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HIStalk Interviews Nancy Ham, CEO, WebPT

March 26, 2018 Interviews No Comments

Nancy Ham is CEO of WebPT of Phoenix, AZ.


Tell me about yourself and the company.

I’ve been in healthcare for 25 years now, which is hard to believe. I’ve been fortunate to work my way across the continuum of care, starting with primary care, then specialist, hospital, and now post-acute, with some forays into payer, pharma, and lab along the way. I’ve been fortunate to work in a lot of different kinds of companies, from a startup that became a billion-dollar IPO to VC-backed companies that became part of bigger companies to being in a Fortune 50 division. I’m currently at WebPT, which is the leading EMR for the $30 billion rehab industry.

What are the similarities and differences between software used in an outpatient therapy setting versus that used by hospitals and physician practices?

It’s all about fit for purpose, especially EHR. As the name implies, it is purpose-built for its user base, which in our case is physical therapists, occupational therapists, and speech-language pathologists. You can imagine how different the diagnostics and clinical workflows might be from dermatology to cardiology to physical therapy. That’s why you’re seeing a lot of growth and activity in vertically specialized EHRs, like WebPT, Modernizing Medicine, and others.

Are outpatient therapy clinicians happier with their specialty-specific EHR than EHRs in general?

We were founded by a physical therapist, Dr. Heidi Jannenga. We often hear from our customers that it’s obvious that the product was written by a physical therapist. It supports their clinical workflow and thinks the way they think. We work very hard on that because we want to be as unobtrusive into the patient conversation as possible and be as compliant and efficient as possible to let therapists spend as much time as with their patients and as little time as possible with documentation. That’s a hard task, and something we constantly come back to. How can we improve? How can we make it better? How can we incorporate new, emerging technologies, like voice?

I also think it’s worth noting that there’s a lot of dissatisfaction with EMRs, both general and specialty. In fact, the last survey I saw showed that only one of the eight major general EHRs had a positive Net Promoter Score. We’re very proud to have a strongly positive NPS at 32, which I think is a reflection not only on the software, but on all the other pieces we bring that help our customers achieve their goal and our mission, which is to help therapists achieve greatness in practice. That means clinical greatness, financial greatness, and patient satisfaction greatness and then wrapping all that with stellar service and education.

We often focus a little bit on the product when having this dialogue as an industry. But to me, it’s about the entire ecosystem that you provide to your clients — we call them members — to support them in every aspect of what they’re trying to do.

Is the trend of consolidation at every level of healthcare, from providers to insurers, affecting your customer base?

Very much so. There are about 36,000 to 40,000 outpatient rehab clinics and we’re very privileged to serve 12,000 of them, so about a third of the industry. But as we’ve seen in virtually every other healthcare vertical, bigger companies are now being created. We have customers ranging from a single clinic to our largest customer’s 1,600 clinics. That’s an exciting change for the industry, because as we create more clinic operators of scale, it opens up a broader opportunity to participate in value-based care, for example. You now have some geographic density that matters to an IDN or a payer and you can participate in bundles or an ACO or whatever value-based care arrangement might happen.

We also see larger operators become able to invest more in data-driven clinical outcomes, which is a topic we’re particularly passionate about as a company. They are able to participate more vibrantly in that care continuum. I don’t know if you’ve been to PT, but I myself am PT patient. I spend a lot more time in that clinic than I do in my doctor’s office. We also think there’s an interesting opportunity for physical therapy to have a louder voice in primary care because of the hands-on time they’re spending with their patients. That’s something we want to support.

The opportunity here is that every year, 128 million adult Americans have a musculoskeletal condition that lasts more than three months that would benefit from physical therapy. Only 8 percent of them make it to physical therapy, so the other 92 percent are getting opioids or pain meds. They’re getting imaging, surgery, or perhaps nothing at all and they’re just sitting at home in pain.

As the industry is consolidating and expanding, it affords us a better opportunity to bring more patients to PT and make that 8 percent 10 percent or 15 percent. There’s a growing body of clinical evidence that PT is the best clinical pathway for a number of conditions in terms of cost and quality and in terms of the patient not just getting better, but getting well.

I’ve read that a big problem in physical therapy is that patients don’t complete their treatments, either because of cost or because they feel better. What have you learned about how your provider customers engage with their patients?

I’ll admit that I was initially a PT dropout myself. I quit going after my third visit because I felt better. But I was not well. I’ve since returned, completed my course, and returned to my best health. That’s a common issue. Patients are busy, and if they’re paying out of pocket, it’s expensive, so they tend to quit as soon as they’re seeing some progress.

That’s where we can use technology to help patients understand what their best outcome is. We have a data-driven clinical outcomes product. We can predict how much recovery of function you will gain based on the number of visits. If we can illuminate that to patients — to show them that if they would complete their course of care, their range of motion, for example, might improve another 30 percent — that would be motivational.

We acquired a company last year that allowed us to launch a new digital mobile platform to help patients communicate securely with their clinician to continue their therapy between visits from home exercise programs, or HEPs. HEPs are an important part of the PT story. Also to share their honest feedback on a Net Promoter Score basis.

Patients drop out because they have a bad experience. It could have been parking, the front desk, understanding their bill, or the clinical care. By helping illuminate that in real time to our practices, we’re giving them a real-time chance to intervene with that patient and have that conversation. We’re seeing good data that this combination of tools increases the stickiness of patients with their prescribed therapy. We’re excited about that as a trend for both patients and our clinics.

Is there any movement toward PTs using technology to help patients do their exercises effectively at home, like a video PT visit?

Yes. One of our new products is a robust, video-based mobile platform for patients to understand what they should be doing. To see it, repeat it, and communicate with a therapist how that’s going.

There’s a lot of invention happening in the next wave of virtual rehab, whether it’s using an avatar or using a 3D camera to literally measure your performance. We’re in the early stage of those technologies and maybe a little early stage on the business models to support them, because telemedicine at large has not yet penetrated into the rehab market the way it has in other verticals. There’s a lot of opportunity there for both patients and for sponsors, like employers who want to offer more convenient, more affordable ways for patients to recover from a work injury, perhaps. It’s an area we’re watching very closely.

