HIStalk Interviews Torbjörn Kronander, CEO, Sectra

Torbjörn Kronander, PhD, MSEE, MBA is president and SEO of Sectra of Linköping, Sweden.

Tell me about yourself and the company.

Sectra started out as a cybersecurity company in Sweden. In 1990, I had just completed my PhD and started up the medical imaging side of the business. Our first foray was in teleradiology and then we moved into radiology. We took what we learned in radiology, and we’re now focusing on enterprise imaging and have added modules for cardiology, ophthalmology, orthopedics, and pathology.

We are seeing the same trend in imaging that we’ve seen in EMRs, where there was a separate information system for every single department of the hospital. Then Epic and Cerner came around, and the CIOs said, we want as few systems as possible, and consolidated all the departmental information systems on one EMR.

What are the most significant trends in medical imaging?

Efficiency is important. There is an alarming risk of burnout among US physicians. You need to have systems that are fast and effective to use.

We see a trend toward consolidating to as few IT systems as possible. Having multiple systems is expensive and people underestimate the costs involved. You may have 100 IT people on your staff in a hospital, but without consolidation, a lot of them are doing the same thing on different systems. We are the only vendor who can manage all images in one system.

Cloud is also becoming increasingly important. Having a lot of hardware on site is expensive, and it is challenging to stay on top of the many updates of the underlying operating systems. If you can use Google or Microsoft to manage the cloud operations, they are, cybersecurity-wise, in a better place than almost any on-prem solution.

Combined, we see a large trend towards cloud and a single system for all your images — let’s call it a “pixel EMR,” which is a quote from one of our customers — and then within that space, digital pathology, which is rapidly coming along.

What role does AI play?

AI is very interesting. It will be large, but it will not be as fast as people anticipated. There is a famous quote that the first law of technology is that we always overestimate the impact in the short term of transformative new things, but we also inevitably underestimate the long-term impact. We see this exact trend in AI.

AI is not where it was a few years ago, when people predicted there will be no more radiologists needed to be trained after 2022, which of course is not a bit true. But we will see AI gradually coming into prominence. I’d like to quote one of our customers, Dr. Langlotz of Stanford, who says, “AI will not replace radiologists, but radiologist who use AI will replace radiologists who don’t.” It will drive efficiency, but it will not replace the radiologist. You will still need that human being in medicine. 

We see a lot of AI vendors right now in the market. At Sectra, we have said that you can’t compete with the hundreds and hundreds of AI startups, so we are going with the open systems approach. We have the Sectra Amplifier Store, where customers can use any AI application that they like. If we’re going to accept the AI software for their use, we will do the cybersecurity evaluation on it and ensure that it is secure.

Cybersecurity is a grossly underestimated trend in medical IT systems, because ransomware attacks are increasing, and healthcare is a primary target. Eighty-five percent of Sectra’s business is medical IT, and the other 15% is cybersecurity, which gave us our name — “SECure TRAnsmisson.” We are one of the most prominent cybersecurity vendors in all of Europe. We protect networks with high-level security. We provide secure mobile workplaces and phones for the entire European Union. We are using that same knowledge when we build our IT systems.

Is the company’s cybersecurity expertise a competitive advantage over companies that just sell imaging systems?

That is a very true statement. For many years, we have run our security and medical divisions in parallel. Over the last two to four years, this philosophy has increased in value. Cyberthreats are dangerous for healthcare because typically health systems have to pay the ransom. If other industries get attacked by ransomware, most of them will not pay if they can at all avoid it. But in healthcare, patients die unless you pay those who are responsible for ransomware. The cyber mafia knows this.

We see huge benefit from having defense-level and national government-level security knowledge in the company. We build our systems to be as safe as possible. We are one of the highest-ranked cybersecurity companies in the entire medical sector today. To have that knowledge in house is important. It’s also interesting to see that KLAS now ranks vendors for their cybersecurity preparedness and they consider Sectra to be very mature and safe in that aspect.

What challenges and opportunities have arisen due to the pandemic, especially with telehealth and teleradiology?

I would say the largest impact has been in telepathology. Pathologists are embracing the ability to digitally send images for second opinions as well as to read from remote locations. Previously, a pathologist had to sit at the site of the biopsy and wait for the sample to arrive from the operating room. Now they can see the slides digitally and make quick and easy diagnoses.

How would you assess the status of image sharing?

That is an important question, because sending images in a taxi from one end of New York City to the other is not very effective and it’s also dangerous for the patients. Sectra has the largest image-sharing network in the world, located in the UK, in which every single hospital is connected through our system which sends approximately 40,000 exams per week. There are no CDs in the UK anymore, thanks to us. We are also applying this technology to some places in the US, but the UK network is our biggest reference as of today.

How much of the company’s strategy and product design has to reflect the healthcare policies of the US that don’t apply anywhere else in the world?

The US is our most important market at this time. We have a market share of greater than 50% in many Northern European countries where we operate, whereas we have about 10% in the US. We do, however, have the happiest customers, as evidenced through KLAS and the Best in KLAS awards, and that gives us the ability to grow. We have some important American partners that we collaborate with for research, and some very prominent hospitals as customers. We spend a lot of effort and emphasis on the US market.

There are differences between regions in the world, but not as many as you might think in the imaging space. Images are images, and the way you need to work with them to complete the diagnosis is very similar in all countries.

You’ve said that the way you beat big imaging competitors is to have better employees, stick with your goals, and treat your customers better. How do you make that happen as a global company?

I’m a good friend with Judy Faulkner of Epic, and she told me once that the only way you can become big in the US is by having more happy customers. That resonates very well with my basic philosophy of life. You need to make money, but there’s more to life than money. Happiness is also very, very important. You cannot create happy customers without happy employees. We work a lot with employee satisfaction and recruiting to finding the best people.

It’s very interesting that the competitive advantage for product innovation is a fairly short timeframe. If a vendor introduces a new feature, by the next year, everybody has it embedded in their product. But that’s not the same thing with customer satisfaction. The only way you can sustain a high level is if you have happy employees who are motivated and who will do the best for customers. That culture will always win.

We also recruit the best possible people to join the company. I personally interview every single one, worldwide, before they get an offer. To maintain exceptional quality, every interviewer has the right to veto a candidate. We also have high employee retention, with many people working at Sectra for 15 or 20 years because they like it. And of course, if they like it, they also do a good job for our customers.

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

As I mentioned earlier, enterprise imaging is crucially important. The CIOs cannot afford to have multiple IT systems and they need to partner with companies who can manage all their departmental images in one single system. We have changed to a subscription-based, SaaS model which allows the customer to acquire new technology without large capital investments and we guarantee the cost for the underlying cloud infrastructure which no other vendor does, to our knowledge.

HIStalk Interviews Eric Rosow, CEO, Diameter Health

Eric Rosow, MS is co-founder and CEO of Diameter Health of Farmington, CT.

Tell me about yourself and the company.

I’ve been in healthcare tech for about 30 years. I’m a co-founder of Diameter Health, along with John D’Amore, and I serve as the company’s CEO.

I started my career as a biomedical engineer with Hartford Healthcare. I’ve always been drawn to solving problems that are at the intersection of tech and healthcare delivery. What I especially love is being part of building, and helping to build, mission-driven, high-performance teams. Our mission at Diameter is simply to make data universally accessible, organized, and actionable for better health and more efficient healthcare. 

We have been at this for almost 10 years and we stay focused on this core capability, which we call upcycling. We have been able to process clinical data and patient records for nearly half the country across multiple market segments, including payers, federal and state governments, HIEs, life insurers, and HIT partners. The common thread across all these folks and partners is that they all recognize the challenges and complexities of wrangling multi-source, multi-format raw clinical data that is often dirty, inconsistent, and incomplete.

Has wider use of technology building blocks such as FHIR and APIs exposed the problem of data that falls short in quality, usability, and interoperability?

We are excited about FHIR and the standards that it brings to offer a much more efficient means to exchange data and to pull data. In our early days, we thought of data as digital, but it is like crude oil. It’s in the ground, in tanks, and in trucks. It’s digital, but it’s crude. We look at the market in three broad segments. We need pipes to move and aggregate the data. We need the refinery to clean up and enrich that data. Then we need to address the use cases where you need high octane fuel to run different engines, whether it be a moped or an F-16.

FHIR makes the pipes much larger and puts a lot more pressure behind it, so it is amplifying the need for cleaning up the data. We think that’s a critical challenge that people are seeing now. FHIR is amplifying the understanding of how dirty the data is in terms of incompleteness, duplication, and just plain old dirtiness.

What did you think of the recent study that found that even sites that use the same interoperable EHR can’t necessarily exchange data?

That’s the driver of why this company was founded. I was moved years ago at the HIMSS conference by hearing Google’s Eric Schmidt give a keynote where he talked about how healthcare has this compelling need for a second tier of data. He concluded that these primary data stores of EHRs have to be supplemented, not replaced, with that second tier. He went on to emphasize that in his 40 years being in enterprise software, he has seen this phenomenon repeat itself over and over.

That’s exactly what is happening today in the interoperability landscape, and frankly, what is needed. It’s also super exciting because the second tier of data can unlock massive opportunities for innovation, better workflows, and better outcomes.

To give you a real-world example of a second tier of data, we all use and benefit from apps that use GPS coordinates, such as Uber, Lyft, Waze, and Apple and Google maps. None of those apps would work if GPS locations were inconsistent, because you can only have one set of coordinates for a given location. In healthcare, we literally have hundreds of ways in which diagnoses like CHF, or COVID status, or lab values like HbA1c, even from the same EHR, are inconsistent and are unable to be exchanged. We feel that it is critical to let these innovators and developers focus on innovating and not the dirty work of normalizing data. Once you can do that, then AI and machine learning algorithms work superbly at scale when they can ingest clean data.

How can we improve healthcare when we look at dirty data, when 80% of the allergies are not coded appropriately — and we’ve found in our work that 30% have no code at all — 70% of lab results don’t use the right vocabulary, and almost half don’t use LOINC? We’ve also found that over 40% of medications don’t have the right coding to run quality measures. That is ubiquitous and why this is such an important field that we are so committed to.

What business models are being created or improved with the wider availability of healthcare data?

As I look back at our journey for almost a decade, it has been following the data. We went after the health information exchange market in 2014. Willie Sutton said that he robbed banks because that’s where the money is, and in our case, that’s where the data was. We wanted to go there, not just because they had Epic, Cerner, Meditech, Athenahealth, or Allscripts, but they had over 100 certified EHR vendors. 

Cutting our teeth at that foundational area where all the data is being aggregated has been so valuable. The experience and scar tissue that we developed during those few years allowed us to expand into other markets, including the VA, payers, HIT vendors, and even life insurance, which wasn’t a market we were thinking a lot of before COVID. But it’s an interesting example of how you can have one core capability that crosses multiple markets and therefore multiple use cases and business opportunities.

The early goal was for hospitals to be able to exchange data, but now many players are creating data that should be part of a longitudinal patient record. Is technology adequate for creating that patient record from sources such as pharmacies, urgent care centers, and insurers?

If I go back to my analogy of pipes, refinery, and use cases, our rebranding to what we call upcycling data is where it all comes together. It’s all about powering innovation, efficiency, and better outcomes across the ecosystem, but it fundamentally comes down to the data quality.

I once had the honor of being introduced as a speaker by Micky Tripathi before he took his role at ONC. Knowing how dirty and incomplete clinical data is, Micky introduced me as “the sewage treatment guy.” I laughed, but I took that as a badge of honor, like Mike Rowe in the series “Dirty Jobs” crawling through sewer pipes with rats on his head. Cleaning up this data, upcycling data, can indeed be a dirty job, but it’s so important. It’s not easy, but it’s so necessary to do it at scale. Turning all that potential from the disparate sources into power is to enable these downstream use cases is key.

What level of data exchange is happening between insurers and providers?

COVID has certainly put a highlight on that ability with life insurance, for example. Efficiently accessing and utilizing clinical data coming out of the EHR supports more cost-effective and timely underwriting. Because in a world of COVID, people could not literally go into healthcare settings and pull charts and scan charts. They realize that this is an opportunity. We’ve done some exciting work with Swiss Re, the world’s largest reinsurance company, that sees that not just as a US opportunity and challenge, but a global one. The data interoperability landscape is so exciting right now, but all these technologies are challenged by solving the big opportunities around the data.

But it’s also confusing. A lot of companies are describing capabilities using a lot of the same language. That’s where we wanted to come up with a different way of how to position and explain that. The pipes, as I call them, are going to continue to be more and more commoditized. FHIR will drive more and more ability to access data. The real challenge is in how to make it usable and actionable. That’s why we are excited by this notion of upcycling, because I think it can transform the industry by having that clean, precise, clear data to run these downstream use cases.

Much of the expense of healthcare is administrative, such as in prior authorizations where the clinician’s eyes on the screen and hand on pen or keyboard become the insurer’s EHR interface. Do you see the systems of providers and insurers being connected to meet each other’s needs electronically?

I do. Value-based care is really is the only way forward, but you have to align the incentives and the risks. You have to accurately measure and quantify outcomes that can be enabled with respect to access, quality, and cost. So, we need to be really clear by what we mean by and how we measure value. At the same time, as you look at this co-opetition of pay-viders, that new model or new business paradigm that can save money and be more efficient for one cohort is taking away the revenue and the profitability of another. There’s always going to be an inherent aversion, in the short run, to change from one business model to another. But in the long run, this journey is going to be Darwinian, in that individuals and organizations have to evolve or risk declining or going away altogether.

Should those who are holding useful healthcare data be paid to share it?

I think they should. That is what defines value. If you, as a payer or a provider, have to spend hundreds of thousands of hours to clean up that data and make it actionable, then it will be worth the cost and the value that comes from that. This whole notion of a clinical data optimization enablement that can leverage today’s API architecture is really what is foundational to enabling these new use cases. But the devil is in the detail, and it’s easy to talk about but so hard to do.

To make it the data valuable so that people are willing to pay for it, you have to do a number of things. You have to semantically normalize the data to national standards. You have to enrich it with metadata through streamline analytics. You have to reorganize it so it can be found in the expected clinical sections of a document. Then most importantly, you have to duplicate it and summarize it back into that longitudinal comprehensive record that you mentioned.

I’ve talked with so many clinicians and I’ve heard things like, “If you give me a 70-page CCD, it’s like 68 pages too long.” Or, “If you give me eight CCDAs for a patient, I’m not going to look at any of them.” That’s where the value is going to come. If you can save a busy doc time, then it’s worth it and I think people will pay for it.

I’m not a clinical informaticist, but I’d love to give you an example of why I think this can be so challenging and also so beneficial. Let’s say you have a patient show up and their record indicates that they’ve been prescribed the brand name drug Vicodin.That could either come across in the machine-readable or the human-readable portion of the document. The first thing you need to do is recognize that that brand name Vicodin is a combination medication of acetaminophen and hydrocodone.Then, you need to compute and reevaluate so that each ingredient can go into the respective RXNorm codes.

This all gets back to prior auth and how you need the right data to make the right decisions. After that, you have to leverage clinical grouping standards and indicate that hydrocodone is an opioid agonist and map that to the NDF-RT, the National Drug File – Reference Terminology. Finally from there, you can add on another meta-tag to indicate the severity of that medication in the case of hydrocodone, or Vicodin by transitivity. You can indicate that this medication is in fact a Schedule II controlled substance. All of this needs to happen to this transparent process.

If you can do that while maintaining visibility and data provenance, you have so much power. For example, you can make a query from a single field in a given state or region say, “Show me everyone within that region, or across the state, that’s been prescribed an opioid.” You can do that from a single field by having that metadata layered on top. Not just doing it for drugs, but for allergies, labs, immunizations, vitals, procedures, and demographics. That’s the opportunity. That gets back to that second tier that Eric Schmidt spoke about to enable all these different downstream use cases and business models.

How will the move to the cloud affect the possibilities?

It absolutely enables innovation and speed to value. It most certainly amplifies the network effect of propagating new knowledge and best practices. We are certainly seeing that across our customer base. I recall reading an interview that you did sometime not too long ago where one of your interviewees made the analogy that on-prem is like waterfall software development, whereas cloud is more agile, lean, and creating minimally viable products. That’s where the cloud has been so exciting, knowing that it can be secure, HITRUST and HIPAA compliant, and people can access that data and share that data securely anywhere. In our case, all of our clients, except a few that require an on-prem environment, are in a hosted environment in the cloud.

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

There’s a lot of interesting opportunities going forward. We’re going to continue to see a tremendous amount of data continuing to come in at exponential rates. I like to look to the future by looking back, and I’ll just share with you what I think might be of interest to your readers. When John D’Amore and I co-founded this company, we had this common vision to address and focus on what we believe is the biggest barrier in healthcare, data quality and usability. We heard of a physician named Larry Weed, a professor from the University of Vermont Medical Center. There’s this incredible YouTube video of him presenting a grand rounds lecture at Emory University over 50 years ago.

