential downstream value on an enterprise level, to be able to create standardization and interoperability that can drive change.

What is involved with taking a PDF document and turning it into useful information?

This is a differentiator between SyTrue and everybody else. I had the privilege, or the advantage, of failing more than most people in pushing an early technology into the marketplace. Before I started SyTrue, I implemented NLP across life sciences, payers, and providers across a number of use cases, but had also seen challenges at failure points. As somebody who doesn’t like to lose, I remember those failures. 

When we architected SyTrue, we knew that it’s not just about NLP. If healthcare data is clean, NLP is easy. It can read the document, parse it, and extract it. But the problem is that we are dealing with inconsistency from organization to organization, physician to physician, EMR to EMR. How do you account for all this dirty data that was created by a million physicians that generate billions and billions of notes annually? And if those notes are needed 20 or 30 ways downstream, you’re creating a exponential data problem that you can never throw enough humans at to solve.

That’s what we thought about. We thought about that document life cycle. We thought about the creation sources. We thought about who needs it along the way. The question that we asked ourselves is, how can we make people money along the way? How can we add value? That approach allowed us to look at it from a longitudinal perspective, because we thought that if you can get to a longitudinal data and you can do it accurately, everything else downstream becomes easy. You have all the Legos, you just have to actually assemble the house or build the car. The structural components of the information are in that longitudinal record. It’s a matter of how you are combining them. 

With HEDIS, you need problems, procedures, and HCPCS codes. Risk adjustment. You’re looking at problems and supporting conditions and payment integrity. You’re looking at elements that would roll up to make a determination — is this truly an acute kidney injury, or is this sepsis? If you have that baseline data, the downstream questions that you’re asking or the objectives that you’re looking to get out of that information become a lot easier. You can do it across many domains, as represented by our client base and use cases that they leverage.

How will the healthcare entry of big tech firms affect your business, such as Google’s work with EHR search?

How soon before they call it quits again? They’ve all taken bites of this apple, only to fail miserably. I honestly think that’s the trajectory they are on. They do the market a bigger disservice than they do a service. They push early-stage technology that’s not prime time into our marketplace. They suck the oxygen out of that marketplace, and organizations that are small and may not have the $100 million marketing budget get squeezed out. True innovation never gets bubbled up to the top because you have these massive enterprises send 14 sales reps into a client to push a product that’s half baked.

You see that in Amazon Comprehend. They just reduced their price by 95% and now it’s this big announcement around SNOMED. Great, right? If it wasn’t good to begin with, it’s not going to be better when it’s 95% discounted. We’ve had SNOMED for nine years. It’s not new. It’s not really an announcement. Talk about how you’re making people money, talk about how you’re changing the system, and don’t just make noise. That’s what a lot of these organizations do. They truly don’t understand the problem and they truly don’t understand the solution that they need to create to solve it.

IBM Watson Health had some pretty grand ambitions and failed miserably.

MD Anderson Cancer Center. The trail of tears goes on. The billions of dollars that were invested into a technology that played “Jeopardy!” and then thought it could solve healthcare was amazing. They had 5,000 people at one point. It had a lot of data. But they couldn’t roll out anything that was meaningful, except for marketing hype. That is true of many of these big tech players getting into healthcare. They don’t understand the problem that they are trying to solve. They see dollars, they think they can throw enough money to grab market share. Unfortunately, I think they do the overall marketplace a humongous disservice. I haven’t seen truly significant impact from companies that took something that was playing a video game and thought it could solve healthcare.

How do you see the investment buzz over AI playing out?

There’s real opportunity in the technology. But I think you apply technology where it makes sense. You just don’t try to brute force everything, and because there’s a new technology out, think you can solve all the problems. We take a pragmatic approach. Use technology where it makes sense to apply it. As we get downstream, AI is going to be really, really meaningful. It’s going to be important in healthcare. But we have a foundational problem today in healthcare that is going to prevent that from becoming a reality for a little while, unless organizations start to realize it. If you’re not creating an interoperable base of accurate information that you are basing your models on, you are building a house of cards. I wonder how many of those actually exist today versus true value.

There’s a lot of hype, but when you actually get into the information, what impact is it actually making? Marketing has latched onto it. Not a lot of people understand it. Everything is a supervised model. Unless you get to accurate datasets at high volume, you’re somewhat playing with fire. But we have clients that actually do this and they see significant improvements in accuracy, sensitivity, and the impact it has on an organizational level, because they are working from an accurate, interoperable piece of base-level data that’s a solid foundation.

Where will the company focus on the next few years?

SyTrue is positioned to be a dominant player across many different solutions — HEDIS, payment integrity, fraud risk and abuse, risk adjustment, social determinants, expansion of radiology, expansion in oncology — all with a single platform and with the focus of making organizations money quickly and being able to get them live fast to enable that ROI. I see great things for SyTrue. I see us going from just shy of 40 employees now to a significant number in that period of time.