What are your biggest takeaways from the HIMSS conference?

It was my 25th year attending. I learn less from HIMSS than I used to. It’s more an opportunity to see customers and partners and network with thought leaders in the industry.

I was struck by the amount of virtual assistant technology being shown. This introduction of voice to make technology easier for clinicians to use while they’re in direct patient engagement is encouraging. While perhaps machine learning, artificial intelligence, and big data are being over-hyped, we’re starting to see some real, practical uses of that data. That’s something we’re doing in continually improving our outcomes product — getting more predictive about what’s your best course of care and what is your likely outcome. Blockchain — not Bitcoin, but blockchain — is something that’s very interesting and I’m starting to become more optimistic that we’ll see some real adoption of it in healthcare.

What would you recommend to women who want to move into health IT leadership roles?

I would suggest they watch the amazing HIStalk webinar that Liz Johnson and I did on secrets to success for women in HIT. Thanks to HIStalk for affording us that opportunity.

Things are getting better, but it is incumbent upon women to actively study and learn what they can do to be more effective in their roles, to be more effective in leadership, and to be more effective in managing their careers.

My best advice to everyone is to make networking a part of your everyday life. Healthcare is such a collegial industry. I’ve virtually never been rebuffed when I’ve reached out to someone to say, “I’m interested in learning from you. I’m interested in your career path.” In those connections, you both learn and are inspired by someone else’s story. You make a new friend and maybe come away with a good idea for your project, your company, or your career.

Do you have any final thoughts?

In my 25 years, I’ve been a passionate advocate for interoperability. I started out in the mid-1990s trying to build CHINs — community health information networks — and most recently led Medicity, the large HIE company in our industry, processing billions and billions of real-time clinical transactions a year.

I would like to call upon my fellow EHR and EMR CEOs to continue to open up our platforms to innovators, to data exchange, and to supporting the patient’s journey. It is the patient’s data. We are honored to be entrusted with that data. Our job is not to lock it up, but to digitize it in an appropriate way that helps the patient achieve their best outcome while achieving the Triple Aim. I would love to see my fellow CEOs step up and do more in this regard.

One thing we’ve done here at WebPT since I joined is to create a vibrant partner ecosystem. We are supporting our customers as they find and implement all sorts of innovative, interesting other technologies that help them run their practices and serve their patients.

HIStalk Interviews Colin Konschak, CEO, Divurgent

February 28, 2018 Interviews No Comments

Colin Konschak, RPh, MBA is CEO and managing partner of Divurgent of Virginia Beach, VA.


Tell me about yourself and the company.

I’m from south Jersey originally and I’m living in Virginia Beach currently. I went to school in Philly. I should have been an Eagles fan, but I ended up a Redskins fan, so I have some slight regret this year. My career started out as a pharmacist in retail, hospital, home health, and hospice. I moved on to some positions in pharma and biotech. My final pivot is where I am now in healthcare consulting, where we saw lots of things being done really well and lots of things that could be done better. That was the impetus for founding Divurgent.

Divurgent has been a pretty good story. We are in our 10th year and have had 10 straight years of revenue growth and profitability. I’m confident that if we talk next year, I can say that that number will be 11. I’m proud of the company. I think we’ve won “Best Places to Work” in Modern Healthcare five times and three times consecutively. Certainly performance aside, we appreciate culture.

What are the top three issues that health system CIOs are dealing with?

The top three are similar to what we’ve seen in the past — implementation and training, optimization, and activation. There seems to be a huge rush in ERP right now, so we’re building out capability in that area. Of course, security, and a lot of times, return-to-basics information technology infrastructure. Physician optimization, with a lot of requests around, “We have this system in place but physicians still aren’t as happy as we’d like them to be — can you come in and help us make that happen?”

You surprised me with ERP. What kind of activities are happening around that?

Now that folks have a lot of their EHR positions in place, they’re revisiting the other side of the house from a materials perspective and otherwise. The investment, it seems, is in the beginning stages of a move in that direction.

Are you seeing much activity with customer relationship management?

We are seeing a lot with customer relationship management, both from a “customer as the patient” perspective and a “customer as the physician or provider” perspective.

What gets CIOs fired most often?

Certainly it’s not like years past where you picked the wrong vendor. We’re past that. It’s around implementations. They get a little bit out of control still, even after as long as we’ve been doing this. They go over budget and people at the end of the day are surprised. Boards don’t like to be surprised. That’s the number one reason.

Do you believe that it’s not as much what a health system buys rather than what they do with it?

We believe that’s true. The systems are great now. The ones that are still left standing are great systems. Of course as consultants, we do our best to help however we can. Client culture is different. Everybody has different access to resources in different cultures that result in very different implementations. I couldn’t agree more. I don’t think it’s so much the technology now as about just getting it right.

Do health systems have the time and interest to pursue technology innovation?

We’re getting there. Those at the leading edge are thinking more about it. They’ve been implemented for many, many years and have moved past the optimization stage. It’s interesting to talk to our clients and especially interesting when they engage us to explore those innovation opportunities that they have. It’s a bell curve and not everybody is there.

Consolidation seems to be leading us to super-regional or national health systems. Will that change the picture of how healthcare technology is used?

I think it will and I couldn’t agree with you more. The merger and acquisition wave to super systems and super-regional systems is simply the future. There’s no way to avoid it. That’s going to provide a ton of business from a vendor perspective, which is great, but it’s going to give those health systems the scope that they need to do what they do. I hope with that scope comes tremendous amounts of data, tremendous amounts of resources, and hopefully at some point we don’t just implement technology, but we take that data and do really cool things with it. I don’t think we’re there yet.

Are you seeing more relationships between health systems and life sciences and an increasing interest in sharing data?

I do. Those that are there are at the forefront. It was interesting to see, as you reported, the Cerner-Surescripts opportunity. That’s something that I hadn’t really thought of, but what a great opportunity. Once we’re implemented a really good electronic health record, what a tremendous opportunity for the life sciences. I haven’t seen any good examples of it from a client perspective of Divurgent. Certainly I’ve read some of the things that you’ve read. There’s tremendous opportunity there, but we’re just at the implementation stage. I can’t wait to start pulling that data out and doing some of those very, very innovative and cool things with it.