Dr. Weed so eloquently spoke to how the patient record cannot be separated from the caring for of the patient. The record is the patient, and that is the practice of medicine. He goes on to say how patient care is intertwined and how important the complete longitudinal record is in determining what the clinician does in the long run. So even 50 years ago, before the adoption of Meaningful Use and the proliferation of EHRs, Dr. Weed had the humility and the perception to recognize how the human mind simply can’t carry all that information without error. 

He also made that cautionary prophetic statement that we’ll either be a victim of poor data quality or we’ll triumph because of it. As we look at the volume of data, two-plus years into a pandemic, this is a hauntingly accurate prophecy. Enabling data in the largest industry in our economy to be actionable, accessible, and organized has never been more important. We are super excited about what the future holds in terms of continuing to improve data quality.

There has never been a more exciting time to be immersed in this world of healthcare IT, and in particular, data quality, or as Micky would say, sewage treatment. It has been an exciting journey. Working with such a special team has been so rewarding. I’ve always believed that the greatest product an entrepreneur can create is other entrepreneurs and leaders. As a rowing coach and a former coach and a rower, I would love to conclude with an analogy that I love being in this Diameter Health boat, being part of a crew that works so hard for a common goal. I can think of no goal more important than transforming healthcare and the ecosystem by enabling better healthcare with better data.

HIStalk Interviews Russ Thomas, CEO, Availity

Russ Thomas, JD is CEO of Availity of Jacksonville, FL.

Tell me about yourself and the company.

Availity is the largest network in all of healthcare, connecting 2 million providers and every health plan in the country and transacting 13 billion healthcare transactions a year. We have a broad scope and broad scale in driving a lot of cool impact in the transformation of healthcare. I’ve been the CEO since 2012 and have loved every minute of it.

To what degree do you see EDI, networks, and clearinghouses still being innovative and vital for digital transformation?

My buddy Sean Wieland, the analyst at Piper Sandler, told me a few years back that he would love to see how we make clearinghouses sexy again. I kind of laughed, saying, “I’m not sure clearinghouses were ever sexy, Sean, but I’ll do my best.” You have to be transformational and innovative. Otherwise, it’s a commoditized business where you are selling essentially transactions at fractions of a penny. If you don’t innovate and evolve, then you become irrelevant pretty quickly. That’s where we’ve been super successful. We have always focused on real time. The company was started as a real-time network.

When you say EDI, I think batch and days in transaction processing and transfer versus milliseconds. That’s a real opportunity for businesses like ours, to take what today is a large network of very important transactional activity and evolve it into a network of interactions between providers and health plans and make sure that, on a real-time basis, you’re serving up content. We’re in the information business. We have to be able to serve up content to the right provider, right time, right patient in ways that can meaningfully improve that patient experience. I think that 21st century clearinghouses and networks like ours have to be able to do that and demonstrate that value in order to thrive.

Your most recent investment was from Novo Holdings, which has life sciences connections. Do you see an opportunity to expand into real-world clinical research data?

That’s not where we’re headed, to be candid with you. We are in such a trusted place with our customers — our health plans, providers and ultimately the members and patients that they serve — that I don’t think we need to go there. Just being a data broker isn’t particularly exciting to me. What’s exciting to me is this evolution of transactional relationship between providers and health plans to an interaction, meaningfully moving to digital engagement, digital platform between providers and health plans.

Today we live in this pretty siloed transaction environment where you run an eligibility check and you get a response to that. It may tell you to do something else. You run an authorization, you get a response to that. Then down the road, you submit a claim, you get a response to that. That’s not how healthcare gets practiced. Physicians are practicing in real time, and they are making real-time clinical decisions about how best to treat their patients.

The administrative networks haven’t kept up with, or at least haven’t advanced, to support that type of real-world relationship between providers and patients. That’s where we are focused, moving to this intelligent network that discerns information from the very first encounter between a provider and a health plan around the patient and helps that provider think forward to what they need to know during the patient visit and when they are making the referral. We need to follow the trajectory of the patient visit more than some sort of made-up transactional flow that has persisted for decades and doesn’t support the workflow in the provider’s office.

Where do you see the line between provider and payer blurring and what are the transactional needs that are involved?

There’s this opacity in healthcare between providers and payers, between providers and their patients, and between payers and their members that just has to get fixed. Payers clearly have to continue to demonstrate value in that, for lack of a better term, the clinical decision process. But that ultimately is a provider’s responsibility as the professional who makes the decision about what’s best for the patient. Where I think we can help, and I don’t have the ultimate answer, is to be able to move that decision-making process to something that feels more like a real-time, intelligent workflow. That would be a great start.

We know from our providers and even our payers that authorizations are the bane of their existence. No matter how big of a smile you put on it, it’s still just seen as a brute force utilization management tool. But payers have information about a member that might not be readily available to a provider, and when that is served up in the context of a real-time workflow process — whether that’s an authorization or referral or whatever it may be – it can drive a ton of value in that overall patient experience. That’s where we are focused.

One of the things I’ve always said about Availity is that we’re not an arms dealer. We are not provider centric. We are not payer centric. We are solution centric, and f we can create more transparency in those complex workflows where both the provider and the payer are bringing value to the table, then there’s a lot of upside for us and a lot of growth potential. 

We can start to knock down some of these walls between providers and payers around who is bringing value and at what point in the cycle. Providers would say that, by and large, payers don’t bring a lot of value in a clinical review process. The payers would say they need to keep a close eye on these providers because in the absence of utilization management processes, you get a significant overutilization and abuse of the healthcare system. I don’t know that I believe that either one of those is true. Value can be delivered on both sides of the equation.

To what extent are providers using clinical information that they can get only from a payer?

Our model is that we sell products and solutions to payers and we sell products and solutions to providers. We sit in a unique place where we are able to grow our business through our relationship with both sides of the equation. The answer to your question is that is growing. We are seeing more utilization of clinical data going both ways. We are seeing more clinical data being served up to our provider network from our payers to help close gaps in care, particularly in the Medicare Advantage space to get to the right utilization for HEDIS and other scoring purposes. We are seeing more and more data flow to the providers and then come back.

We’ve done a lot of integrations into provider systems to be able to pull out clinical data, attachments, charts, other things that are then consumed within a payer’s system to try to help come to a better and faster solution to an authorization workflow, for example. We are doing real-time, automated authorization workflows where we are reaching into the provider system, extracting clinical data in the provider context, translating that to payer-speak, and using that to help automate the authorization workflow within the payer systems. That is a big area of growth in the market and for us.

What challenges remain with building a network and integrating with EHRs?

You have to look at the endpoints on the network, which in healthcare are its users. We have solved a lot of the core administrative network issues, getting to the right person within the billing office, the front office, or other places where historically the adoption of technology has been pretty high. But we are still not nearly 100% penetrated into the parts of the provider organization where clinical decision-making is being done. We’re not penetrated into the clinical coordinators, the nurse practitioners, and the folks that all day, every day are trying to help manage these more complex clinical workflows with unstructured data and that sort of thing.

As a company, we have 2 million connected providers into our network, but we haven’t gone deep and created connectivity to the right users in all of those offices and all those facilities. There’s a real focus on expanding the use of Availity within a provider organization to make sure that we are bringing value not just to the scheduling person, billing person, or front desk intake, but also to those clinically oriented professionals within the organization.To a large degree, we have only scratched the surface of the value proposition there.

I think you build that all from a single network. There’s no reason to have a clinical network, an administrative network, and a financial network. When you do that, you create silos that then create more opacity in the process. But there’s work to be done to get to that nirvana state of a true holistic network.

What is driving investor interest in companies that offer patient payments technology?

We’re pretty small in that space right now. We help a physician collect a deductible upfront, but it’s not a big piece of our business. The interest comes from the right place. What we’ve done over decades is fairly completely disconnected the consumer from the provider. It’s the only section of the economy where we’ve done it quite so thoroughly.You and I as consumers of healthcare are still mostly ignorant to what a service costs, what the options are, and what is being billed versus what is being collected. We’ll do $2.5 trillion of billed claims through our network this year, of which 50 or 60% actually gets reimbursed. Where did the other trillion dollars go? You and I as consumers certainly don’t know where it went.

The desire to move into the patient billing and patient reimbursement space comes from the right place of saying that to drive the demand-side healthcare economy, you’ve got to connect the consumer with the provider of a service and the cost of that service. Strategically, I think that’s where these companies are trying to go. I’m not sure that anyone has completely figured out the timeline the process to get there. But it comes from the right place, even if it’s just to create awareness with a consumer that even though my responsibility for the services is only $50 or $100, I want to know what it really cost and what the options are, because there may be an option where I don’t have any deductible or there may be a higher quality option. Today, it’s just so difficult for us to get any visibility into those choices.

What will the company’s focus be in the next few years?

We’ve built a great culture here as a company. By and large, people really like working here. We have a revitalized leadership team with some great new leaders who joined us over over the last year. One of the things we’ve learned is that COVID has changed the way we work, changed our business, and changed the way we run the business. I’ve been in healthcare tech for over two decades and the energy around change and faster evolutionary processes is higher than I’ve ever seen it. It has to be.

The move to digital should be user experience driven, not technology driven. This move to a digital platform and a digital experience for our users is going to be our top area of focus. Moving to this interaction-based workflow within both our products and the way that we serve up data to our B2B customers is a great place for us to be as a company and a place where we can both grow and bring a lot of healthcare system. As we sit here today, we transact, by our estimates, half or so of all the healthcare transactions in the country. We sit in a pretty interesting place to be impactful if we try. We are going to give it a hell of a try.

HIStalk Interviews Guillaume Castel, CEO, PerfectServe

Guillaume Castel, MBA is CEO of PerfectServe of Knoxville, TN.

Tell me about yourself and the company.

I’ve been with PerfectServe two and a half years. We offer clinical communication collaboration software. We have put three main assets together covering optimized scheduling, clinical communication, and patient engagement. We believe that putting the three capabilities together three years ago is what the market needed to provide collaboration at scale the right way. Prior to PerfectServe. I spent time as an executive in a health system and then a few years with The Advisory Board Company, which was an amazing experience. I grew up in IBM and Cisco Systems.

How are health systems using your platform creatively to address clinician burnout?

This is a bit of an overused term that has lost a bit of its integrity, but we have been in a number of discussions with clients of all sizes about helping with the most important issue that health systems face today, which is to find good talent, retain them, and help them provide care for their patients. We help in a number of ways, but the most practical is probably through our scheduling capabilities. A fair, balanced schedule leads to a better work-life balance and a better disposition for clinicians to provide good care to patients.

We allow administrators and practice leaders to understand who has been on call more than others and who hasn’t received the schedule they wanted in the last 3-4 weeks and therefore is likely to be disappointed and at a high risk of burnout. We allow for that data and analytics piece to be available to the majority of our clients. We also do spot surveys for users of our technologies to say, are you happy or not happy today? We try to balance that in contrast that with the reality that is showing up in the data. We’ve been involved in not just diagnosing burnout, but also predicting it.

Your competitors Voalte and Vocera have ended up being owned by huge medical equipment companies. What drove that?

First, I have congratulated the Vocera team for their news last week. Vocera is a high-quality company, and I’m happy to be collaborating with them on a number of contracts, clients, and locations. 

A great deal of consolidation is happening. You’ve seen it in our space, and it’s happening in other spaces. Clients want to deal with enterprise-grade vendors. There’s this connectivity around patient care that stays in place and goes occasionally past the communication lens. What some are trying to do is connecting medical device with clinical workflow, which makes good sense. People have wanted to do that with beds for a long time. I suppose they are trying to connect it with other areas of the care continuum.

We believed that we had the right thesis three years ago. We believed and continue to be a strong proponent of the fact that collaboration at scale, no matter the care setting, is what is going to win the day. For that to be successful, you have to have intelligent scheduling. You have to have cloud-based, rules-based clinical communications. You have to have the ability to engage with patients wherever they are. We know that care has moved from mostly being inside the hospital to being in the outpatient setting, the ambulatory network, to now increasingly the physician’s office. More and more we are seeing that care is going to be done at home. We’re focused on ensuring that we equip and help all of our clients with the ability to seamlessly deliver good collaboration and good communication among their care teams, regardless of the care setting.

You told me last time we talked that your goal was to make acquisitions where the whole is greater than the sum of its parts. As someone who has done that, how hard is it to find complementary offerings, figure out how they fit, and then actually acquire a company? [note: PerfectServe announced the day after this conversation that it had acquired anesthesia staff case assignment software vendor AnesthesiaGo].

The hardest part by far is to have the right pieces. I can tell you that I’m grateful for the thoughtfulness we put into thinking about what pieces to put together. The second piece is integration, which is something that people don’t want to talk about a lot. It’s a lot more exciting to talk about deal terms and multiples, but the reality is you get true value by integrating the pieces properly.

In our case, it has taken us at least 18 months to get to a place where we could start to see the equation equal or exceed “one plus one equals two.” Now we are far in excess of that, and I think our clients see it. We are continuing to be focused on messages getting to the right person, care going faster, care providers finding happiness again, and being an element at the disposal of large health systems all the way down to small physician groups to allow them to gain productivity and anticipate the next phase of care delivery changes. We’re very happy that we made the acquisitions three years ago. It has taken real work to get them to work in a way that made a difference for our clients.

How do you see the company responding to market demand for remote patient monitoring and chronic condition management?

The way your platforms are architected will either help you be flexible and go beyond where you shine — either inside the hospital or in the ambulatory network — into the patient’s home, or not. In our case, our premise was to be present across the continuum. We had that ability to have a technology that was flexible enough to branch into areas that we weren’t known for. Our PFC, Patient and Family Communication offering, was put in a bright light during the early stages of COVID, where we engaged with patients wherever they were. We helped health systems deal with an onslaught of patients who were in the parking lots waiting to be seen because they thought they had COVID. I’m simplifying a situation that was dire, confused, and tricky for health systems to manage.

What we believe now is that it was easy for folks to say that telehealth really jumped through that period. Yes, virtual care visits increased. They’ve come back down a little bit, but we’ve made a lot of progress, all of us, in allowing care providers to do virtual visits and care delivery with patients wherever they are. That is good progress for our clients and good progress for society.

What we believe is happening now is that virtual care is just one aspect of changing the way care is being provided. Increasingly sophisticated and innovative health systems will want to actually touch patients in their homes to the extent possible. If there isn’t a reason for someone who is not well to get in the car and go back into the emergency room, the person should stay home. The health system and the care provider should be able to serve them and care for them in the safety and quality of their homes.

Remote patient monitoring — and it goes beyond that to the ability to do remote exams — is going to be core to the next level of delivery. We are deeply embedded in continuing to ensure that communications flow naturally with that new care model. It’s not just about engaging patients, it’s about ensuring that the engagement is routed properly, that care teams are aware of the feedback loop, and that actions are being triggered and taken. That’s what good care looks like. It’s much more than just a bunch of solutions that are solving very small problems.

How  do you see the industry and the company changing in the next 3-4 years?

We are committed to making certain that we have a very direct impact on accelerating speed to care. Everything we do at the end of the day is in a search to allow our clients to accelerate the way they provide care and improve the care they deliver to their patients. Full stop. There are adjacencies that we are very interested in that fit into that. We want collaboration among care teams to be increasingly more intuitive. We continue to believe that schedules and the routing of messages to the right person using the right channel in any care setting and at home is a differentiator.

We know that we’re having a good month when usage of our platforms is up. We track this religiously because it tends to be a good indicator. There are areas that we continue to track pretty closely. Extensions of our capabilities and our scheduling suite of products. Extension of our capabilities and our ability to engage with patients differently. Extension of our capabilities with our core clinical communication products, which could include the ability to track devices that are being delivered at patient’s homes so that we can enable this remote patient exam paradigm that is upon us. We are looking at a ton of stuff.

We are excited about where we are. We are grateful to have patient investors who like what we do and respect what we do, and we’ve done very well with it.

HIStalk Interviews Lisa Esch, SVP, NTT Data

Lisa Esch is SVP/provider industry solutions leader of NTT Data of Tokyo, Japan.

Tell me about yourself and the company.

I’ve been with the company for a little over a year. I get to work with our clients and our customers as we tackle the challenges of healthcare and how IT supports that with services and technology. I’ve always been in healthcare. I started out as a clinician. I’m a dietitian by training and I worked for non-profit and for-profit health systems. I worked in the space around healthcare systems for many years, then in startups as well as large IT global systems integrators.

How will health systems use technology differently as they grow in size and geographic scope?

We’re seeing a lot of the innovation come out of the nimble, small companies, the ideas that can be executed and how we problem solve. There’s a balance between the large and the small, what the large can accomplish at scale versus what the small can do in driving innovation. There’s this blending of both that we need in the marketplace to drive the change that’s happening and to keep the patient at the center of what we’re trying to accomplish in this healthcare transformation, this digitization of healthcare.