People argue passionately both ways whether patients are true consumers as they are in all other industries. What do you think?

I couldn’t believe that premise any more than what you just said. I certainly believe there is, to a certain extent, an age gap. The younger you are, the more of a consumer you are in everything that you buy. That’s going to turn into healthcare. The move to consumerism, and the more that younger generation demands more from their healthcare providers, will will be one of the major things that push the industry further.

Have you seen anything promising on the technology horizon that would make insurers a more welcome participant in the provider-patient relationship?

We have. We’ve seen enough that we’ve launched, towards the end of last year, a payer division. We’ve seen so much interest, particularly from the payer side, in trying to align better with the provider side. At 10 years old, we have a good understanding and good subject matter experts on the provider side. We know what the payers are looking for.

I think it’s still about cost for them. Certainly I would hope that it’s about client satisfaction and pulling whatever data that they don’t have, which probably frankly isn’t a lot. I hope the goals are more than reducing costs and improving claims processing and those types of things. I think we can get way more out of it than that.

What kind of cybersecurity problems have you seen?

From our perspective, someone has done an audit previously of the client and they look to Divurgent to come in from a remediation and project plan perspective. That’s probably the number one source of security work for us. Then there are those clients that haven’t done that, realize they probably have weaknesses, and they want us to do the assessment. Those are the two biggest opportunities right now.

User management and patch management seem to be the items that get providers in trouble most often. Is there renewed interest in revisiting those practices?

It’s renewed interest in all of the above. The threat from within is still a major threat. The bad guys are getting sophisticated. It’s to the point where sometimes you have to double-check looking at an email — it just looks so good, so tempting to do what it’s asking you to do. The threat within is huge and I’ve seen renewed interest in trying to educate users.

What healthcare IT opportunities will be most significant over the next few years?

I think it’s still going to be driven by mergers and acquisitions. Some of the common theories around the constriction around implementations, optimization, all the work on the blocking and tackling that still needs to be done is missed on super systems and super-regional systems. That amount of merger and acquisition activity is going to generate a ton of business that is underestimated.

I don’t think it’s going to happen in the next three years or five years. It will will take a little bit longer. It’s going to be a lot more of the same. Unfortunately, one of the things you’ll see is that a Cerner-using system buys an Epic-using system or vice versa. Dollars that were spent are going to be reversed to get on that same platform.

What will be the biggest theme at HIMSS18?

Data analytics, artificial intelligence, cybersecurity. I think it’s still going around all of the data implications of what we can do with this. I predict this year maybe it’s around artificial intelligence. The HIMSS buzzwords and the HIMSS trends are usually a little bit ahead of the game.

Do you have any final thoughts?

First, kudos to you and your team. Your readers certainly realize that it’s not easy to do what you do, but what a valuable resource you’ve become.

As far as we’ve come, we feel in many ways that we’re at the starting line. We have highly capable systems implemented in most cases, but we’re taking very little advantage of them in the grand scheme of their abilities. We’re passionate, as are other firms, about taking advantage of those large investments and leveraging them into what they can inevitably do, whether it’s reduction in costs, improvements in patient care, and hopefully leapfrogging innovation with data, science, and technology. This is going to take many years. We’re in this for the long haul.

HIStalk Interviews Tom Borzilleri, CEO, InteliSys Health

February 26, 2018 Interviews No Comments

Tom Borzilleri is CEO of InteliSys Health of San Diego, CA.


Tell me about yourself and the company.

I spent many years in the finance business. My first dive into the healthcare space was back in the late 1990s, having founded and operated the second-largest patient finance company in the country. As I progressed on through the years and had a successful exit of that company, I then moved into the PBM space in the mid-2000s. I spent five years founding and operating a pharmacy benefit management company, where I learned and deployed many of the processes and tricks of the PBM industry.

I realized that there had to be a better way to be able to address the market and deliver value, savings, and benefits to patients and companies across the board. I set out to create a solution that would disrupt what had become the status quo of that industry, or for a better description, the profiteering by the PBM industry, to specifically deliver the ability of true price transparency and ultimately deliver the absolute lowest drug cost for all patients, consumers, and at-risk stakeholders.

How do PBMs make money?

PBMs are exactly what they’re described as — pharmacy benefit managers. They manage the pharmacy benefit, or the prescription benefit, on behalf of plans, payers, insurance carriers, ACOs, and self-insured employers. Those functions include setting up a formulary and creating a network of pharmacies in which members can acquire their prescriptions through the plan.

PBMs negotiate the price of a drug with the manufacturer and then negotiate a contract rate with the pharmacy. They profit by creating an ingredient spread, the difference between the acquisition cost to what they are charging their clients or customers, which would be those clients, payers, ACOs, and insurance carriers.

Why are insurance companies willing to overpay for the PBM’s services instead of pressuring manufacturers to give them lower prices?

Their contracts are convoluted. Most insurance carriers really don’t understand or have an ability through the language in those contracts to determine what the actual acquisition cost is. There’s a lot of functions that the PBM fulfills, especially with regard to patient management and formulary management. The role of the PBM is as a buffer between the pharmaceutical manufacturers and doctors.

Pharma manufacturers used to send their reps into doctors’ offices, bringing in lunch or other compensation to doctors. That got them to prescribe their medication or their brand. PBMs took over the role of managing which drugs are included in that formulary. They acted as a buffer to eliminate what was called steerage, where it was illegal to compensate a doctor to prescribe a specific brand over another. It’s kind of like payola in the radio industry for playing songs on the radio many years ago.

PBMs acted as the intermediary, but at the same time, it also opened the door for them to set their profitability in acting as pseudo wholesaler, buyer, and then reseller of those prescriptions or drugs to the insurance carriers insuring those members.

How can technology help doctors answer the deceivingly simple patient question of, “How much is this drug going to cost me?”

We have brought together all the necessary components to offer true price transparency. First off, we have created our own network of pharmacies. We operate on what is called the no-spread model. Whatever the acquisition cost is of that drug, that’s what is being charged to the patient or insurance carrier at the end of the day.

A great deal of price disparity exists between pharmacy chains as well. You can go to a CVS or Walgreens and expect to pay anywhere from 30 percent to 75 percent more than you would pay at a local independent or even a grocery store pharmacy. It’s really amazing the price disparity that exists.

Consumers assume that the large chains buy in volume and therefore get the best pricing on drug ingredients, but that is far from the truth. Because they maintain such a significant footprint, they can command that price. Patients ultimately don’t know and they don’t have the time nor the resources — and that includes doctors as well — to do the research to find out find which chain or which store — which may be even a store closer to my home — has a price that’s 50 percent less than what they’re paying.

That goes for the insurance carriers as well. Insurance carriers are looking for convenience for their members. They’re forced to enter into these contracts to provide access to pharmacies so that when the patient arrives, they only pay their co-pay and then the insurance carrier will reimburse that pharmacy for whatever remains on the cost of that ingredient.

How do free consumer coupon programs like GoodRx work?

In my PBM, I administered what were called DDCs, or drug discount card programs. In the GoodRx model, they are signed up with multiple PBMs. Their mobile application searches out the lowest-cost drug discount card programs to provide the best discount to the patient.

But there are ingredient spreads that the PBMs have built into those prices, as well as very high admin fees. The patient who is uninsured or underinsured will save money, but until you strip out those admin fees and that ingredient spread, they’re not saving as much as they could.

DDC products, because they’re sponsored by the largest PBMs in the country using their networks, pricing spreads, and admin fees, generate $5 billion in annual profit for PBMs and programs like GoodRx.

Did you say $5 billion? Wow.

Between 60 and 100 companies are marketing these drug discount cards under a plethora of names. In some instances, it’s the same PBM and the same program. There are basically only five PBMs in the market today — following our exit four years ago — that still sponsor and administer these drug discount card programs.

So GoodRx isn’t some kind of disruptive organization demonstrating transparency, but rather just another way for PBMs to make money by working with consumers directly instead of through an insurance company?

That’s correct. GoodRx gives comparison prices across different pharmacy chains. I mentioned that there is price disparity across the pharmacy chains, but there is also price disparity across the PBMs that administer the drug discount card programs. PBM A will have a different price on an ingredient versus PBM B.

The GoodRx model looks at the discount card program pricing across multiple PBMs to give the lowest price — of those inflated prices — that all the PBMs are charging. It is a form of transparency, but it’s really not true price transparency because it is not providing the actual cost to the PBM on that drug.

Our model strips out all the ingredient spread. We strip out all the administrative fees that are built into these prices. It’s delivering the price that the PBM is paying themselves to the pharmacy down directly to the consumer. We’re undercutting and disrupting that entire drug discount card market with our tool.

Why did you decide to work with prescribers rather than consumers?

The primary objective of physicians is to get their patient on therapy, get them well, and create a better health outcome. They have a dog in the hunt because essentially their scores will increase based on their ability to get that patient well and have a positive outcome.

Physicians prescribe a drug based on a familiarity of the condition. Physicians have no idea whatsoever what the cost of the medication is. They leave that up to the patient to find out at the pharmacy. In many instances, the patient is hit with sticker shock.

In addition to that, patients may either not have insurance or they have insurance with high co-pays or high out-of-pocket minimums. There is such vast variety of insurance coverage currently on the market that patients don’t know what is going to be covered, if it’s on formulary, or if they’ve met their minimum. They know they have prescription coverage, but they don’t know what it’s going to cost until they get to the pharmacy.

Our software analyzes the patient’s plan information. We’re conducting a real-time benefit check on that patient, so we know what their co-pay will be based on the drug that the doctor has chosen. They will know at that time if the co-pay is inflated, meaning that there could be a cash price that is less than their co-pay, which eliminates a claim being processed through the insurance carrier and gives a lower cost to the patient.

It also looks at the drug that the doctor has chosen. As I said, doctors prescribe based on familiarity of a drug with the condition. That may not be necessarily the cheapest drug for the insurance carrier that’s going to pay them that claim. Our software analyzes the formulary of the plan and identifies, if one exists, a clinically and therapeutically equivalent alternative drug to what the doctor has chosen that will cost the insurance carrier the least amount of money.

Insurance carriers today have no idea what the doctor is prescribing. They only know what they have paid on after the claim has already been submitted and adjudicated. They’re in a very awkward position, a disadvantage, because they can’t control or they have no input and ability to be able to help that doctor choose the most cost-effective and most therapeutically-effective drug because they don’t find out until after the fact.

Our software brings that price transparency. The patient can see the drug price before it’s sent to the pharmacy, eliminating sticker shock. When they get hit with sticker shock, one of three things happen. They’re on the phone with the doctor, creating a second encounter that disrupts the workflow and takes staff time and the doctor’s time to re-prescribe because they just found out that their insurance company is not going to cover the drug or they’re going to have to pay a ridiculous amount of money out of pocket. Or if the doctor chose a brand drug when there was an available generic that could have been prescribed instead at a fraction of a cost and the pharmacist is on the phone with the doctor doing the same thing. Worst-case scenario, the patient abandons at pharmacy and never gets on therapy, which opens up the issue of financial risk on the part of the insurance carrier and obviously health risk on the part of the patient for never getting on therapy.

We can eliminate this in the encounter as we’re sitting in the exam room with that patient, providing actionable, beneficial, and valuable data to the patient and their doctor before that prescription is sent out. That is the most efficient method for addressing these problems.

What impact will the CVS – Aetna merger have?

It’s not going to be of any benefit to the patient. I think it’s going to reduce options and locations in which patients will be able to get their prescriptions filled.

Number two, I believe that they will try to herd patients into CVS to create pull-through revenue. Pharmacies don’t make their money in the pharmacy in the back of the store. Their profits are generated through products sold in the front of the store.

This is a mechanism in which that they may incentivize patients to go to CVS rather than going to Walmart or their local independent or grocery chain to get their prescriptions filled, to be able to pull patients out of other chains and herd them directly into theirs.