Are health systems more consistently using their corporate approach and brand so that patients feel known at any of the health system’s venues?

Having the health system know them is a conversation that we are having with many of our customers. There’s this balance between “creepy know” that you get from commercial businesses that we interact with online versus knowing you so we can improve outcomes, engagement, and personalization.

You shouldn’t have to repeat things in your healthcare experience. You shouldn’t have to have nine portals. Even though you’re accessing in multiple places, it’s a single system, so personalization needs to come together. There’s a lot of fear around information and being proactive because of some of the rules and laws we have about how you communicate with patients, and the difference between marketing versus education and those types of things. But convergence is coming together with commercial industry and healthcare, and we have to figure a good way to make that happen.

What are health systems considering when developing their digital health strategy?

A lot of it involves how to humanize the digital experience. How we bring in information and data around people that isn’t traditionally healthcare that can help us drive engagement, make it more personal, make it a better experience, and make it a better outcome for the clinician as well as the patient. We are having conversations around that. We are building into our digital accelerator things that are AI driven, next best actions, personas, and different things that help with that digital experience and make it more personal.

Some organizations are more ready to have those conversations than others. Some react with, “Amazon knows more about you and Google knows more about you than you know yourself.” That’s not what we’re trying to get to, but how do we leverage the good that’s coming out of those things to bring together the clunkiness that we have in healthcare today? Imagine having a unified patient experience for someone so that an organization’s brand can stay connected to a patient as they traverse this healthcare delivery system where more is happening outside the four walls of the healthcare system than inside. There’s risk with brand and with connection. Patients have a lot of choice.

Is anyone looking far enough down the road to connect a variety of services and tools together to create an Amazon-like experience?

We are working on that strategy now. We’re putting together a marketplace where we can make it easy for organizations to have a problem to solve. We have partners that are pre-built or pre-vetted to make that process easier. We also have the capability of the technologies that can bring those things together, to make them all work together and better to get more out of them. We’re tackling this with our customers right now. 

A lot of decisions were made a couple years ago early on in the pandemic in buying technology. I need this and I need that. Now organizations are sometimes stuck with a bag of rocks. We are beefing up our healthcare consulting chops and advising organizations on, maybe we pull the plug on this. Let’s have a strategy here, and put more of a strategy around this transformation versus having the world put all this pressure on organization and people just buy things because they need something. 

Who is in the best position among healthcare players in getting the consumer’s attention as an information source or service choice?

The organizations that create this unified personal experience are further ahead. What that unified experience is is key. When I talk about a unified experience, I’m not talking about a single EMR across an enterprise. It’s much more than that. Patients become engaged in many more ways than just that their portal, which they don’t use except when they need to pay their bills. There’s this much more enriching experience, and patients can sometimes get that more easily from outside their healthcare system in other industries. Those other industries are obviously looking at healthcare.

The term “provider” is being redefined. There’s lots of ways healthcare is being provided lately. So it’s going to require partnering with people that you haven’t thought about and doing things in new ways. We’re tackling hospital at home, health at home, and it’s really complex. It seems like it shouldn’t be that hard, but we know that it is. That’s going to require a new way of thinking about delivering healthcare, new partners, and non-traditional things to move to that space. The ones that will win are going to be driven by experience and those that will invest in that unified personal human experience. Health and wellbeing is going to be delivered outside of just healthcare systems.

Is it hard to segment the wide variety of patients that a health system would serve, such as by preferred communication channel or the desired depth of the ongoing relationship?

That ties to a healthcare persona. It really is an engagement persona — how frequently they access and what kind of communication. It still is an omni-channel strategy. Some people still want to be communicated with or educated on paper. Some people want pure digital. The omni-channel experience is key, but the persona is a big part of it. We’ve tackled a lot of what we do with, “Here’s the technology. Just plug everybody into it.” Beyond that, we have a lot of research around engagement that can be driven digitally. We probably need to look outside of healthcare a little bit more to bring those capabilities in, to drive that and have it become part of our digital strategy as we transform the healthcare system.

Will we have enough providers in the right locations to support the business models involved in offering services in new ways?

Telehealth fit a need. A lot of clinicians move to it that because, wherever they were in their careers or whatever they were doing, it worked for them. Telehealth is here to stay and we are going to have that capability. Health systems need to balance out how they will deliver it because telehealth is still going to drive a different demographic, and when you look at the lifetime value of a patient, that experience will be important as people move and age through the healthcare system.

The partners you have how telehealth is delivered needs to ensure availability, but a lot of the telehealth that was stood up was disconnected from the health system and from the records. It was disconnected for the patient. They got what they needed in that moment, but it wasn’t part of a connected healthcare journey or their healthcare experience. That’s the part that’s a little messy still, and we’re working on determining the best next going-forward strategy and how we  balance that out.

Banks deployed ATMs so they could get rid of tellers, but also addressed an unmet need of customers who ended up rarely needing to interact with a bank employee anyway. How will the rollout of technologies such as chat bots benefit patients rather than just limiting their access to clinicians?

When AI and chat reduce access, there are probably unintended consequences that aren’t so positive. It’s finding the right place to leverage that and to have it improve and enhance the experience and not be a way to block the experience. There are times where certain personas will engage with that and others won’t. That’s part of the strategy with AI —  how do you find those who will engage with that and those who will not?

An example where it worked great was putting together a SOAP note prior to a visit by having the patient chat with AI before they saw the physician. They found that patients shared more with this bot than with a human being, so they got a more robust background prior to that visit. That’s really cool technology. Sometimes AI can be a better experience than the human one, while at other times, it’s not. We  have to sort all that out as we build this strategy. There will be a place for it, and there will be a place where it’s not helpful.

Where do you see digital health and the company advancing in the next few years?

The digital health innovation that we’re going to see over the next two to three years will be similar to what we’re seeing now. The ideas, the startups being disruptive, and then elements of those things moving into mainstream. I’m also seeing the big transformations that have to happen in healthcare, the digital ecosystem and how we deliver healthcare, as that is also being transformed. We’re going to see AI and robotic process automation. We’re going to see all these small things find the right place in the bigger picture that will drive the transformation. We are excited about is helping with the roadmap, the strategy around that, and helping to find those partners and put those things together that are unique to a healthcare system.

It will be exciting to see what that transformation will going to be. We will see this transformation of, who and what is a provider? How is healthcare provided in the community? With COVID, everyone in the workplace is in healthcare. An employer is responsible for understanding and keeping their patients safe and healthy, so this definition of health and wellbeing is also being redefined and identifying who is responsible for that in our communities. This conversation is going much more broader than just healthcare providers. We’re in the middle of all of that, trying to bring that together and help communities deliver.

Digital healthcare and the digital ecosystem are patient driven. There’s a consumer aspect to it, there’s a technical aspect to it, it is driven by innovation, and it is driven by tradition. These things are coming together in a new way than we’ve seen before. It requires all of those different points of view to move forward, and that’s what I’m so excited about.

HIStalk Interviews Rajesh Voddiraju, Group President, Health IPass

Rajesh Voddiraju, MS is founder and group president of Health IPass, a Sphere Company of Oak Brook, IL.

Tell me about yourself and the company.

Sphere is a payments company that, across multiple industries, streamlines the payment process for consumers and in healthcare in particular. We are all about taking friction out of the payment process through an integrated solution that meets the needs of large health systems all the way to the smallest of the healthcare practices.

To what degree is healthcare still using clipboards and badly designed paper forms instead of electronic systems for collecting check-in and billing information?

As we look at how the industry has evolved, the first generation of solutions effectively came up with electronic ways to change these forms from paper-based to an electronic clipboard. Maybe a kiosk, maybe a tablet, and having folks, when they come into the clinic, be able to use electronic mechanisms in terms of the data capture.

We’ve always believed that’s just a starting point. The more you enable patients to be able to do it in advance, the better. The second generation of the evolution focuses not just on doing it in the clinic, but enabling people to do it on any device, any time, with a mobile-first kind of a strategy. Baked in there were some really cool innovations, such as enabling the patient to take a picture of their driver’s license to validate their identity or to take a photo of their insurance card. Being able to read information and ensure that we’ve got a good capture, just like your banking apps do when you scan a check, for example. That type of innovation was a second generation.

We’ve always focused on predictive analytics way beyond just the data capture, how that can streamline the billing process and ultimately make that experience good for both the consumer as well the healthcare provider.

As patients become a significant source of revenue for provider because of health plans with high deductibles, there’s a real pain around collecting patient responsible dollars in a streamlined, easy manner that both educates the consumer as well as makes it easy for that transaction to occur. It’s not just about replacing the electronic clipboard. That is now table stakes. It’s enabling that workflow to occur any time well in advance, on any device, with the right kind of smarts embedded into it.

The third generation is to take it one more level in solving the key issue in healthcare, which is that the consumer doesn’t know what things cost and the merchant — the healthcare provider — literally has no guarantee that they’ll ever get paid. Solving that in a way that educates the consumer and enables price transparency so that there are no surprises later is a big part of the transformation that we as Health IPass and Sphere have brought to healthcare consumer engagement.

Does that inability to tell patients what they will owe upfront limit their willingness to leave their credit card information on file as they do in almost every other industry?

I’ll answer that from two standpoints. One is the regulatory implications. The No Surprises Act is the next evolution of regulatory intervention by both state and federal government to avoid surprise billing and to make sure there is advanced notice for the consumer in terms of what their out-of-pocket is going to be. From a technology standpoint, providers have often struggled to have the right type of technology that enables them — as they become in-network with various insurance companies — what that contracted rate is.

The first part of a triangulation that we do within our platform is to know what the contracted fee schedule is with a particular provider across the different insurance companies. The second is to be able to set up the right kind of rules to say, for example, that if you had a surgery and multiple procedures were done, how does that affect the reimbursement in terms of what the provider would get paid? These were rules that were here before in a black box, where nobody quite knew except the super specialist in billing. Technology now has been able to bring in and codify all of that information.

On top of that, we need to know how that affects a particular patient at a particular point in time. Luckily, through the Affordable Care Act and the administrative simplification that was put forth many years ago, the black box of where a particular patient is in meeting their deductible, the balance remaining, their max out-of-pocket, and the plan design data are easier for companies like us to access.

We built a robust solution around being able to, for regular office visits all the way to surgical interventions, compute, based on all three of these factors, what the patient’s out-of-pocket is. We present it to the patient so that there is no surprise. Then it becomes easier for the patient to opt in and leave a credit card on file because they know it’s not going to be hit for just any amount, that payment assurance is being procured or secured in conjunction with the estimate that has  been provided. We get incredible adoption rates across millions of patients every month and every year.

If a patient checks in through Health IPass, the healthcare provider typically gets paid almost 97.5 cents on the dollar, which is unheard of when most healthcare providers get 50 to 60 cents on the dollar with paper-based practices and the surprises it yields. An educated consumer is definitely a better payer, and our data and our history has proven that for the healthcare provider, that is absolutely the case.

How do you tune the various factors that impact the likelihood of being paid, such as insurance history, provider specialty, the emergent nature of the encounter, and the level of co-pay and deductible involved?

There’s definitely multiple layers of complexity to your point. The first is to take the payer-specific rules and create a library of rules that can be set up across providers. I mentioned the example of multiple procedures, where perhaps the first cohort is paid at 100%, but is the second cohort paid at 50% or is it 33%? Those are typical rules that you could layer a global set of rules. On top of it, we need to always be able to model the individual contract. If you are at Northwestern here in Chicago, for example, who’s a client of Sphere, you have a special contract with Blue Cross Blue Shield of Illinois that enables you for a different reimbursement model on that multiple procedure example. We have to be able to overlay that with a provider-payer specific set of rules within our platform. 

On top of all of that is the variability of where an insured patient is at that particular point in time. We have real-time connectivity with 926 insurance companies across the country. In real time, we know that the patient has this much money remaining on his deductible and this much money on his out-of-pocket maximum, both at an individual level as well as a family level. There’s a lot of computation and artificial intelligence / machine learning that is in play here in terms of making it simple at the end of the day to educate the patient that for a suggested procedure, here’s your out-of-pocket.

Ultimately, the card-on-file mechanism enables the consumer to have peace of mind. The provider is still filing a claim with their insurance company and letting the insurance company adjudicate the claim. Only when you have it down to the penny, the exact amount that is truly the patient out-of-pocket, does an electronic bill get presented. Patients get a text message or email, whatever they prefer as a consumer, and they still have the opportunity to ask for payment assistance or things like that before their card is auto-debited for the exact, down-to-the-penny amount as adjudicated by their insurance company.

Dentist offices make sure that outstanding balances are addressed before they schedule the next appointment. Is it hard on the medical side for practices or clinics to discuss the balance owed, a low propensity-to-pay, or a possible financial hit for patients who are early in their benefit year when they haven’t met their deductibles?

The big difference between dental and medical is typically when you go to a dentist, the dentist knows exactly what is going to be done. A treatment plan has been pre-established. That’s not always the case in the medical world. That’s part of the reason, along with lack of the right tools, that we have surprise billing. There’s a lot more complexity to in-network and out-of-network. The best practice is to embrace this notion that transparency creates better patients and better patient engagement. Obviously that has to be assisted with the right technology.

We’ve taken pride in helping clients remove this paper and these black boxes, whether it’s on the front end of the process or post-visit engagement. We talk about how can we streamline the entire appointment to payment journey as part of our patient engagement process. It’s about allowing the patient to schedule themselves, answer the appropriate screening questions, get on the schedule with the right provider as most convenient for the patient, and take the journey all the way through in terms of setting the expectation based on the type of visit, how the patient has answered a certain set of pre-screening questions, the expected out-of-pocket, and educating them on what the insurance company will and will not cover and where they stand on their benefits early in the process.

Certainly if the patient has outstanding balance — regardless of whether that bill came from a specialist visit like a dermatologist, an orthopedic surgeon who is part of the group, diagnostics, surgeries, or labs — being able to present a consolidated single bill at that moment of engagement by the patient. Eliminate getting 16 different bills that all come at different times. It’s too confusing for someone who may have a household with a few more interactions with the system. Transparency into what their outstanding balance is and presenting payment assistance or payment plans that may be available for that particular patient, as determined and customized by that healthcare provider, is an important step of what we do.

As I mentioned before, the more you educate folks in advance for future care, the more you are able to secure their payment assurance through a card-on-file and streamline the electronic billing process. It works out well for all parties involved. The patient is happy. They don’t get surprised. They don’t have to go look for a stamp. They don’t have to go look for a paper checkbook. It’s very, very good for the health system that was getting 50 or 60 cents on the dollar to suddenly realize that moving to 97.5 cents also creates better patient engagement and better patient satisfaction.

What factors will have the most impact on patient payments and healthcare in general in the next few years?

Number one is increased transparency into patient out-of-pocket expense. We welcome this and are certainly glad to see regulatory intervention, including the No Surprises Act, that will put more impetus behind creating that level of transparency. The second is owning more of the patient journey. We now do everything from upfront patient self-scheduling all the way to, after you’ve had your surgery and you’ve gone home, what are called patient-reported outcomes. What’s your range of motion? How is that improving over time? Being able to leverage technology to provide that type of clinical insight to the surgeon, in this case, to be able to intervene properly with the particular patient.

That’s the range of capabilities that are important, so you don’t have a hodgepodge of vendors that are doing different things and you can create a more streamlined experience for the consumer. Those two big trends is what we are excited about. We feel that we are in a great spot to be able to service the needs of consumers.

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

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

Tell me about yourself and the company.

I have spent my whole career at the intersection of healthcare and technology. I worked for SMS, Shared Medical Systems, right out of college. I grew with that company and ended up running sales for them when Siemens took over. I did that for a few years, then went to Microsoft and ran their US healthcare business. I got involved with the Health Solutions Group through Amalga and HealthVault products. I then went to Caradigm and was their chief commercial officer. 

I started to Get-to-Market Health about almost five years ago to help healthcare technology companies improve their go-to-market activities.

Does the number of recent eye-popping funding announcements mean that the old rules have changed, or is it more of a situation where those companies, who may be new to healthcare, need to learn some hard lessons about carving out a niche?

They are eye-popping to everybody. I see good that comes from it and also some challenges. When the right company gets funding, it helps them go faster. We’ve been working with a company in the medical device space that is well funded, on a really solid track, and they are just able go faster than they would be. The investor is betting on a long-term bigger return by letting them go faster now. We have seen examples of telehealth companies that just got incredible valuations. Whether they hold up over time is the question.