I think it’s going to eliminate options for patients. It may in turn increase cost for patients, because they’ll have fewer choices. Ultimately it will probably be a very profitable opportunity and enterprise for CVS and Aetna.

Do you have any final thoughts?

With our software and our technology today, we are addressing price transparency as well as price and drug affordability, which will benefit the patient, the payers, and somewhat the doctors. We will be introducing in the coming weeks a new product, which is a e-prescribe solution that was specifically developed and designed to address affordability for the doctors themselves, to help them save money and have positive and financial impact on them.

What’s so unusual about this solution is that there are over 400 EHR systems in the country that use third-party e-prescribing tools. Those doctors are forced to have to pay anywhere from $15 to $150 a month to be able to prescribe.

Our product will be 100 percent free to every doctor who uses it and every EHR system that integrates it. It will also create an alternative revenue center for the EHR company. We hope those profits will turn into savings and reduction on the rest of the subscription fees that these doctors have to pay to have access to an EHR system.

Our objective is to lower cost and bring benefit and value to the entire healthcare value chain across the board. That’s the focus of InteliSys Health.

HIStalk Interviews Neil Smiley, CEO, Loopback Analytics

February 22, 2018 Interviews No Comments

Neil Smiley is founder and CEO of Loopback Analytics of Dallas, TX.


Tell me about yourself and the company.

My wife and I live in Dallas. We have three children, all grown with now kids of their own. I have a computer science degree from Dartmouth and spent the first 15 years of my career in management consulting, first with Accenture and then EY. Then in 1997, I got the entrepreneurial bug and decided to leave consulting and start a company called Phytel. It is a software as a service platform company that, over a number of years, we grew to serve about 30 million patients. Phytel, along with another company called Explorys, was acquired by IBM as part of their launch of the Watson Health platform in 2015.

Loopback Analytics, where I serve as CEO, spun off that effort in 2009. The company provides a cloud-based platform we call EpisodeInsights. It enables health systems to proactively identify at-risk populations, match those patients with the appropriate services, and then evaluate the impact of those interventions on outcomes. The platform allows provider organizations to selectively and securely share data with network partners across care settings to coordinate care beyond their own walls, certainly outside of facilities they own. The key there is protecting data that should not be shared and sharing data that should.

How do you differentiate the company in a crowded population health management and analytics market?

We don’t go to market as just an analytics play. Instead, we’ve focused around specific solution areas where we feel like we can have a meaningful impact. Then, we’ve developed the specific competency within those verticals — specialty pharmacy, behavioral health and high utilizers, and then this area of bundled payments. When we go to market, it’s typically not to sell, “Here’s some analytics. Why don’t you go plug it in and see what it can do?” We come as a value proposition built around our return on investment, specifically around one of those verticals.

How do you address specialty drug use as a significant driver of cost?

There’s an interesting trend that’s happening. Our primary customers are large health systems. For a long time, they have been banned from managing limited distribution specialty pharmacy, which is the leading edge of innovation. Folks are concerned about how much these new meds cost and whether they’re worth the money. We equip health systems with a framework so they can establish real-world evidence around what they do and leverage the fact that they have a much better opportunity to coordinate all aspects of the patient’s care — particularly a complex patient who’s on some specialty therapy — and differentiate how well they can do that relative to potentially other distribution channels.

We see big pharma as being under increasing pressure to provide real evidence that there’s value. Pharma would like to do that, but struggles. How do you set up a measurement framework that you can believe in and all the parties can agree upon? This is where our company is going — providing a foundation for managing value-based care reimbursement models.

Some drug companies are hinting that they are willing to go at risk in getting paid only if their drug delivers the desired outcome for a specific patient. Are those companies showing interest in using provider data to monitor the process?

There’s a couple of problems to solve. One is that absent some kind of independent arbitrator, our role is as a data custodian. We can pull in data from a number of different sources that’s needed to complete that picture, but not be beholden to any one aspect — pharma, the health system, or in some cases, drug distribution centers. How do you provide a degree of independence so that as we’re looking at the efficacy of an intervention, it can be evaluated objectively? It’s interesting.

We’re seeing something similar with medical devices. Manufacturers are interested in engaging with health systems, potentially going at risk and getting into the clinical outcomes business rather than selling a widget and saying, good luck with that. It’s a requirement that for them to continue to defend their margins, they have to be able to point to the value that they’re creating.

We take data availability for granted these days, but these conversations couldn’t have happened five or 10 years ago

That’s absolutely right. Even today, how to share that data is a sensitive topic. People are obviously and appropriately sensitive about sharing protected health information, because if there’s a breach, that’s not good for anyone. The key role that we play is not to put all the data together and share it indiscriminately like it’s in one big pot. Instead, we very selectively share data around populations that individuals or stakeholders have in common, but then be able to protect the data that doesn’t need to be shared. If you don’t have that sort of governance structure, all the technology in the world isn’t going to help you.

Hospitals and skilled nursing facilities have mostly ignored each other and didn’t share data. What benefits are they seeing when they work from a common pool of data?

It’s a relatively recent phenomenon. Until there are financial incentives for these parties to come together, there’s just not a business reason to do so. It’s really the emergence of ACOs. We’re intrigued with this relaunch of bundled payments with the BPCI Advanced that CMS announced a few weeks ago. These provide the financial incentives for stakeholders to get together. Previously, they’ve each done their own thing, leaving a patient to be their own general contractor.

We see a tremendous role for us to come alongside the health system that wants to form a network with the best quality providers and hold them accountable for quality of care, but also the economics of the care that they’re providing with aligned financial incentives. If you’re doing a great job, you stand to profit from it, but if you’re not doing a good job, then it’s going to cost you. I’m excited about the emergence of these new models. They are going to pave the way to a higher degree of care coordination than has existed in the past.

Is that kind of vertical interoperability going to be more important than expecting competing health systems to share patient information?

Folks are increasingly aware that the social determinants of care play a significant role in terms of patient risk factors. Clinicians, for the most part, have ignored these characteristics.