Every company we talk to or work with is in the middle of some sort of funding discussions. It’s healthy overall that entrepreneurs can get capital to build a business, but there are some messy spots to it. Think about Practice Fusion, which ended up being worth maybe a fifth of what people thought. Allscripts had to pick up the pieces. Theranos is still in the news every day. So there certainly are some not-pretty pictures, but on balance, equity investors, private equity investors, venture investors, and hospital-backed venture funds are trying to do their due diligence. They are evaluating companies. Saying that it is spawning a renaissance is maybe a little strong, but it is certainly spawning a lot of interesting companies.

The Silicon Valley model involves grabbing market share and chasing growth at all cost. Is the healthcare investment model still valid that assumes that companies need to be able to improve outcomes or reduce cost?

It’s no surprise to anyone that healthcare is slow. Nobody is imagining that they are going to build a real, honest, billion-dollar business in three years. There’s no confusion that healthcare takes time and it’s a complicated business. What is encouraging is that most of the investors we see today are people who only invest in healthcare. They understand it, they get it, and they know the successes and the horror stories.

Providence has a fund. I think Jefferson has a fund near me. Hopkins has a fund and has launched an interesting company. Those folks clearly get healthcare and they are pretty long-cycle investors. They have more patience than some pure private equity company that maybe spend its mornings in manufacturing and its afternoons in healthcare. You have a little smarter investor than you had even a few years ago.

Is it good or bad that the line between investor-funded companies and providers is blurring as providers start funds and companies and companies are opening clinics and telehealth practices?

There are certain things that a for-profit hospital can do a good job on. I’m not sure you or I would want to go get the most complicated surgery ever at a for-profit hospital. They have different niches. For-profit investors have a different horizon in terms of when they want their money back, and their tolerance is low for any hiccups. There will be a fair amount of appeal to the hospital-backed venture and maybe growth equity funds, because the entrepreneur will look at them and say, they get healthcare. They know how hard it is to get things going. I think they will be pretty successful.

They have a lot of work to do to become as capable of investors as the private firms. Whatever you say about the private firms, they know how to crunch the numbers. They know how to value companies. So probably there’s room for both, and I don’t think it’s bad to have them both in the space. If I was an entrepreneur, I would consider both. There’s going to be a better fit depending on what the business is, the model and how much money you need, and how long you’re going to take to build your business.

How will executive job changes affect the plans of companies?

I wonder if what’s behind that is new investment or a need for new investment. Companies that are taking a round of money or have just taken a round have to demonstrate that they are making changes. A lot of times, the investor comes up and says, let’s build a big go-to-market plan, let’s go to three countries instead of one, or let’s go into some new markets. That is probably a big part of the exodus that you see — there’s a financial transaction coming or has happened, and for whatever reason, they decide they want to bring in a new regime to help steer things, or there’s an exit and those folks move on.

We’ve gotten called in several times to help people build go-to-market plans for a new market because they are anticipating some investment and they want to be able to demonstrate to the investment community where they’re going and how they’re going to get there.

Private equity companies are rolling up companies and acquisitions to earn rich returns, with Athenahealth being a recent example. Will that trend continue?

Five years ago, private equity was somewhat of a novel thing in this space. They were able to buy multiple companies, invest in them, and grow them. They are finding out that it’s not so novel. An alternative to buying lots of companies is to buy one and then buy some smaller adjacencies around it to build a bigger, more complete company. HBOC tried to do that, but had trouble integrating all those pieces. I suspect there may be some issues around the corner for those companies. You can buy companies and put a common brand in front of them, but getting them to work together is a big challenge.

Does a successful exit require customers to be satisfied?

It should 100% matter. If I’m an investor and I’m buying a business that has a bunch of unhappy customers, I’m sure not going to pay $17 billion for it. Either there are a bunch of happy customers that the investor found or they didn’t look carefully enough. My thesis is that a company is only worth as much as its customers are willing to stay with them and willing to pay. Happy customers that are renewing, adding on, and buying new things are worth a lot of money. But you look at some of these companies that have disgruntled customers, it’s hard to imagine that the math works. I would think that investors have figured that out and are taking that into account.

Epic would be worth so much money because they have a loyal, happy, renewing, expanding, and growing customers. They are worth more than another EMR company that might not have happy customers and might have lots of negative press. In our experience, the companies that are doing well are worried about taking care of the customers. It’s not all math. They can’t just think that just because they sold 10 systems, they are a valuable company. They have to have happy customers who are going to renew and buy more stuff or else their future value isn’t what they think.

What kind of help do companies need to support their intention to do more than just make short-term sales and instead to position themselves for long-term success?

Getting your product and your company to be viable in the market includes making sure you have a product that customers can understand, value that they can understand, and that you are serious about a happy, successful deployment and an ongoing relationship. We spend a ton of time in that area, because maybe the investor or CEO who doesn’t have a ton of experience in healthcare may not grasp all that. 

If you’ve been around healthcare, you know how important it is to ensure that you have happy customers, that you invest the time and money, and that you have an empathetic viewpoint about what it takes to make customers happy. An unhappy customer is far more important than 10 happy customers. You have to focus on it, and we absolutely get pulled into those discussions all the time.

I had responsibility for our overall customer satisfaction at SMS, Siemens, Microsoft, and Caradigm. I appreciate it. It’s hard. It’s hard to keep them all happy. But if you take care of your customers, even if you have tough times, they reward you for it. They get how hard it is. When Epic or Cerner fixes a rough customer situation, those customers are loyal to them for a long time.

Do you think HIMSS and RSNA exhibitors were as happy as those organizations claimed that professional in-person conference attendance was down two-thirds?

Those conferences are like a stock market that gets overblown and it takes a drop. It’s actually healthy in the long term. RSNA and HIMSS are doing what they have to do, which is putting on as good a face on as possible. But I’ve talked to enough people who were at both shows to know that there was a real lack of potential buyers. If you were interested in meeting with vendor partners, it was helpful, but it was out of balance between what the vendors would have hoped and expected to see in terms of potential buyers and who was there. The shows have gotten too big and too full of themselves and they need to reorient.

I thought the HLTH conference was pretty good. They had a better balance.They didn’t have a ton of buyers there, but it didn’t feel as out of balance as HIMSS and RSNA have felt to me of late.

They are putting a good face on it, but it wasn’t the show that everyone hoped. I talked to some vendors who had a great show at RSNA, generally the newer entrants that had something exciting, innovative, and disruptive. I don’t think the big mainstream players in any of those shows felt good about them.

How have health IT sales and marketing changed as the pandemic approaches the two-year mark?

We have one client that has never had the luxury of a attending HIMSS or a trade show. They have built their business on having connected advisors who can make introductions for them. They built a comprehensive easy way to showcase and demo their product remotely. They figured out a low-cost way to deploy it and even trial it. They never knew the old way since they are pretty new, and they have seen tremendous growth. 

The old model was to get ready for product announcements in the fall, release them in January or February, go to HIMSS, show them, do a couple of events for customers during the year, and then go back to HIMSS. That model was broken and is broken.

We have clients that have done a phenomenal job with social media. They are on every day and they are using customers and third parties to help promote and educate people about their product. We have one client that has done a great job with social, and as we have helped them go to other countries, people in those other countries are already aware of them. They haven’t spent any energy or time yet in those countries because social is global and they’re on their LinkedIn or Instagram pages learning more about them.

When I was at Siemens, I think we had 600 people at RSNA. Clearly HIMSS and RSNA were multi multi-million dollar investments for those big companies. That model is going to change for sure. After RSNA, most of those companies are going to say, OK, next year we’re going to do something different. They will be at at RSNA, but they probably can’t justify as much space.

I did hear from one client at RSNA that there weren’t a lot of middle- and lower-level people at RSNA. The company sent fewer people. They were able to connect with executives who they wanted to see to talk about a product or an issue or something they had. They felt better about that. I don’t think it was all bad, just not a home run.

How will the vendor-CIO dynamic and conference focus change as health systems create more C-level roles that carry IT and digital responsibilities?

The CIO and IT department  are as critical as they’ve ever been, but I don’t think they are the front line any more. The front line is the ultimate end user of the product. Then you have to persuade and educate the CIO, CISO, and the IT department and make sure your product fits in with their protocol around security and IT tech and that you meet whatever their criteria are. I still think that there is benefit for IT folks, including the CIO, to attend HIMSS, especially if they want to get a quick look at 10 different companies, if that’s really the best part about it.

There was a day not that long ago where you would sell an EMR or a piece of medical equipment to IT. Now the CIO defers and says, who’s the champion within the health system who wants and needs this product? Then, how do you help that end user understand the product? What’s the market fit for it? How’s the price? Then the CIO has to judge it and figure out whether it fits in their environment.

What industry changes will we see in 2022?

I’m impressed by companies that meet three key things that separate them. They have an innovative product and an innovative pricing approach. They are disruptive, in a good way, to what has been done before. They have a compelling story behind them.

Every company that has done well in this business has a compelling story. Think about Judy building Epic from one scheduling app at University of Wisconsin into a giant, successful company. Her attention on customer satisfaction and all that. There’s a compelling story there and in other companies where the entrepreneur has believed in his or her niche and built the business.

Successful companies are thoughtful about the business, have a disruptive product and/or pricing model —  because people just can’t spend unlimited money — and they have a compelling story that people can latch onto. When I was at SMS, the two founders had put together a business that met a key need, people could understand it, and there was a compelling story. That helped people buy it. That’s still very true today.

HIStalk Interviews Steven Scott, CEO, VitalTech

Steven Scott is CEO of VitalTech of Plano, TX.

Tell me about yourself and the company.

I’ve been doing healthcare for much longer than I like to think, probably about 30 or 35 years. That includes the areas of senior housing, long-term care facilities, large hospital groups, software analytics, and healthcare IT. I joined VitalTech three months ago. What brought me here was that services are getting more and more pushed out into the home setting and we have the ability to provide services there that are driven by information and data. Remote patient monitoring is just one aspect of that. Using the biometric information helping people make decisions and helping them age in place — those are the concepts that attracted me to VitalTech, which does that on the remote patient monitoring side.

Will we see new advancements in wearables, sensors, and in-room technologies that will support advancing that concept?

If you look back just two years ago at the things that were available versus what’s out there today, there have been pretty good leaps in technologies in both size and connectivity now that 5G is out there. The ability to leverage and move data around from the home, which is helping the hospital-at-home concept, and the types of monitoring that we know will be done in the hospital that are being pushed out in the home and the companies that are looking at leveraging the technology.

In a lot of aspects of our lives outside of healthcare, technologies are advancing rapidly. We’ll see more devices that have an even higher clinical capability, if that’s a way to describe it, as complexity in the types of patients that need to have that at home come online. Technology is rapidly advancing. What we saw two years ago versus what we see today to what we’ll see two years from now will grow prior in a capability perspective. Connectivity has had a big impact in that, too. We’re just now beginning to realize what 5G is to recognize and utilize it.

The remote care market includes platform vendors, telehealth services, behavioral health providers, remote patient monitoring, senior living support, and patient engagement. How do you see that market of providers and vendors either consolidating or changing over the next few years?

There will be some consolidation. Some of that will be driven by not just the people who are out there providing the services, but also in the payer world. UnitedHealthcare just announced a couple of weeks ago that they basically have a digital-first health plan as the first level of engagement with their patients. The premiums are paying for those digital cares services. Virtual care is here. Virtual care is being adopted, both on the payer and the provider side. When your benefits start to align, you receive those services at home, and you get your equipment through your payer, you’re going to see he adoption grow significantly.

Then for those people that provide services in and around that — as technology advances, as the investment community takes a look at that as owners, and vendors and physician groups and those things engage, you’ll see some consolidation. That’s a normal progression that we’ll see over the next three to five years.

How will the payment policies of insurers and employers as well as patient spending lag or lead adoption?

It’s a little bit of both as it shifts. A lot of that is driven by government programs. CMMI has had a lot of initiatives around that. The physician fee schedule, remote patient monitoring, care coordination, and chronic care management leverage those virtual care aspects. Those are now reimbursable and they are changing the codes along those lines, which influences the fee-for-service world or an ambulatory setting world. You see in the risk arrangement side of the world where people — whether they are managing a population, a disease state, or interacting with their high-utilization chronic care members — leveraging technology, remote patient monitoring, and care coordination services for the home setting and the managed care environment, and it’s HCBS type services are getting deployed and moving along that line.

The incentives are all being aligned from a reimbursement perspective, an outcomes perspective, and a care delivery and services perspective. This has been in motion for several years. It’s just starting to snowball. A lot of that was influenced by COVID, where we needed to manage chronic care patients or were dealing with a high-risk disease state where we couldn’t have them come to the office. When you couldn’t have them in the hospital and no one was showing up in the ER, you needed to be a more proactive. When you look at how telemedicine intervened, people realized that we also need to get the biometric data. We need to see what going on with the weight gain or the weight losses or the glucose monitoring.

Those types of things were highlighted during COVID. People were looking to provide those services. Commercial and government programs and large employer groups recognize the need to provide those services outside the hospital walls.

How will health systems participate in the hospital-at-home concept, which otherwise threatens their revenue?

Some of our largest clients are hospitals. It’s usually because hospitals are involved not just as the provider of services, but also on the payer side, whether that member or patient is most likely part of an ACO arrangement. They’re responsible not only for the inpatient stay, but what happens on the outpatient world also. Hospitals have grown in their physician practices and in their marketplace, staying engaged with the patient post-hospital, whether it’s a readmission prevention type of a thing or trying to improve an outcome. Staying engaged with the patient, not just a phone call, but staying engaged in the actual care and the care delivery, whether that’s remote patient monitoring or care navigation. Keeping them within the network, utilizing their provider groups or the groups that they’re aligned with. Hospitals are probably more active in that today than they have ever been.

Hospitals have some number of lives where they are in a risk-sharing arrangement. Even if it’s still a fee-for-service patient, there’s some kind of a shared savings program. It’s relatively low incremental cost to run a virtual care program that keeps that patient engaged, that keeps them utilizing within their network, that keeps the readmission rates lower. It’s the net sum impact of that, not the small incremental cost, that they are shifting their focus on. As those arrangements become larger and more lives are doing it, hospitals are reacting.

How much does the local mix of patient payers, such as Medicare Advantage, lead hospitals to decide how actively they want to be involved in remote care?

A lot of those Medicare lives are in some kind of an ACO arrangement on the fee-for-service side. Large employer groups in a regional market that has a large employer footprint or a heavily managed government program — whether it’s managed Medicaid or managed Medicare — are influential on that. The commercial is looking at that also and seeing the impacts and the outcome improvements to do that. They are all aligning together and the hospitals are right in the middle of all that.

What are Best Buy’s ambitions in healthcare?

They’ve been doing a lot of acquisition in and around the homecare-bound services side, whether that’s in the senior area or just the general population. People are more interested in monitoring their own health at home with the evolution of the Apple Watch, the Apple Health app, a multitude of apps and  peripherals around the Fitbit and those types of things. They see an opportunity there, from being a vendor of the hardware, but also on the services side. They have bought services companies to be a player in that space. Just like Amazon, to some extent. Healthcare is such a huge segment of the general business world right now that they are looking to how they can participate and do that. Then just by size and leverage, they can bring some economies of scale that other vendors don’t have.

Does the ability to scale remote patient monitoring depend on AI that can monitor the data and then alert humans when interventions are needed?

The biggest part of remote monitoring is people who monitor themselves. I have an iPhone, I’m counting my steps, I’m capturing my heart rate, I can do my own EKG, and I’m looking to see if anything is wrong. That’s the largest portion of who’s doing it.

As you go up the complexity of the medical condition, when the payer gets involved and the provider gets involved, they are actively monitoring a condition. They are doing it with their own staff or using a third-party vendor, but as  you move up the acuity chain, that’s where you start seeing the other service vendors actively involved in that case. Case management, care navigation, care coordination, or your doctor wants to know weekly what your average blood pressure has been for the last three days as he is working through your medication regime. That’s where service providers start to get involved. But the largest market and the largest number of people are just monitoring themselves.

I have an IPhone and I have to walk 10,000 steps. What does that mean? I get on my scale that I just bought at Best Buy and hooked it up on Bluetooth, so now I weigh myself every day. I’m entering my nutritional data. I’m putting the barcode in, or talking about how much I had and what I ate. I’m monitoring my sodium level. I just got diagnosed with cardiomyopathy, so I’m managing my own care. Then when that condition worsens to a point where the service providers, the doctor, is more involved, I need that help, and assistance evolves into that.

Maybe I wasn’t doing any of that. All of a sudden I had a sentinel event, and now I need to be involved in that and I need a service provider to step in and do it. There’s several different scenarios of how that plays out. But as we adopt more and more technology in the home, we monitor our home security. We know who when FedEx drops off the package. We have the Ring doorbell so we know when people are at the door. This monitoring your health and that evolution that adoption of technology getting out into our daily lives is growing.

What are the most valuable lessons you’ve learned from helping companies find a successful path?