We’re doing an intriguing project in North Texas. We have the largest health systems, many of which are competitors, getting together with the criminal justice system, jails, and the outpatient mental health services. They are knitted together through our platform to impact a difficult problem, which is unmanaged behavioral health issues with high utilizers who, up until now, were bouncing between the jail and the emergency departments in a way that is unsatisfactory, both for them and also for the community. With these kinds of formerly intractable problems, there’s a real opportunity, with the right kind of precise data sharing, to begin to make an impact that just wasn’t possible before.

What lessons did you learn from Phytel that you can apply to Loopback Analytics?

One of the things that allowed Phytel to take off was providing a return on investment guarantee. We basically said, we have the data flowing through the platform. We can ensure that a physician who’s now being held to pay-for-performance or trying to manage their practice more effectively by using targeted analytics and getting patients the care they need can benefit via to their bottom line. It was doing well by doing good. You have to connect the dots. It helped, of course, that we were doing all this at a time when population health was becoming more mainstream, so we rode that wind as well.

This continues to be one of the key challenges of anyone who is trying to innovate in healthcare. We still have a predominance of the fee-for-service reimbursement model, which often pays people to do things that aren’t helpful to patients. We have to pick around the edges still, finding those intersections where we can provide better outcomes, make providers more money, and reduce cost. If we can’t do all three of those things, then we have to stand down until reimbursement models change.

Your hit a home run with your first swing of your entrepreneurial bat with Phytel. How would you assess today’s health IT business climate with regard to innovation?

I don’t have a crystal ball, but I will say that if you’re trying to launch a health IT initiative on soft dollar benefits, it’s a lot harder. If you can find the intersection where there’s a compelling return on investment, those are the kinds of initiatives that I would get more excited about. Healthcare is entrenched and isn’t as nimble as a lot of other industries that I worked with in my consulting days. You have to have something compelling to interrupt somebody from their current set of priorities. Typically, it has to make financial sense for them to change.

Do you have any final thoughts?

Healthcare is in the middle of historic transition from volume-based to value-based care. The pace of change is uneven and messy. I don’t have a completely rosy picture that it will all be up and to the right. Perverse incentives still work against the goals of better outcomes and lower cost. Thankfully, what started out as this small niche play a few years ago is steadily expanding as value-based reimbursement models become more pervasive.

We’re particularly excited about the relaunch of bundled payments by CMS as BPCI Advanced. Initiatives like that provide an opportunity for providers to make more money by doing the right thing and improving the care system. It’s a rare opportunity to get visibility, specifically data of full episode claims, to inform their network design and prepare for broader adoption of value-based payment models. I would certainly encourage health systems and physician group practices that have an opportunity to at least apply and get their data. We’re putting a lot of effort into that.

HIStalk Interviews Kamal Patel, CIO, Ellkay

February 21, 2018 Interviews No Comments

Kamal Patel is co-founder and CIO of Ellkay of Elmwood Park, NJ.


Tell me about yourself and the company.

I am one of the co-founders of Ellkay, along with Lior Hod. We started the business in 2002 in his basement. Both of us are developers. We learned about business along the way.

We are now close to 200 people. When we started the business, our first client happened to be Quest Diagnostics, which was fantastic. We started with New York and New Jersey and then we expanded across the whole country with demographic connectivity.

We are known as the healthcare data plumbers in the industry. We solve key problems around all kinds of interoperability. Any data, any system. We assist in migrating data from all the legacy systems within a healthcare environment and ambulatory environment.

How would you describe the current and future state of interoperability from a technology perspective?

When you look at the lab environment, that is where you run into a lot of point-to-point interfaces, where you are connecting the ambulatory locations or reference lab locations for sharing lab orders and results back and forth. There’s a great need for interoperability in technology to streamline this process.

When we started the business, we started doing demographic interfaces. We were doing it across the country, most of them with point-to-point interfaces across all the various systems. We focused on building a platform that allows for all kinds of interoperability.

The way the industry is headed, some form of normalization or structure is required. But in the current state, the problems that everyone is having around interoperability is that it’s not necessarily standard, which is what everybody seems to focus on. There is no single platform that offers speed of deployment, cost effectiveness, and full monitoring of everything that is happening. Whether the data is going to APIs, HL7, FHIR, or sharing CCDs, any of those forms.

Do you see a lot of problems related more to the non-technical aspects of exchanging information related to individual system rules of how data is edited and stored?

When these systems were designed, they used the best available way to store that data. When you have two different systems, they are obviously going to have different ways of storing that data.

There are two parts to normalizing that data. One is the ability to take data from one system — it could be a database or CCD share — and standardize the data in a simple form. This is what everybody is talking about. Standardization will allow for easy viewing of data at the point of care.

The second part within standardization takes it to a different level with cross-reference mappings. Medications might be stored in one system using the RxNorm format, while another system uses some other format. These mappings need to occur around medications, problems, allergies, immunizations, and document types for analytics engines to work and to build machine learning pieces and so on.

These are some of the challenges the industry is solving. We are doing our part, but there is still a lot of work to be done.

What advice would you give a practice that is considering migrating to another EHR and wondering what data can be moved over?

Don’t be afraid. Today, when you ask a practice which data they want to move, they’re scared. Our approach has been that we’ll take everything you have and migrate it over. Whatever went into the old EHR, we will put it into the new EHR. We will map each destination in the EHR, medication to medication, and so forth. When they start using the system on Day 1, all the pieces are there.

Anything that can’t be migrated, we will move it into an archive, a repository where we are managing it. We will link those patients back to the existing EHR via a single sign-on. When they open a patient’s chart in the new EHR, they can simply click on the archive link and it will pull in all the historical data.

It’s a completely different world in health systems. They have all these legacy systems where we get the data, but we also get the same patient records from their ambulatory locations that they may want to archive. We consolidate these patients and link them to their primary EHR, whether it is Epic, Cerner, or others. We get the patient IDs from the primary EHR and then match it with the legacy systems, then we match it with the ambulatory patient IDs. When they open the patient record in their health system EHR, they see a consolidated, longitudinal view. Not only from the legacy system, but also from all the ambulatory practices that the health system may have acquired over time.

The company is of significant size with 200 employees. What created the growth and where will the company go in the future?

We’ve been growing on both sides because of the problems in the market that we can solve. We’ve been growing our connectivity and interoperability sites with labs, clinical data feeds, and scheduling interfaces. In solving all these different challenges, we have tremendous growth opportunities.

On the archiving side, when Meaningful Use Stage 2 was going on, we were doing a lot of data migrations for newly purchased EHRs. Now we’re doing a lot of health system migrations on really large scales. If a health system has 200 practices and 20 legacy systems that they’re constantly paying maintenance on, our goal is to help them reduce that maintenance and streamline all the data in a central, secure repository. We keep all that data discrete and still have it available at the point of care.

On the interoperability side, there are a lot of different types of challenges. We don’t believe that any form of standardization is going to solve all these things. We partner with a lot of EHR vendors. We partner with a lot of labs. We partner with ACOs. Everybody has different needs.

We recently moved from 13,000 square feet to a 74,000-square-foot building that we purchased. We are on a significant hiring spree. We are super excited about the growth and the direction of the company.

How would you describe the company’s culture?

The company is awesome. We focus on culture. We very rarely have people leave us.

In our office, the environment is amazing. We have had free lunch every single day since we started in 2002  — we even wrote a software program for handling the lunch orders and processes around it. We have bees on the roof and we make our own honey. All the beekeeping is done by Ellkay employees and our president even goes on the roof.

We are involved in two specific charities that we are tied to as an organization. One is for kids on the autism spectrum, Alpine Learning Group, where we assist them in fundraising and bike events. Our next event is rappelling from our building for this charity. We are also involved with Embrace Kids Foundation that helps families that have kids with cancer. They can use the money to take the kids to Disney or use it for whatever expenses they may have.

When we hire people, we’re looking at, are you going be a lifer at this company? The interview process is intense, but once they come through, it’s an amazing family environment. As we grow, we may struggle to maintain that, but so far, it’s been fantastic.

Do you have any final thoughts?

Our strengths are customer service, speed, reduced cost, and our platform.

We put great emphasis on the fact that it all starts with the customer and the service we provide. Even though we like to think about delivering products, platforms, and speed, the fact that our customers are extremely satisfied with what we do is critical. Everything we do is transparent. Our customers can see, through our online portal, every single phone call that our service reps have made and the amount of time they spend working on their projects.

We believe our interface interoperability platform, LKTransfer, is a completely new way of thinking about interfaces. In traditional thinking, health systems purchased an interface engine and scaled by hiring more resources. Our thought process is that interfaces in a health system should be done by just one person, and instead of taking weeks and months, it should be done in hours and minutes.

We are extremely focused on innovation and we have a dedicated R&D team that is focused on solving the new challenges in the healthcare industry. We are super excited about what we have been doing and where we are headed.

HIStalk Interviews Tom Skelton, CEO, Surescripts

February 20, 2018 Interviews No Comments

Tom Skelton is CEO of Surescripts of Arlington, VA.


Tell me about yourself and the company.

I’ve been in technology for 30 years. I’ve been doing this a long time. I still find it challenging and interesting and I hope that all this technology that we’re all deploying is making a big difference out there.

Most people probably think of Surescripts in terms of electronic prescribing, which is now widely implemented and in some cases mandated. The next wave involves add-on capabilities, such as prescription price transparency and automating prior authorization. What is the status of those efforts within the industry and within Surescripts?

I think you are absolutely right. There’s a lot of information going back and forth. Prescriptions, eligibility, and some of the core things have made huge strides.

Price transparency is a big thing and we as an industry need to rise to the occasion. We’re now able to provide, at the point of care, information about co-pay and therapeutic alternatives. These are extremely helpful for consumers and fit very well into a consumer-driven world.

I would say it’s early stages here. It took 14 or 15 years to get 90 percent of prescriptions on the network. Electronic prescribing for controlled substances was introduced in 2011 and at the end of 2016, the number was up to 14 percent. The transparency piece is going to take a little while, but we expect a very big year in that regard for 2018. We have a lot of rollouts going on and physicians and patients will start to benefit from that very quickly.

Will the model follow e-prescribing, where the initial effort involved standalone applications that were rarely used that were then integrated into physician workflow?

Yes. Physician workflow is one of the absolute keys here. We’re in a market where physician burnout is rampant. Pressure on their time is just absolutely amazing.

Since its founding, Surescripts has been focused on partnering with electronic healthcare records vendors and other technology providers to make sure that physicians and pharmacists don’t need to step out of their workflow to do what needs to be done for a patient. If you’re looking at price transparency, the issue goes just beyond pricing and the alternatives. It’s a lot deeper than that. It sets the stage for whether or not a patient adheres to the treatment regimen that the physician has prescribed. That’s one of the key things that gets lost. That co-pay differential — $10 here, $20 there — makes a big difference in adherence levels.

That’s a huge issue for the industry. It’s a huge issue for the country. You move into the world of electronic prior authorization. All of this ties together when you look at what’s going on in the market. This front door of understanding what the patient’s benefits really provide them. Also, understanding whether or not that prior auth is really necessary. Making that as easy as possible is key.

When you look at adherence, the introduction of prior auth alone causes adherence scores to fall substantially. They approach a 40 percent decline in some cases. Not just prescriptions — when I was running a radiology company, we saw 25 percent declines in utilization as soon we sent letters saying that we were introducing prior auth for MRIs. This is something the healthcare system has to get good at.

That’s also true when you look at specialty drugs. You’re seeing a huge increase in utilization and cost of specialty drugs across the system. That’s also driving prior authorization work, and that’s important as well. When you’ve got $500 billion worth of specialty pharmacy spend, you want to make sure that very sick people get access to the drugs that they are required to take.

Is it a challenge for EHR vendors now that many other software vendors want to connect to them and it’s hard to determine whether a given company is a partner or a competitor?

Absolutely. I don’t think there’s any question that the EHR vendors have a tremendous challenge in dealing with all of the requests that are made of them and in meeting those requests. We’re coming out an era where government mandates drove a lot of the innovation and pushed a lot of the coding towards the EHRs. As that era recedes into the past a bit, they’ve got tough choices to make about what innovation they code first.