There is so much opportunity in healthcare to make a positive impact, as a business, but also in making sure that a patient is taken care of correctly. Are they getting where or what they need on time? The information that they need? Then as a business, are you providing that service and is there value-add? The businesses that I’ve been involved with have been in the early development of the market, where people are trying to figure out what’s going on. 

I was involved with one of the original hospitalist programs. The hospitalist has a huge amount of value, but people didn’t understand what they did. We got involved in a high-risk member management in another company when people weren’t really sure how to start providing services and finding these people in the home. Then here the same thing with remote monitoring – we are starting to leverage technology and gain information that can make a huge impact on the delivery of care. There is so much opportunity in that.

From a business perspective, where do you focus and how you make that impact? The performance of a business will come along at that point. One thing that attracted me here is that coming through COVID, people were realizing we have this technology and we can leverage it. We can improve a grandmother’s or a young child’s life by knowing this information upfront and getting it to the right service provider.

The business will follow in doing that. People see that. They see the value of it. They see not only from an outcomes perspective, but also from a business perspective and the ability to do that. That’s what’s exciting. That’s what I personally like doing. I think that’s one way you give back.

HIStalk Interviews Bret Larsen, CEO, EVisit

Bret Larsen is co-founder and CEO of EVisit of Mesa, AZ.

Tell me about yourself and the company.

EVisit is the market-leading virtual care platform. We help the largest health systems in the country craft excellent consumer experiences for care delivery. I’ve been in telemedicine for the last decade, give or take. I started originally on the national provider network side with a company that was acquired by Teladoc. I saw an opportunity to help simplify healthcare delivery for local healthcare infrastructure.

Telehealth boomed not because consumers were demanding it, but because regulations and payment rules were adjusted to support virtual care as the only safe way to conduct encounters. To what degree do those temporary changes need to become permanent to keep telehealth as a mainstream service?

Telehealth needs to be an option in care delivery. Gartner estimates that telehealth utilization will normalize at about 30% over the next three to five years. As CEO of a virtual care platform company, I wanted to believe that the pandemic had accelerated and changed telemedicine and the utilization of telemedicine forever, but what I think it actually accelerated was the consumerization of care. It has caused local healthcare infrastructure, health systems, and hospitals to take a close look at their care delivery strategy and when and where to apply specific delivery mechanisms — whether it’s in-person, virtual visits, or asynchronous — to make sure that they are helping to support the delivery of the right outcomes.

Insurers are offering virtual-first health insurance, which should expose even more people to telehealth. Will those consumers remain in the telehealth fold?

We started the company to help local healthcare infrastructure maintain the relationships they have. Those virtual-first plan approaches can only work if they connect patients with local providers. A health plan or payer’s job is to manage and mitigate risk. I think that down the road, as we look back at the data, the outcomes diverged with the utilization of national provider networks, like call center-based national provider networks. They are working to do good. They are trying to change accessibility for the better.

But we will see a massive disconnect when you pull a patient out of the ecosystem and the PCMH that knows them best. Those will struggle to find efficacy, because when a patient needs specialty care, where does that patient get referred to? Does the provider on the other end of that virtual-first encounter have context of the market to know where to refer them to ensure the continuation of the right care for that patient?

How will the market shake out between companies like yours that sell the platform versus those companies that sell clinical services, which may augment but also compete with those offered by the local health system?

If you look at the strategic roadmap for these national provider networks – and don’t hear me saying “shame on them” – they are working to do what’s best for the end-user patient. But if you look at the strategy that they’re driving at, look at what they’re acquiring. They are acquiring specialty groups. When these large national provider networks showed up on the scene, there wasn’t a ton of concern from the health system side, because they were going after an ambulatory side of the business where we lose money anyway as a loss leader to feed our specialty groups. 

But the reality is that the acquisition strategies show that where they are headed long term is specialty groups. They are acquiring respiratory and chronic care groups, so they are moving into the specialty side. For health systems, that means that when a patient is in need of specialty care, and their first interaction is with one of these national provider networks, they will refer to their own specialists, not to the local group. Health system executives need to keep a close eye on this.

Health systems need to answer the question of, how do I craft an excellent consumer experience? Because that’s what they are competing with. The pandemic accelerated the transition, not necessarily the adoption, of telemedicine long term, because admins are still going to refer back to where they did from muscle memory. But rather it accelerated the consumerization of care. As consumers, many of us would never bring our business back to a service provider that didn’t show up on time to an appointment or was 45 minutes late. It’s really about, how do we craft excellent consumer experiences to serve the consumer, not the patient?

Some providers created ill will among their patients who felt abandoned during the pandemic, as offices were closed and calls weren’t returned. How much education or marketing do health systems need to provide to get consumers to value an ongoing relationship and to trust them to deliver it?

It’s a business strategy question. Where do your strengths lie? The strengths that I would expect health systems to have is in the care they deliver. There’s a lot of responsibility on the health system to educate the consumer and to help repair some of that disconnect. Having the right tools to accomplish that will make it easier. I would rather pull out my phone and order dinner from an app than call the restaurant and order it over the phone. Consumers want to be able to navigate to their own outcome.

I have allergies, so I could self-diagnose, but having the support of a provider to make sure that’s actually what’s going on and helping navigate efficiently to that reality and the corresponding care that I might need — if it isn’t allergies and is a sinus infection, a cold or the flu – that’s important. It can go a long way for health systems to help to start to find the right technologies to help consumers navigate to the most appropriate point of care for the issues they are experiencing and the value that comes with the downstream impact of that when they need more hands-on care.

From the food delivery analogy, we don’t yet know if telehealth shifts demand from in-person care or creates new demand. How will telehealth volume impact the availability of providers?

I saw a stat recently that for every hour a provider spends in delivering care, they spend as much as two hours charting care. That’s staggering. If you look at the top 10 compensated roles in commerce, in industry, those top 10 are all physicians. The number 11 is CEO. In a health system setting, it makes more financial sense for the CEO of the health system to be charting care than it does for the providers who are delivering it.

At EVisit, we are big believers that the best interface for a provider is no interface at all. The tools need to come around the provider to help support the delivery of that. The provider’s willingness to adopt that technology will be directly correlated to how easy that technology makes their job.

I hesitate to say this because I’m not looking to be confrontational, but the only reason that electronic health records have a business today is because the people who buy it don’t have to use it. If they did, they wouldn’t buy it, because it’s not easy to use. It is solving a super complex problem. There’s a bunch of various issues that it needs to address. But it’s not built for users.

If I were on the strategic side of a health system executive team, it would be about choosing and crafting the tools that are around a provider to help them more efficiently deliver care in a remote setting versus forcing them into a two-way video visit where it requires seven more people than it would need to, hundreds more clicks, and three or four more interfaces that makes care delivery more complicated. The way health systems should be thinking about it, especially from the provider adoption side, is how do you make it as simple for the care deliverer as possible?

Unless the business model is different, providers still need to document for billing and legal purposes, recording the same information that is required for an in-person visit. How can virtual visits reduce that documentation burden?

My point in bringing that up isn’t the fact that they will have to document less, it’s that technology can make it more efficient. We are working on using natural language processing for auto-charting. The microphone that is listening to a provider can differentiate between what the provider is saying and what the patient is saying, pull out the relevant information around self-diagnosis and the provider diagnosis, and pull together a fairly accurate depiction of what’s happened in that visit, how it should be coded, and where it should be submitted. All with cursory review by the provider, not with the provider having to sit down, or use a scribe to sit down, and run through that interaction and spend the two-to-one ratio of time against it.

How many early adopters of offering video visits are revisiting their technology choices and what are they looking for?

The vast majority of them are looking. The sound bite that we consistently hear from CIOs of large health systems is, we recognize that two-way video is not virtual care. It’s not the same thing. Video visits are not the same as virtual care. We have some great data around the margin impact of using a two-way video solution like a Skype, FaceTime or Zoom versus using an all-in-one comprehensive virtual care solution like EVisit. The margin impact is almost triple on the gross margin side, because patients are able to self-serve through much of the experience.

Early video visits involved just the two-way video conversation. Will we see them evolve to look more like in-person visits, with waiting rooms where information is collected upfront and satisfaction surveys and patient education afterward?

Two-way video is a commodity. You can go to a number of places and find great solutions. It’s the workflows and the efficiencies that can be gained around that. The advancement of that is moving outside of just a single interaction of, I have a sinus infection, I need a Z-Pak, so let me go through this workflow to get it. How does it fit into the care delivery strategy that you’re crafting? What does it look like? When should a patient present to a synchronous video visit versus an asynchronous chat visit versus in person?

There’s an outcomes question there. There’s a financial implication question there. It’s important to answer that question appropriately, bring the right tools and the right integrations with the core electronic health record to make sure that the data is all sitting in one place and that there’s a comprehensive view of who the patient is and what they’ve experienced, and determine how that informs care going forward. The ecosystem grows by moving ahead.

Other forms of virtual visits got lost in the excitement over virtual visits. Doctors might provide expertise via email messages, telephone conversations, or asynchronous messaging that is appropriate given the patient’s need and preference, with the only difference in outcomes versus a virtual visit is that they might not bill for their time or get paid for it. To what degree will the choice of communications options be driven purely by payment?

It’s absolutely an important mechanism to consider. At the end of the day, we need to make sure that as an industry that we can support the services being delivered financially. I think what you’ll find is that many patients would opt to pay out of pocket in certain scenarios where convenience or accessibility comes into question. If an asynchronous visit isn’t reimbursed, I still would be willing to pay a fee for service.

Our data shows that one provider can handle up to 200 interactions in a shift asynchronously for minor things like sinus infections, UTIs, colds, and flu. But the efficiency gained there, if you look at the productivity of that provider and a nominal out-of-pocket fee in that scenario, is interesting. It’s also interesting from a patient retention perspective. As a business, I would rather provide a service that ensures my customers continue to come back to me. I may eat the cost on that rather than have them go elsewhere and potentially lose the opportunity to bring them back to my services when the time comes again.

We’ve seen a lot of investment, separately, in telehealth and remote patient monitoring. Do you see the services or the business of those two entities converging?

Yes, yes. In a lot of the RFPs that we’re seeing, remote patient monitoring is a key question. 

One of the key trends, and this existed before the pandemic, is that health systems and hospitals are trying to figure out how to transition care to home and the RPM ecosystem. How that plays into it is going to be a very important component of that. That transition’s happening, not because of the pandemic, but  because you can deliver care more profitably when the patient can be out of the physical setting and can be monitored and that feedback can be quick. When and where the patient needs physical attention, that can happen where appropriate. It absolutely will continue to converge. The market and the landscape are in early days in how that’s being addressed, but it is on every health system’s five-year strategic roadmap.

How do you see the company and the industry moving along in those areas that you monitor?

The key question that all healthcare IT companies need to answer is the consumer question. How do you craft an excellent consumer experience? The pandemic forced us as patients to become consumers. It helped us recognize we have choice. To your point, there were certain avenues that were closed to us and we had to find other ways to receive care that we needed. As you look at the various players in the market, what that turns into, and how it is shaped, the key question is, how do we create excellent consumer experiences that support the right outcomes? That is the question that we’re hearing most health systems ask themselves, either explicitly to the market or via the RFP questions that end up coming together. That entire ecosystem of how a solution handles acute ambulatory and RPM. Health systems want to deal with one vendor that can address a lot of the value chain versus cobbling together nine or 10 different point solutions that drive a semblance of that same outcome.

HIStalk Interviews Tom Cox, President, Experian Health

Tom Cox, MBA is president of Experian Health of Franklin, TN.

Tell me about yourself and the company.

The mission of Experian Health is to simplify administrative processes and improve operational efficiencies so that we can improve the healthcare journey. We primarily do that through patient access, revenue cycle management, and identity services. I’ve been with the company for two years, having joined through the acquisition of MyHealthDirect.

We’ve heard for years that collection of patient financial responsibility would become significant, and not only has that finally happened, investors are rewarding companies whose technologies and services support that collection. What trends do you see?

You will continue to see an acceleration of the digitization of healthcare. Certainly we’ve seen that through the pandemic, as folks were operating in a more remote environment. We saw the digitization of registration scheduling and even telehealth become more important. That trend was absolutely accelerated by COVID and I think you will see that trend continue in the future.

That dynamic of consumers paying a higher portion of their healthcare will drive a number of facts. First, it will require the whole healthcare system to operate much more like the rest of the economy. That is, to provide a better consumer patient experience from the beginning of the process through payments and collections on the back end. That will continue to accelerate.

From the provider’s perspective, the patient is paying a bigger portion, and what the patient pays is the hardest part to collect. Getting the right data upfront and collecting as much of the cost upfront will also be important for all providers and health systems.

How will healthcare use technology more other industries that use technology instead of handing their customer a clipboard and photocopying their documents?

You touched on a number of them. You will see scheduling, registration, and payments being digitized. You will also see healthcare start to use more data about consumers to improve the process of reviewing social determinants of health, understanding what challenges people might have in accessing the healthcare system, to make it easier for them to access the healthcare system and to improve their healthcare results. We know a lot about individuals that we’re not taking advantage of today to improve the healthcare system. You’ll see that change over time.

How do you see providers using consumer data insights, rather than just their own EHR data, to engage with their patients differently before, during, and after a visit?

That is still pretty nascent in healthcare. That provides a big opportunity for a company like Experian, which has a lot of consumer insights. The retail environment reaches out to individuals based on their desires and their wishes, engaging them in the process and then all the way through the process. That should happen similarly in healthcare. We know when patients need to engage in the healthcare system, so we should reach out to them proactively and get them engaged in the healthcare system so that they get the care that they need in a timely manner and improve their overall health. That’s what I think you’ll start to see changing going forward, but it’s still pretty early.

What technologies does Experian offer that would help providers treat their patients more like members?

We have a number of those tools to help the patient feel more like they are a valued patient, which is maybe is a better way to say it instead of as a member. I always worry about member because that tends to get associated with a health plan. From the consumer insights on the front end to anticipate the needs of an individual patient using our data and insights on consumers, to using our tools, to engage staff members through outreach, and to patient communications. Then facilitating the entire process, making that process easy for the patient along the entire journey through digital scheduling, digital registration, and online payments as a seamless, touchless process.

How do you see propensity-to-pay being used in a consumer-friendly way?

Having a propensity to pay will have help patients make more informed decisions. One of the challenges with healthcare, historically, has been that you make a very large purchase decision without any knowledge up front. Many times you only find out about that purchase decision on the back end. We are doing  couple of things to help that process. We provide estimates to patients so that they can make make an informed decision. Then, based on your ability to pay for that, you can then arrange different ways to pay for those services. Most healthcare systems are flexible in their payment terms because they know the patients need the care. They want to make that process as easy for them to get the care as possible.

Some diagnostic radiology practices offer patients a big discount if they pay cash upfront instead of using insurance or being billed. Will we see more of that?

I absolutely think that providers will continue to do all that they can to get the payment upfront. Providing that estimate is the best way to collect that upfront.

I recently experienced that myself with a procedure. I was offered a discount to pay in advance and certainly wanted to take advantage of that. The key to that process, though, is ensuring that the estimate is accurate so that there is no surprise on the back end. You are creating an expectation with the patient or with the consumer that your estimate is correct. When you make that advanced payment, you are not expecting to get another request on the back end. An accurate estimate is critical.

A significant part of patient satisfaction comes from the front end, such as ease of getting an appointment, to the back end, in getting a timely, accurate, and understandable bill. How are providers using those practices for competitive advantage?

In the US, the healthcare that individuals receive is always of really high quality, so you don’t get many complaints about care. The complaints come from the administrative processes, both on the front end of the process — scheduling, registration, asking for the same information repeatedly — and then on the back end, the lack of understanding of the billing, the explanation of benefits, and the statements. Providers are definitely realizing that improving those front-end and back-end administrative processes is a way to differentiate themselves in the market. Convenience and simplicity are the easiest outcomes to measure in healthcare and they drive how how many healthcare consumers make their decisions.

How important is it that providers react to negative patient feedback as part of their marketing efforts?

It’s important for the healthcare systems to engage with those patients who didn’t have a positive experience so they can learn and improve their processes going forward. Again, it’s most likely not related to the care that they received. It’s going to be most likely related to something on the front end or the back end of the administrative process.

What are the benefits of identity management beyond the obvious ones of efficiency, fraud prevention, and patient safety?

A number of benefits come from our identity solution. The first is eliminating any duplicate records that might be created when you’re going through the registration process or the intake process. Understanding that an individual may have moved or changed their names and making sure that you’re not creating a duplicate record. That has downstream effects of making sure that you have a complete view of that individual when you’re providing care, so that you don’t have a fragmented health record and information showing up in two different places.

A key element that we are seeing with identity getting access to digital tools. With COVID vaccinations, most health systems drove patients to their portals to register and then schedule the vaccines. Ensuring that the right identities and the right patients were getting the right vaccinations and attached to the right records was a key component that drove a lot of our growth for identity through the pandemic.

Would having a national patient identifier provide the benefits that people expect?

Having a unique identifier would certainly simplify things in healthcare. We have 328 million unique individuals that are represented through our universal identity manager tool. Using a tool like that, having a universal identity would make it easier to link your records from disparate systems to provide a holistic view of medical information.

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

We are excited about the future and feel like the company is well positioned for growth. We think that many of the trends that were accelerated by COVID, like the digitization of healthcare, will continue. We think we are well positioned for that trend and are excited about our opportunity to deliver on our mission of simplifying the healthcare journey for all.

HIStalk Interviews Stephan Landsman, JD, Emeritus Professor of Law, DePaul University College of Law

Stephan Landsman, JD is emeritus professor of law and organizer and director of the Clifford Symposium on Tort Law and Social Policy at the DePaul University College of Law in Chicago, IL. He co-authored “Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm” this year.

What malpractice risk is involved when clinicians conduct virtual visits?

One of the things that is most concerning is the need for continuity and follow-up. If you are going to conduct medical care by telephonic means, you need to have a reliable system that will keep track of what you’ve advised, what you’ve observed, what tests you need, what the results of those tests are, what follow-up is necessary, what medications ought to be prescribed, and so forth.

Care is not a one-shot deal. It’s not a one phone call kind of thing. It’s a heck of a lot easier to keep track of folks if they show up in your office. It’s more challenging when they don’t. 

The same is obviously true with respect to the kinds of data entries that you make as well. Medical records are incredibly important. Tracking care, tracking information, building up the profile of what the patient’s issues may be, or how they develop or what the reaction to medications is. All of that stuff needs to be entered, needs to be available, and needs to pass before the eyes of the person who was given advice.

By analogy, the hardest time in hospital treatment is the time when one doctor passes the care of a patient off to another. In that situation, you have to have effective communication. You have to have a kind of underscoring of what’s valuable. The same thing is going to be true if the tele-treating physician is not practicing alone, but rather is in a large group, which is usually going to be the case. You need good systems, good data management that’s will get everything of relevance to each of the physicians each of the times that contact, care, or assistance is being done.

Is it sustainable in a litigious environment that telehealth doctors who don’t work for health systems often don’t have access to the patient’s medical records?

There are a couple of kinds of considerations that we ought to think about. The first one that comes to my mind is helping the patient understand that this is real medical care — it’s not a one-shot deal. It may require follow-up, and if follow-up is what we’re thinking about, is there a local physician? Is there an appropriate testing facility? Is there appropriate laboratory? All of that stuff needs to be worked out between the patient and the doctor so there is no perception that you have a one-shot deal. Even if the patient thinks that, the doctor and the treating organization have got to work on the assumption that it isn’t so. That it’s not simply a sore throat and an appropriate prescription that is going to kill a bug, if it’s that kind of thing.

This seems to me to be a very important cultural change to make, both patients and for medical organizations, that when there isn’t an understanding that medical care and medical examination is an ongoing process, then you get particular problems that can lead to legal claims to malpractice and a big mess.

What risks would you warn physicians about as they consider doing virtual visits for a for-profit company as a contractor rather than an employee?

That creates the possibility that there won’t be follow-up. That there won’t be that connection and commitment to patient care that I think is important. That model is one that needs to have some pretty clear ground rules, and some of those have got to come from the physician providing care. He or she has to understand that it’s not ever going to be a one-shot deal.

Lawyers at our school, or at least when I do it, are taught that you can’t give advice without being ready to follow up on that advice and without being committed to the relationship. That first conversation is only the beginning of a relationship. You have to understand this set of situations, patients and doctor, as presenting very similar sorts of demands.

We’re in the midst of culture of change here, and it ought to be emphasized that the treatment via contacting a doctor on the telephone is a very valuable plus to extending care, especially into parts of the population that for financial reasons, psychological reasons, or whatever are very resistant to real face-to-face medical care. But it’s got to be thought of as a relationship. These are not one-shot deals. That’s when you get in trouble, when you think that they’re one shot and don’t have follow-up and don’t have understanding. That tends to be the place where we are likely to see the greatest trauma.

The pandemic led to a relaxation of regulations involving state licensure and requiring initial visits to be conducted in person. Will this loosening of requirements, whether temporary or permanent, raise new legal concerns?

I think it will, yes. We’re feeling our way here. We’re moving in new directions, and the professional responsibilities that will arise out of those new sorts of relationships are ones that we haven’t fully and completely defined. The requirement of face-to-face first has generally not done well in court and has been viewed as a restrictive protection of in-state doctors.

We need to extend the umbrella of care, but having said, that it’s not one phone call. One phone call does not address chronic conditions like diabetes. One phone call does not address progressive heart failure. It’s got to be understood that there’s more going on here. That is part of the change in the universe.

Medical malpractice has often been a signaling device by which medical profession is informed of things that are just not good enough. I’ve done that with things like informed consent, and with a variety of kinds of decision-making between patient and doctor. You’re going to see some of the same kind of considerations being hashed out in future litigation. I certainly would advise to have good insurance coverage in providing this kind of care for any organization that wants to do it, and at the same time, a very careful kind of assessment of what good medical practice requires.

Some investor-funded companies sell prescription products such as unproven COVID-19 treatments and vanity drugs online and use telehealth providers to prescribe them. Does the pressure to issue the prescription increase clinician exposure to risk?

I think that it does. It’s hard to say because it really depends a lot on what’s said, what’s required by the people who are paying the rent, and all that kind of thing. My mind immediately jumped to the time in the United States when online or similar sorts of pharmacies were providing opioid prescriptions through call-in or online mechanisms. Eventually the Congress said, we can’t live with that. That really is in essence of way of fueling what we now believe is the opioid epidemic. Now if you think about that as a model where the danger is fairly substantial, you can say, we are again as a society going to see those kinds of problems and we’re going to react to them.

In the interim, it’s going to be a fairly unpredictable situation. I would not think that it is wise to offer what is in essence medical advice and treatment in situations where your hands are tied about what reactions you can provide and what products you have to present or sell or whatever.

What due diligence and malpractice insurance review should a physician consider when considering doing contract virtual visits for a telehealth company?

You would really want to ask all of those sorts of questions. This is going to sound excessive, but you probably want expert legal advice. We are in a changing field. I would not want to be committed to providing care that was limited in ways that I knew or should have known were handicapped to the patient’s detriment. Part of that is medical due diligence and part of that is legal inquiry. Each of the states is different with respect to these matters. It seems to me that you want to be pretty darned careful about this kind of thing.

I think physicians are pretty concerned about exposure to med mal when they sit down with patients. They should bring that concern to the situation where they’re providing medical advice over the telephone. Part of that is medical scrutiny. Is it good enough? Does it meet the standards? That’s really a question about the profession in the particular state. But part of it is also, where are the courts? Where’s the legislation? What’s been happening?  You need some legal advice. I’d be careful about this kind of thing. 

It’s a great area. It’s a changing area. You miss something if you don’t see the positives here, because I think there really are substantial positives, but  you know we are talking about people’s lives and people’s health and their safety. When that’s going to be jeopardized, you’re going to see a social reaction and there interested parties who are going to push that. Medical societies are not particularly happy with this stuff, they’re going to push, and they have some clout.

HIStalk Interviews Mike Linnert, CEO, Actium Health

Mike Linnert, MBA is founder and CEO of Actium Health (formerly known as SymphonyRM) of Palo Alto, CA.

Tell me about yourself and the company.

Actium Health helps health systems and payers with CRM intelligence. We take all the data they have about their members and identify “next best actions” to drive lifetime value for the members. Before founding Actium Health, I grew up doing similar things for companies in the wireless and financial services industries, and before that, I was investing in consumer internet companies.

What could “next best action” look like for me as an individual consumer, both inside and outside healthcare?

Starting outside healthcare, the goal is to drive lifetime value for a customer relationship. Some “next best actions” don’t have revenue or profit associated with them in the near term, but their investment is in the long-term relationship.

I’ll give you some of the simplest ones I started with. When I was in the wireless industry way back in the early 2000s, you might have called the call center with a question about your bill. While we had you, we might have observed that last month you could have saved $3 had you been on the 100-messages plan instead of the 50-messages plan. You as a consumer would think, “Great! That’s great,” and we as the wireless provider would feel like, “We helped you save some money, but also we probably encouraged you to do more texting, which is something that we wanted you to do anyway because it attaches you to your device more.” Things that you liked about our service, and in the long run, we probably decreased your propensity to churn. And if we increased your usage of text messaging, we hopefully increased the value that you saw from us.

As you get more complex, you can think about perhaps your wealth advisor at your bank. At any given time, your wealth advisor might know that you forgot to make your 529 education contribution for one of your kids, you didn’t make an IRA contribution this year, you haven’t rebalanced your portfolio, or mortgage rates have gone down and you could potentially refinance your mortgage and save some money. The ”next best action” involves which of those things is most valuable to you. I’m a wealth advisor, so my job is to stand by you, not to stand by the products and broadcast out to you, “Hey, this product fits you.” I stand by you, you tell me about your needs, and then I say, “Here’s the most important thing. I know your kids are important to you. If we only have five minutes to talk today, let me focus on the 529 plan.” But to do that, I have to come up with what the most valuable thing is for you. We bring AI to do that on behalf of the wealth advisor or the health advisors here in healthcare.

Is it uncomfortable for providers to think of the lifetime value of a given patient and to reach out to them to offer more services, either to bring in more revenue, to benefit the patient, or both?

It shouldn’t be. The goal is to drive the lifetime value of the relationship. If I ever slammed you products you don’t need, I should assume that you’re going to turn and go somewhere else. Maybe there’s some near-term profit, but over the long run, you’re not going to be with me any more. You’re going to find somebody who takes care of your needs better.

In the financial services example I gave, the goal was to say, “What is most valuable to you and to our relationship?” In healthcare, let’s assume that I’m on a value-based care model with my local health system. The health system knows that I’m past due for a colonoscopy, and maybe they know that I haven’t seen a primary care doc in the last three years. Maybe from looking at their data, they suspect I’m high probability for having kidney disease and don’t know it.

At least for me as a patient, I would love it if the health system didn’t worry about whether they were violating the revenue goal, or violating something about our relationship, and instead felt a moral imperative to reach out and tell me, “Hey Mike, based on the data we have, we think it’s worth you taking this health risk assessment for kidney disease” or “here are the top three reasons that you should come in and see your primary care doc.” I would like them to be reaching out.

Certainly what I don’t want, and what would be violation of HIPAA marketing, is for them to be hawking drugs that may or may not fit me, or to let me know that they have a new partnership with a local imaging center and I should consider going there. Those aren’t the things I want. But I do want things that help drive health for me and my family.

Some patients, especially younger ones, don’t necessarily see the value of ongoing engagement with a health system or primary care physician. How do providers convince them of the value of that engagement or use “next best actions” to address their needs?

You have to step back and, again, talk about what drives lifetime value. Your point is exactly right. What drives lifetime value for my dad in the health system is very different from what drives lifetime value for my son in the health system. My dad wants to know that the health system is proactively thinking about him, looking at the data they have about him, and proactively reaching out to engage him. My son wants to know that they are there if he needs them, so maybe they let them know that he can schedule through text messages or which simple conditions could be managed at urgent care at a lower cost and shorter wait time than the ER.

You have to think about what these things are for each cohort. That is the whole point of the “next best actions” approach. We are developing one-to-one dialogues that for each customer, think uniquely about the things that we have that can create value. I’m not trying to upsell and cross-sell so much as I’m trying to up-serve and cross-serve. If I serve you better, that will drive the loyalty.

I’ll give you a stat so you have a sense of why I think this is important. If I look at Verizon and AT&T, I might say it’s customer churn. I haven’t looked in a while, but last time I looked, it was around two to three percent. Two to three percent of their customers leave them each year. Health system churn, from our back of the envelope math, is between 20 and 30%. It is 10X. What we think we provide is a highly personalized, highly customized solution. You have to ask ourselves why that’s happening.

Healthcare switching costs might be lower than for changing cell providers, and some degree of unavoidable churn occurs because people change employers or their insurance changes. Some people also don’t need or have any provider interaction in a given year. Is healthcare different where they might come back to a provider when they need them or decide that someone else might address their problem more readily?

The difference between total churn and addressable churn is absolutely important. Someone may have moved away someone or switch to plans your physicians aren’t in. But that doesn’t put a big enough dent in the 10X difference that you would say, “This isn’t important to me.” For a lot of health systems, if you haven’t been in to see your primary care or other doctor in two to three years, they make you re-onboard. You have to go see a nurse again before you can see the doctor. We don’t want to do that.

We especially don’t want to do that for the younger generation you mentioned. We’re just helping them. They may not want to see a doctor for one to two years. But during those years, those patients have been thinking about their health. I saw a study that said that the average American spends 11 to 12 hours a month online reading about health information.During that time, I promise you that the people online who are giving them that health information —  it could be Google, it could be other health websites — they want those members, patients, or customers as customers of theirs, too. People realized that the lifetime value of having a customer relationship centered on healthcare is very high.

The other big trend that’s happening right now is value-based care coming on scene. Value-based care is enabling a lot of competitors to build lucrative businesses around having deep customer relationships. In the old model of healthcare, to make a lot of money, you had to have a lot of specialists, because that’s where the money was. In value-based care, you can make a lot of money by keeping people healthy and having good, loyal relationships. You see people like One Medical, VillageMD, Walmart and CVS getting in and saying, “If there’s a new way to have consumer service-based relationships with patients and healthcare, that’s an opportunity.”

How does a health system run “next best action” programs for both their population health and marketing programs without confusing the consumer and making sure that each campaign’s messages are appropriate?

This is where you have the two-canoe problem, with fee-for-service and value-based care competing. But if you scratch a little deeper and look at individual contracts and different incentives, you probably have closer to a 200-canoe problem, with different people and different incentives. But that’s the whole point of the “next best action,” one-to-one dialogue approach. We want to figure out for everybody, what is the most valuable thing we can say to you based on what we know about you?

Let me give you an example of what the differences could look like. I’m going to give you some directional numbers that aren’t exactly correct. If I was a health system, I might ask, what is the value to me as the health system of bringing someone in for a breast cancer screening? Of course there’s value in that I am supporting my patients, but if I look at it on a dollar basis, I would say for every 100 screens I do, I’m going to do about 10 diagnostic follow-ups. I’m probably going to discover one case of cancer, and about half of those I’ll end up treating. Just ballpark numbers there.

For most health systems, if you did the expected value of the margin at each level there and multiplied them up, you’d get about $250. And if I get really good at predicting that women in this cohort are six times more likely than average, reaching out to those women and getting them in is potentially worth $1,500 to me, six times more than average. If I flip it around and ask the community, “What’s it worth if I reach out to you, invite you to come in, and we find that you have cancer and you weren’t otherwise going to come in?” it’s a lot. Because if you didn’t come in, that cancer was going to be much worse by the time we found it.

In a value-based care world, where I make money is by not finding cancer, or finding it so early so I stave off the later costs. That’s worth $250 for an average fee-for-service, but double that on a value-based care contract, closer to $500, to be doing those screenings to avoid the cost of finding later-stage cancer. That’s in addition to bonuses that I unlock or business value I unlock because I hit five stars on my screening, or because I met some threshold in a contract, and I’m able to market my Medicare Advantage plan differently. If you start to take all those into account, you start to realize that for health systems that are truly in value-based care models, there’s enormous value to proactively reach into the community and find people who have cancer and don’t know it. Or reaching into underserved communities and pulling people in that need care from us.

A survey written up on your website found that consumers perceive that their doctors and hospitals ignored them during the pandemic by not answering their phones or reaching out. What is the opportunity for health systems to move ahead from that?

I’m going to give you three quick examples. From January 2020 until now, our customers have increased proactive digital outreach by 10X, and I think there’s still another 10X to go. I think my health system should be reaching out to me at least once a month proactively with, “Here’s your family health income statement and balance sheet” or “Here are new services we have” or “Here are things you should know about what’s going on in the community.”

Second, I move around between health systems. Kaiser is not a customer of ours, but I’m going to mention something they did. During COVID at the peak, Kaiser was sending me three emails a month or even per week on some occasions. Three emails a week. And they were valuable, meaty emails. I liked reading them. They were telling me about positivity rates in my community. Stuff that I was really curious about and stuff that, had they not said it, I would have gone on Google. Kaiser was providing me a service.

The third thing is that last year, cancer diagnosis in the US was down by about half. We didn’t cure cancer last year. What did happen is that half of all the cancers that we probably would normally have discovered got worse. They went untreated, they went undiscovered. Health systems, to my way of thinking, have almost a moral imperative to be reaching out to people, to be looking through the data and saying, “Where are the communities that are most underserved? Who are the people that we think are at higher risk of breast cancer? How do we reach out to them and get them in for screening?” Most of those screenings are free. We have a free service that helps you discover and stave off cancer. That’s not to say anything about kidney disease and all the other diseases that went unaddressed faster that we need to get back to.

Where do you see the industry and the company in the next 3-4 years?

We’ve been talking for a long time that healthcare is a consumer service. If we are a consumer service, then there are some things that are fundamentally true, and you can look around at other consumer service industries. Most importantly, we need to stop thinking about patients as customers. We need to start thinking about people as members. Members have a recurring relationship with you. It’s enduring, it needs to be taken care of, and if you don’t, other people are going to come take your members. And if we have members, then we need to be thinking about how to drive value, delight, and loyalty among our members. Value means value they get from us, delight how happy they are, and loyalty our ability to influence behavior. We do that with “next best actions.”

Value-based care is the sport of the future. It may take a while, but it is the sport of the future. That pay-vider model is coming fast. New competitors are coming in to take advantage of that if our current health systems don’t. Our job is to work with today’s health systems and payers to say, this what’s coming. We can help you bridge the gap to this membership model. To this proactive engagement, where you drive value, delight, and loyalty. We have the portfolio of “next best actions” to do it. At least as I know it today, we are the only company that is working with healthcare providers that hang expected values on “next best actions,” and that is critical to investing and making them happen.

HIStalk Interviews Shawn DeWane, CEO, TransformativeMed

Shawn DeWane is CEO of TransformativeMed of Seattle, WA.

Tell me about yourself and the company.

TransformativeMed focuses on the clinical workflows of physicians and nurses. Healthcare is a team sport and COVID-19 has made this a focal point. We are looking to bring a revolution to healthcare IT by delivering smart technology, smart algorithms, and the organization of clinical information in an intuitive manner so that clinicians can effectively and efficiently impact patient lives with a strong patient safety aspect.

We got our start in rounding and handoffs, then moved into other smart care capabilities, such as diabetes. The focus of our company has always been around research and development, done in partnership with our customers. Some of those customers are among the most prestigious in the country, so we have some great thought leadership as a result. Clinician satisfaction is high, in the 95th percentile range. Our implementation experience is exceptional. The product is sticky and clinicians love it. We are in 26 health systems around the country and we have one overseas. We have over 170 hospitals that use the products. There are a lot of hospitals that we are not in and a lot of beds that we’re not servicing at the moment, so we have a lot of opportunity, a lot of green space in front of us.

I grew up in rural Northern Illinois in a Midwest farmland culture that emphasizes hard work and fair dealings. I’ve hade a successful career in healthcare IT and technology and have developed a system of sorts that I can assess, grow, and scale businesses with great talent. My focus has always been around relationships and a fundamental commitment to delivering success to customers and my teams. Some of the key bodies of work that are most significant for me in the past are a 13-year run with IDX, then McKesson, and most recently with Hayes. My wife of 37 years and I live in the Chicagoland area. We have three great kids, all adults and on their own.

How would you describe the relationship between Cerner and Epic and companies that develop embedded or connected apps that extend the capabilities of their core EHR products?

I’ve had a great deal of experience with large enterprise EMR production systems through McKesson and IDX. They typically can’t handle the level of precision a clinician needs for problem-based care. With the changing landscape that COVID brings to the table, it makes it even harder for an EMR system to be both nimble and effective in addressing patient care. Problem-based care and the precision of what the clinician needs is at the heart of why a company like TransformativeMed exists. Recently a CMIO of one of our customers, a large health system, told us that we come in with the eyes of a clinician and know exactly what they need. That’s really what it boils down to.

User testimonials on your website talk about how your product improves clunky EHRs, provides financial benefit, and increases clinician satisfaction. Do those comments get back to the EHR vendors in highlighting seeming shortcomings in their products?

Some of that probably does happen. My experience with large enterprise production systems do just that. It’s hard for them to be nimble and focused on the moment and the issue when you’re standing over a patient, whether you’re a nurse or a physician. The ability of a system to be able to gather information, suggest a treatment of care, and then document that back into the EMR — that level of efficiency in a fluid situation is difficult for a large production system to handle. At some point it is what it is, but we make the EMR what the user thought they should have gotten.

How much of clinician EHR dissatisfaction and burnout is caused by plain-vanilla implementations that avoid personalization for individuals and clinical specialties?

Each specialty has its own angle that they’re coming at in terms of the problem that the patient presents. You have to have smart care algorithms to address the unique needs of the specialty and by type. Not just the needs of the physician, but of the nurse as well. The cumulative nature of what happened, what is presented in the moment, what to do, and then the further documentation along the lines of that specialty is what TransformativeMed does, which is what users like the most.

Some issues are time-based, where I get 15 minutes extra a day or 30 minutes extra a day or two hours extra a day back into my life so I can see more patients. Bed capacity management, especially these days, is chronic. How do I treat the patient as effectively as possible and move them into a discharge status so I can make that bed available to another patient? All of that is expedited and made more efficient when you have specialty-based algorithms to provide them the information they need.

Does the underlying architecture of EHRs support real-time capabilities and user personalization?

EMR systems are sound technology to store batches of information like lab data, nurse documentation, or physician documentation, but it’s gathering up that into an efficient way to present those findings to the provider at the time of care for the patient. That efficiency of gathering that and presenting an algorithm for care is where TransformativeMed fits in. The ability to gather effectively, present it in a smart manner, and then — and this is the main thing — to be able to document back to the EMR while in the event, the moment with the patient. That’s the part that creates the efficiencies.

How much of the company’s efforts will be driven by which EHRs you work with and how you work with them?

We are embedded at the EMR level through FHIR API kind of technology. It’s important to get that connection and linkage done correctly. It’s also important to make sure that all of the rich features and functions that the clinicians need are intact. We have some partnerships with clients to make sure that from a qualitative point of view, everything works the way it should. We have some other partners lined up to make sure that that happens.

Whether it’s Epic or Allscripts, the quality of the connection and delivery of the function for efficient problem-based care delivery are the focus. We are on that journey, it’s moving along pretty well, and we’re going to continue that journey. We are going to take a more qualitative approach and make sure that it’s done right.

Is it difficult to create or maintain a brand identity when clinicians may not be able to tell which parts of the system were provided by the EHR vendor and which parts came from TransformativeMed?

Because the embedded nature of the solution, the clinician really doesn’t know that they are in TransformativeMed, because it is just brought in from the Cerner screen or the Epic screen. There’s a seamless nature to it that is very attractive to clinicians.They don’t have to toggle in and out of one system to another.

From a branding point of view, CORES is the brand title. Physicians who have used CORES want to use it again. If physicians are thinking about getting a solution that CORES addresses, the referrals are made. We get inbound interest from clinicians who want CORES because their colleague used it at a different health system. There’s a seamless usage of that through the UI, but the CORES brand is very strong out there.

Has their been interest in making the company part of a vendor or consulting organization?

Valuation and general value are dependent on the revenue you have coming in, your customer satisfaction, and the breadth and depth of products that you have. Right now our focus is to grow the company in a sustainable manner. If our customers are happy, they will stay with us and our revenue will continue to grow. We will have to see from there.

Where do you see the company’s recent work with the VA in Puget Sound leading?

We are super excited and honored. I’m very excited to be able to have an impact on the care of veterans. It’s a nice mission for our company. We have a great culture, but it’s a special honor to be able to do this.

This initial site will go fairly rapidly. We should have some pretty good results in the next two or three months. With that said, as we make progress through the rest of the VA, we will have some great use cases as a result. We are looking for other avenues with the government as well. It’s going great so far and we expect great results and are looking forward to further use of the product throughout the VA.

How will the VA and your other customers determine the impact of implementing your product?

We always do a compare and contrast of the situation before we were installed and afterwards as a use case. We document what the problem was, what we did, and what the results were. We will be doing the same thing with the VA.

The specific aspects that we will look to impact here will be around rounding and handoffs, and also with diabetes care and management for both the physicians and the nurses. They will be permeated throughout the VA. We expect to chart and document those results. 

In the short term, we will be able to coordinate care better. As I mentioned before, healthcare is a team sport. Statistically, you’ll see in a typical episode that maybe 50 clinicians of one sort or another are involved in a patient’s care. We’ll be able to coordinate that better. We’ll be able to hand off that information better and they will use their time more efficiently.

On the diabetes side, diabetes care is fluid and it’s conditional depending on a number of factors. We will be able to coordinate that better, especially with the CMS regulations that are coming out around performance and generally regulating diabetic care. We will be positioned to affect the diabetic care of the veterans that we’ll be serving.

Where do you see the company’s future over the next three or four years?

We are focused on adding new customers, keeping our customers happy as they typically are while expanding the footprint in our customer base. We are going to look to a lot of revenue growth, a lot of expansion into both the government and international markets. We will invest in additional product development, research and development for new modules to help support our customers. We are looking at not just solutions for residents, hospitalists, or endocrinologists, but a number of other areas to continue to expand our footprint.

HIStalk Interviews Bob Bailey, Founder, Healthcare IT Leaders

Bob Bailey is principal and founder of Healthcare IT Leaders of Alpharetta, GA.

Tell me about yourself and the company.

I’ve worked for 25 years in enterprise IT professional services firms that I have owned and operated. Our company is focused on enterprise applications, deployments, clinical information systems, business information systems, and a practice we’ve launched for COVID called Healthy Returns.

How has your business changed during the pandemic?

Our business changed dramatically as work-from-home became a strategy that we all had to get our arms around. Specific to our industry, a lot of our projects went offline by definition. We had to rethink who we are and what we do. Healthy Returns was a nice practice that we were able to establish in finding a way to be helpful to the communities we’ve served for the past 10 years. That has been a lot of fun and it has become a great success, so we are happy with that.

But it was clearly a time where we all had to sit back, reflect, and think about the business we have today and what might it look like tomorrow, then pivot in a number of directions to get it back on track. As the revenue came offline in the systems, a lot of these projects just started to disappear. It was a challenging time.

What changes are you seeing in the kinds of people who want to do consulting work?

I would say that we’re a work-from-home winner, our industry being professional services and software support. It has opened up wonderful opportunities for consultants, by and large, because they have so much more flexibility in their personal and work life. To us, it has been a tremendous uplift to employee morale internally and also externally for those that are working on behalf of our clients.

What services are health systems most commonly seeking?

We are a heavy Epic firm, as a good two-thirds of our revenue comes from the word Epic. There continues to be a dominant stance for that company, and therefore, a lot of work that we do on behalf of Epic-related clients and also due to continuing consolidation within the industry. We have also seen a tremendous uptick over the last two years in the business systems applications such as Workday, ServiceNow, Oracle, and Infor. Our business was built to support both the clinical systems and the business systems that an enterprise would have to implement and support. We are in the mid-innings, in a baseball analogy, of the overall business systems refresh that is going on in the health system.

Your mentioning Epic made me think of the consulting services arm it was launching a few years ago. To what extent do big software vendors support third-party consulting?

Epic and Epic Boost do a very good job inside of their customers, who then become our customers. Oftentimes we’re working side by side. We don’t see that as a threat to our business, but rather as complementary. If you look at Cerner, they traditionally have had a professional services organization on the ground implementing their software and we work very closely with them as well.

The key to working well with those two large vendors is understanding how they like to support their customers, what they want to do in addition to the software license sale itself, and then how we can cohabitate with them. We have found working with both firms to be a pleasure over the last 10 years. It’s a different set of challenges between those two organizations when you’re working with them, but once you understand what they’re looking to do and then how you can work with them, it becomes harmonious. Success for the client is what we’re both interested in. It has been good for us as a business.

What is the future of conferences such as HIMSS and Epic UGM?

In the healthcare enterprise, we talk about digitization. I think digitization of the conference world is a healthy thing, because we can get together more frequently and with less cost. It’s good for the customers. It’s good for the end clients of the software firms. It’s good for the vendors, in our case, the services firms. That’s healthy.

On the other hand, we are humans and we need to see each other and be around each other. The conference of old, let’s say HIMSS using that as the example, will never be as large as it once was. That’s actually a good thing. But we need to have a little bit of both.

How is the CIO role changing?

We were talking with a client recently who brought in a chief technology officer, who works for the CIO, from the retail industry. We have a number of those scenarios across the system now, where it used to be the CIO and his or her staff was always from the healthcare space, because it’s a unique space today. The good news is that we are starting to see that turnover and we’re starting to see a lot of the outside influences. When we talk about consumerism and healthcare, that’s an interesting thing to say. but does the CIO over the last 20 years really understand what to do about that? These outside influences that are coming in at leadership levels is helpful to that.

But clearly the CIO’s role was changing dramatically. The CIO has to think not only about traditional security, which is an incredibly complex topic, but now they have to think about the same thing for their at-home workforce. It’s a huge challenge. How do we secure Tim’s office, Bob’s office, and the devices they are working on? In addition to digitization, it’s the security piece, both inside the four walls and also now with the work-from-home piece of it.

A lot of the CIOs historically are clinically oriented, as they should be. They are driven to satisfy the chief medical officer and the clinicians with the applications that we bring to life. In today’s world, there’s this massive shift going on to large business systems implementations. They require a totally different set of personnel and leadership techniques. That’s the HR line of business or the finance line of business versus the clinical line of business that they are accustomed to supporting. That CIO seat is a challenging one these days.

How do you balance the value of bringing in outside experts in technology or consumerism who suddenly find themselves trying to understand the complexity of healthcare?

I’ll use as an example B.J. Moore, a friend at Providence who I’ve known going back to his Microsoft days, when he ran their finance division and we were helping them at the time with call center software called Siebel about 20 years ago. Since he came to Providence, you see them moving light years ahead of so many other organizations that are in healthcare. They are acting like a large enterprise, a large corporation, as relates to technology. Providence has been a long-time client of ours as well and they have tremendous healthcare domain expertise inside their IT organization. What they were missing was somebody with a vision to say, what do we do in this new world? How do we turn on the consumer? How do we interact with the patient? How do we treat the clinicians in a different way, to engage them and pull them into these systems that are so important for a place that large? How do we look at our EMR and how do we think about running that EMR as a mature client to reduce the cost of ownership? How does cloud impact our budgets and how can it help us scale our business and secure the business in ways that we’ve never thought about? Those influences are terrific and he has done a wonderful job.

My personal background is that I come from corporate business services for many years and started in healthcare when I created Healthcare IT Leaders 10 years ago. We are happily at our 10-year anniversary right now, so I have a perspective that is a little different than others that have been in the industry for 20 or 30 years. I think it’s wonderful. You need more of that kind of thinking, particularly now as we’re trying to get out to the consumer and make your life and my life that much easier before, during, and after our encounter with said health facility.

Providence has gone deep into providing commercial services as an IT vendor under the Tegria umbrella, while Ascension has decided that IT is not its core business and is outsourcing almost all of it. How are health systems defining IT as core competency?

Whatever industry you’re in, you’re going to have people that think about that question differently. You look at back to what Mercy was doing years ago and today, and look at what Providence is doing today. And then to your point, Ascension, with much different philosophies on core competencies. Providence and Rod Hochman and his team there are very much leaders and visionaries in how they are thinking about healthcare and healthcare IT services. They are looking at it as ways to increase revenue, being as important as it is when you’re an organization that large. Ascension is obviously an incredibly large place as well with a totally different viewpoint on this.

I’m not 100% sure what the right or wrong answer is, but I think you will see both of those models persist depending on the leadership in an organization. I like what Providence is doing. On one hand, it is competitive to what we do, but on the other hand, it’s collaborative. We work together to support Providence in partnership with Tegria. In my view, that’s all good.

Going back to Ascension, no question, that’s a great strategy.  We know a lot of the people there and the leadership and they’re doing wonderful things on behalf of all their clinicians and the patients that they serve. That model is working very well for them as well.

What near-term changes do you expect that will affect healthcare and your business?

Our business was created to satisfy the most important element in the IT organization, which is the clinical information system. But then after Meaningful Use came and went, we turned the chapter on clinical systems in 2017. We will always be there to do the good work we do, but we put a lot of focus and investment in business systems because we knew there would be this natural refresh cycle. When I look out three to five years, from our company perspective, we want to be an organization that is understood by the CIOs to be able to handle the clinical systems and the business systems.

More and more, this Healthy Returns practice becomes important with President Biden’s recent mandate on how you test, trace, and maintain the credentials of employees, vendors, and patients. We start to get into consumerism and pulling all this data together to say, it’s safe for Tim to enter a building and it’s safe for Bob to enter a building based on our policies as a health system. That will persist long after COVID comes and goes because we will never, ever allow ourselves to come offline to the extent we have during COVID times.

Over these next three to five years, those three elements and cornerstones of our business will continue to be dominant trends in the eyes of the CIOs, CFOs, and CMOs that we support.

An HIT Moment With … Ajay Kapare

An HIT Moment With … is a quick interview with someone we find interesting. Ajay Kapare, MBA is chief strategy and marketing officer of Ellkay of Elmwood Park, NJ.

How was the HIMSS21 experience for Ellkay and what are your plans for HIMSS22?

The team at Ellkay had a very successful HIMSS21 and our overall experience was just fantastic. And of course we would also like to thank you for the special shout out during HIMSS. This year’s HIMSS was smaller than in years past, for obvious reasons. However our team found a way to make the most of the opportunity and finally meet with industry colleagues in person again. Although we have accomplished a lot through virtual experiences over the past 18 months, nothing beats making personal connections face to face. It was really great and exciting to see how all of our hard work and planning had such a big impact and result.

As for HIMSS22, our planning is very much underway as it just around the corner. At HIMSS21, we had the chance to start new relationships, rekindle old ones, and revisit other facets of previous partnerships. We want to build on this momentum. Our goal now is to ensure we keep our HIMSS presence strong and establish the most effective methods of engagement from our HIMSS21 experience.

How do you go about setting goals for a conference like HIMSS and then developing a plan to achieve them?

Like with any marketing initiative, the first step was to evaluate Ellkay’s purpose of presence at HIMSS. We researched whether our own attendance would increase the chances of achieving strategic objectives, based on who we anticipated attending. Once our executive team determined the HIMSS audience would be an asset, we knew we wanted to make valuable use of our time there.

We take on an integrated and holistic approach with our marketing. Team Ellkay does not take on a project unless we can do it well. It’s like “Moneyball “in healthcare. We believe that many small things, done well, add up to make a big difference. All of those small items from our efforts, whether it’s training or graphics or social media posts, add up to make the event the best that it can be.

To pull this off requires collaboration between all of our contributing teams. The marketing team was essential in planning a dynamite, functional booth and scheduling innovative activities for sales to invite attendees to enjoy. The sales team then collaborated with strategies that attracted customers, colleagues, and of course prospects to our booth. We couldn’t do it without our product and operations teams, which have given us the foundation for compelling conversations and solutions we can be proud to demonstrate.

What advice would you give to to a small health IT company about developing or expanding its marketing efforts?

Ellkay’s event strategy is proactive marketing and sales collaboration. We did not just set up a great booth, then sit and wait for people to show up and ask about our products and services. Instead, we had already taken valuable time to build relationships and a reputation. Our colleagues at HIMSS intentionally sought us out, knowing we were there. The sales team was also in full partnership with our marketing efforts.

Each team member from Ellkay that attended HIMSS knew the type of HIMSS attendees and who they should connect with at the conference. This involves extensive research and pre-work for our sales team to set meetings in advance.

Ellkay is known for its conference giveaway of honey from its own bees. How did that come about?

Our co-founder and president, Lior Hod, had a long-held dream of raising honeybees. In 2015, there was a lot going on in the news about the declining honeybee population, so Lior decided to act. He called his beekeeper friend, who set up the first 36,000 bees on Ellkay’s rooftop. Our honey is harvested right at headquarters for our friends, colleagues, and conference attendees. Today, we have more than 1 million bees on Ellkay’s rooftop from 22 active hives. Every event we attend, we find the honey to be both a great conversation starter that really reflects our culture, as well as a memorable takeaway. Year after year, we have people returning for our honey, and of course good conversation.

How should a marketing team work effectively with the company’s executive team and its salespeople?

Events represent a significant investment of time and resources for every company. Before committing to an event, the executive team needs to evaluate whether it is a good fit for their strategic objectives. Once they determine if the event’s audience and message are advantageous to the business goals, the marketing team steps in. Marketing develops a strategy to provide the sales team members with the tools they need in order to achieve substantial relationships through the event.

All teams involved should be aware of the purpose in attending the event, the audience, the company messaging which best appeals to the specific audience, and the strategic targets all parties must try to achieve. We spend significant time internally strategizing and communicating to ensure everyone is on the same page and recognizes the significance of the event.

Additionally, no team should enter an event without a plan for evaluation afterwards. All teams must have metrics in order to assess how they performed at the event, and how event attendance helped the company achieve its overall objectives. The evaluation plan should be shared before attending so all teams know how their performance is to be graded.

After attending an event, our team always asks for feedback from all members of participating teams. This allows our colleagues to share their personal perspectives on areas they found that could use improvement, or methods that were particularly successful, for consideration on future event participation.

HIStalk Interviews Steve Cagle, CEO, Clearwater

Steve Cagle, MBA is CEO of Clearwater of Nashville, TN.

Tell me about yourself and the company.

I’ve been with Clearwater for about three and a half years. My background is all healthcare, over 20 years working in a number of healthcare-related firms building businesses. At Clearwater, our mission is to help our healthcare customers protect their patients and their data to help them be compliant and to develop capabilities that allow them to be more effective and efficient at the business of cybersecurity, which is becoming extremely difficult in today’s age.

We talk about pandemic fatigue. Are we experiencing cybersecurity fatigue?

We as an industry had to pivot quickly to work-from-home for employees and in patient care and patient delivery. That involved a lot of new technologies and deploying those quickly. At the same time, threat actors recognized the enormous opportunity to target the healthcare industry. The data is so valuable, and the historic underinvestment in cybersecurity, more so through the pandemic, made it a juicy target. 

There may be a bit of fatigue with regard to what we’re seeing with ransomware, unfortunately. We will have to continue to understand that, because we are probably still at the beginning of where we need from a maturity perspective in healthcare.

Has the cybersecurity significance of employee behavior changed, especially with regard to ransomware?

It’s very significant. Cybersecurity is not just about the tools that we have in place. It’s really about the people and the organization. It’s about establishing a culture where everybody in the organization understands they have a role in keeping their information safe and being vigilant. We have to continue to remind people through training and not just rely on tools. Security processes become important as well.

The top healthcare cyberattack threats remain centered around ransomware and email phishing. That’s an important part of how we need to deal with the problem.

What is the maturity level of tools that can prevent that single employee click from bringing down the enterprise?

Unfortunately, there is no silver bullet. There are some important controls that all organizations should put in place from a baseline perspective. We hear a lot about multi-factor authentication, encryption, having good protection on endpoints, and identity access management. A number of security practices should be employed. But every organization needs to have a thorough assessment and analysis of their specific risks. 

When we talk about risks, we’re talking about vulnerabilities based on the specific information systems that they use in their organization and threats and the threat actors that could exploit those vulnerabilities. We have to assess the effectiveness of those tools and other types of controls, administrative controls, physical controls. How effective are those controls in preventing that threat from exploiting that vulnerability?

We also have to think about not only the likelihood of an event being successful, but also what the impact would be to our organization. That’s a risk discussion, because when you think about what you’re going to do in your organization to optimize security, it’s about your risk tolerance. Everybody’s risk tolerance is going to be a little bit different. There’s no way that we are ever going to eliminate risk completely, but we can make better decisions about where we’re spending our limited resources and our limited time by understanding, through a risk analysis, where those risks are and what we can do about them.

Health systems have recently reported some huge costs from ransomware attacks. How do they tailor what they can afford versus the possibility of huge losses due to downtime?

University of Vermont is a great example and Scripps Health incurred about $112 million in lost revenue and other expenses. What stood out there was that their insurance covered only covered a fraction of that. That was the same for University of Vermont, if I’m not mistaken. There was a time where we would hear, “We have insurance and we can cover that if we need to.” But it’s not just about the financial aspects — it’s about patient safety, it’s about brand and reputation, it’s about mission to provide safe and effective care. When you hear about health systems diverting ambulances to other hospitals, you’re talking about precious minutes where those patients who need emergent care aren’t getting that care as quickly as they could be.

There is a cost perspective. Those costs are getting to be more expensive. Insurance premiums are going up – we are hearing more than 50%. We are hearing from CFOs about limits on what will actually be covered in terms of their insurance policies and needing potentially to buy multiple insurance policies. Insurers are becoming more prescriptive when it comes to specific security controls that are in place, and the security questionnaires are getting to be more extensive.

Certainly we need to look at all those implications. For many healthcare organizations, there has been historically an under-investment relative to what we see in other industries. At the same time, healthcare is going through this digital transformation. We are deploying all these new technologies. We will need the appropriate amount of investment in security as well to ensure that we can keep our applications secure and keep patients and patient data safe.

What can health systems do about the risk introduced by their business associates and vendors?

Through the first half of the year, somewhere around 40-plus percent of healthcare breaches resulted from business associates, third-party vendors, or other third parties that have electronic protected health information that was entrusted to them by a covered entity, a provider or a payer. Healthcare is shifting to cloud, using third-party service providers, generating a lot more data, and sharing and accessing that data from many more endpoints. As we continue on that journey, the threat landscape and the vulnerabilities that are created through that type of model are going to increase.

Every covered entity under HIPAA needs to ensure that they have a business associate agreement with their third parties, but that’s really not enough. We are seeing healthcare providers and healthcare payers turn up the dial in terms of what they expect from third parties, from their vendors, and from anybody that wants to do business with them who is going to receive that electronic protected health information or other sensitive data. It is still the covered entity’s responsibility to ensure that data is being protected.

What role will the federal government play in health system cybersecurity?

There have been some good efforts, public and private partnerships. The Cybersecurity Act of 2015 resulted in the establishment of the 405(d), the cybersecurity working group and task force. They recently came out with a good best practices guide that has, for small, medium and large organizations, the top 10 cybersecurity practices that can be used as a baseline. That’s been a great effort that is supported by 150 or 200 members. In January of this past year, there was legislation H.R. 7898, which basically said that healthcare organizations that are implementing or have implemented best practices — which include the NIST Cybersecurity Framework or 405(d) best practices — should not necessarily have a safe harbor, but should be looked at a little bit differently from regulators when it comes to audits or potential fines and penalties after a breach.

We have had some good momentum coming into the year. We’ve seen some good activity from the Biden Administration to work with private industry and to some communication that we’ve seen suggests that there will be more support. The recent executive order that required additional security practices and controls to be in place from government contractors hopefully will also transcend to the healthcare industry. Obviously there’s a lot of technology providers out there that support the VA, for example. 

There’s some good movement there. We would like to see more. The healthcare industry just lacks resources, dollars, and people. Those are things that the government can do to support healthcare, as a critical infrastructure industry, to respond to the challenge.

What developments will see in healthcare cybersecurity over the next few years?

The challenge of cybersecurity will continue to be more complex. That’s a result of the increased adoption of new technology and the vulnerabilities that come along with that. For the future, organizations have to develop core competencies in cybersecurity and in risk management in particular as part of cybersecurity. They have to get good at identifying, prioritizing, and responding to risk, and doing that in a methodical way and a programmatic way.

We are already seeing a lot of movement at the board and leadership levels, conversations that weren’t there before, when cybersecurity was considered to be an IT problem. It’s not an IT problem, it’s a business problem, and it could potentially be one of the largest risks to the overall organization.

HIStalk Interviews Coby Skonord, CEO, Ideawake

Coby Skonord is co-founder and CEO of Ideawake of Milwaukee, WI.

Tell me about yourself and the company.

Ideawake helps large healthcare systems or providers create a highly engaging experience to capture, evaluate, and implement ideas from frontline employees. The biggest customers we work with in the healthcare space are UnityPoint, Advocate Aurora, and Sanford Health.

To what degree are health systems underusing their workforce as a source of ideas for innovation and improvement?

We are seeing a large uptick in getting better utilization of frontline staff, especially once they implement our system. A lot of the time when we come in, there’s a large underutilization, because things they tried in the past, like running one-off contests, didn’t work all that well. A lot of the time, systems are built on top of SharePoint or another solution that’s already internal. Since you don’t run these often inside of the system, things will fall through the cracks and you don’t get the results that you want. There’s no action plan after the fact. 

Once we come in, we see much better utilization. It’s easy to get started, but it takes a couple of cycles of running these challenges to get a lot more adoption across the large swaths of the organization. We normally like to start pretty small.

How much does using a technology platform democratize the process to avoid having the highest-ranking person choose their favorite idea?

One hundred percent. You hit on a great point. The best ideas to improve patient experience and process come from those who are closest to the patient every day. To your point, we democratize the process of capturing ideas. We do this in a couple of ways, but it empowers anyone at the front lines of the organization, regardless of role or title, to make their voice heard based upon the quality of their idea versus their job title.

What kinds of ideas are health systems looking for?

It’s all over the board. About half of our use cases, or challenges as we call them, are around continuous improvement. General process improvement within the system ties a lot to quality improvement programs. That’s pretty much exclusively how Sanford Health, as an example, uses the system.

You can also go to the other end of the spectrum, which would be product innovation or solutioning, which is split pretty evenly. How might we better attract millennials? How could we reduce patient anxiety before, during, and after care takes place? We’ve seen challenges that focus on solutions to better enable the aging in place trend that’s happening in the market.

The challenges focus on the major categories of healthcare trends that are being talked about from a consulting perspective. What trends will affect us? Then, putting those in the  form of a question and asking frontline staff for input on them.

Is this a way for health system executives to avoid paying consultants to simply talk to their employees and then report back a summary of what they said?

I like to say that we are more fun than consultants. The system is gamified. Users earn points as they submit ideas. There’s a leaderboard and you can offer prizes. Unlike having consultants interview employees, we create a transparent experience that allows for peer-based recognition. Employees can like each other’s ideas.They can track their idea from when it’s submitted to when it’s decided upon and ultimately implemented. You complete the loop of, hey, I gave input and something came out of it.

Health system executives sometimes solicit employee input on such decisions as choosing an IT system or how to implement it, but then override the frontline employee vote. How do health systems handle cases where a popular idea isn’t considered workable?

We do our own primary research. It’s important to complete the loop and to make sure that there’s transparency around where ideas go and why. We did a survey of 700 employees throughout the continental US, who told us that the number one reason that people who had ideas stopped sharing them – 20% of respondents – was because they didn’t hear feedback on where a previous idea they shared went and why it went there.

As far as prioritization, certain ideas that flow to the top from the frontline staff might not be workable for several reasons. But we have a transparent prioritization process where leadership who reviews the top ideas can say why something will or won’t work. That is communicated back to frontline staff automatically.

How do health systems decide who they want to participate and then encourage them to do so?

Our philosophy is the more, the merrier. We believe in the wisdom of crowds and the power of large numbers when you have the ability to sift through the ideas automatically using our technology. Our rule of thumb is if you’re under 5,000 participants when you get started, you can target that entire population. If we go over 5,000 or you have a complex network with a lot of locations that span several states, we’ll normally roll it out to a specific service line across several locations, or do it in a region and then expand out from that. But overall, we believe that everybody has ideas to improve quality of care and outcomes, so we try to make sure that everybody is involved.

Would the best prospect be a health system that has a track record of innovation, or should they just have a general interest or a specific idea to try?

Most health systems have some type of quality program in place. We see the easiest way to get started is making that quality improvement process more collaborative. Many health systems, regardless of their organizational makeup or culture, have that baked into the culture. We can help significantly improve the results. 

From there, looking at the innovative side of things. Innovation is happening in healthcare all over the place. If you don’t innovate, you will be left behind. Look at Blockbuster to Netflix, taxi cabs to Uber, or Amazon Care. Where primary care is getting disrupted now is on the fringe, but events and trends will continue. Health systems will have to be innovative and center their overall care model around the patient, continuously getting that patient input and feedback. If your culture doesn’t support it yet, then the best place to start is quality. But if you hear words around patient-centric care, and investment is going on around patient-centric care, we would be a great fit.

Are for-profit companies interested in paying health systems to participate in product evaluation or development?

We haven’t seen too much of that yet. In my past life, with the inception of the company, we were doing something similar that was entrepreneur focused versus enterprise focused. What we see most commonly now is an enterprise reaching out with an open call to startups for solutions, instead of just focusing internally on employee ideas.

Do health systems invite patients to be part of the process?

We are seeing the first iteration of that right now. It has been talked about for a long time. There’s a hesitancy to go directly to the patient or to replace some of the things that are in place currently, but it is something that we are starting to see. We should have our first rollout to those in early 2022. We just need to work through some obstacles such as security and compliance and making sure there are no concerns about HIPAA. When you go internal to employees, there’s a lot less concern. Sometimes there is more of a fear about working with patients, but we have the technology to do fully anonymized feedback.

What is the future of health system innovation?

Employee engagement and employee experience were already critical, but with COVID-related attrition rates, retention strategies are becoming even more important. Our system is being leaned upon more because of the need to engage employees and empowering them with a voice. That trend will grow. Most health systems think that their culture doesn’t support innovation, but every culture inside or outside of healthcare can support it. It’s a matter of where you start it. There will always be a leader in a region who will support the initiative. The sooner that leaders realize that, and more and more are realizing it now, the easier it will be to bring innovation and patient-centered care into the mainstream.