Our job is to make it as easy for them as possible. We’ve built tools that help do that. We have accelerators that make it easy for them to do that integration, taking advantage of standards that exist in the market, both technical standards in the information provided and the standards around how that’s formatted. They’ve certainly got a lot of work that they need to do. They are the front door, in many cases, to these hospitals and physician offices.

FDA and drug companies are interesting in using provider EHR information for market surveillance. Do you see Surescripts as having a role in provider-FDA data exchange?

As our role in the industry has grown and changed, we’ve tried to support certain key initiatives, whether they’re government initiatives, research initiatives, etc. We’ve been pretty selective about that, but we try to help out where we can. When they are looking for a comprehensive story, going to the EHR is the natural place for them.

Should we be optimistic about the current and future state of interoperability?

It has changed and improved substantially. I worked at a company in Raleigh, NC where we had a huge team of people doing nothing but HL7 work. It was unbelievable the time, energy, and resources we put into that. The industry has moved so far beyond that now.

One of the challenges that the industry has is that we’ve not done a great job setting the bar for success. Like many industries that don’t have great data to support a position, we end up living on anecdote. I can tell you 10 stories about my mother and elderly relatives and what they encounter in the healthcare system with interoperability. Those anecdotes are going to rule the day until we as an industry come together to help explain what the interoperability journey looks like and help provide criteria upon which we can be judged.

What role do you see for pharma in using healthcare data?

You’re asking specifically about data, but I’ll tell you one of our learnings. We just had some folks come back from JPMorgan. Emerging firms, smaller innovative firms, are being founded to fulfill a specific niche need. Pharma and life sciences are being viewed as important to their business models. Whether that’s a good thing or a bad thing is probably less the point than the fact that these are large, healthy firms that are seeking to foster innovation and further their interest. A lot of these smaller startups are looking to them as key components of their business model.

How much of the success of Walgreens and CVS was due to innovative IT work and what can providers learn from that as the market consolidates?

The key word obviously is consolidation. Whether it’s horizontal or vertical, the entire healthcare ecosystem is undergoing another wave of consolidation.

As you pointed out at the beginning, when you and I used to talk 15 years ago, there were 800 EHR vendors. That number is down substantially. If you look at the market share on the hospital side, you’ve really got three key firms. If you think about the fact that firms like Walgreens and CVS have historically been innovative, both in technology and in evolving their business model, I don’t think that’s a surprise. That would also be true of groups like United Healthcare and others. There are a lot of large firms that have been innovative in terms of what they’ve done to evolve both their model and the infrastructure that they’ve built to support that new model.

Where do you see the future direction of Surescripts?

You highlighted a couple of these things that we would talk about. We would certainly talk about price transparency. The other thing that we would talk about is that there’s a lot of commentary and interest in how interoperable the system is. The second piece of that is you have to peel back the onion a little bit. The information that’s being moved — how actionable is it when it arrives? How accurate is it? We’ve made a huge investment there over the last few years.

The introduction of Sentinel was an important moment for us as an organization. It moves us beyond just talking about how data is formatted to how actionable it is when it arrives. It puts us in a situation where, instead of having one in 10 prescriptions requiring some type of phone call or human intervention, we can work with our EHR partners to help identify areas where those prescriptions might benefit from different work up front to make those scripts more actionable when they arrive. We think that’s a important.

We’re going to scan 2 billion prescriptions this year and eliminate 50 million instances where somebody’s got to do something. That 50 million is a monthly number, not an annual number, so 50 million times a month we’re saving a pharmacist, physician, pharmacy tech, or a physician assistant a lot of time trying to sort through these. That’s what technology is all about. We’re proud to be moving down that path.

The ability to get information at the point of care is still an aspiration. Forty-eight percent of all diagnostic errors are still due to a lack of access to the appropriate information at critical points in the care process. We’re doing work around medication history. Delivering that information in a natural workflow for the physician is an important piece of what we do. A lot of folks do those things, but they do it with information that has lags in it or information that’s incomplete. But we’ve got big and deep coverage there and we’re providing a billion medication histories annually.

When you’re looking at informing care decisions, it is still a heterogeneous world. Health systems still rely on information from other medical practices and other healthcare institutions. The ability to locate a record for a patient in this heterogeneous healthcare system is an important piece of what we do. We can help people locate records, and once they’ve located them, there are a number of mechanisms for moving them and we have offerings in that area. You have to be able to know where that patient was and we think we can help.

Those are the types of things that we’re working on today. You can see additional intelligence coming to bear with us helping physicians and pharmacists through clinical alerting based on rules and engines that they help configure. We see all of that as natural for us and part of the prescription and medication ecosystem.

We haven’t even discussed opioids yet. Certainly from our standpoint, that is a huge situation that needs to be dealt with. We certainly respect, understand, and applaud all of the attention and the scrutiny, but there’s still a lot of work that needs to be done to make that real.

Our medication history offering is a big part of that solution. Doctors are allowed to see a lot of that information in most states. That’s important. I just saw some data the other day that shows that following the I-STOP implementation in New York, they’re approaching 90 percent penetration. When nationally you’re at 14 and New York is at 90, you can see the digitization that has occurred.

Digitizing those prescriptions is an important part of allowing people to do the analysis they need to do. If society as a whole decides that we need to do more behavioral work to support those patients, or whatever it is that we decide to do to treat them, the sooner we can help recognize it, the better. This problem is not going away without some type of intervention.

Do you have any final thoughts?

You asked a great question. Where are we on the road to interoperability? Should we be positive about it? Should we be concerned? What I would say is that there’s a huge amount of work to do, There needs to be an appropriate amount of focus on that work. There’s also a huge amount of progress that has been made, and will be made in the future.

I continue to be optimistic that with the combination of private entities partnering, and then private entities partnering with the public interest at the state and federal level, you’re going to see continued progress and acceleration over the course of the next few years. It’s not a panacea, but I think it’s going to be very positive and will have a huge impact. Patients and all of us US citizens are going to benefit enormously.

HIStalk Interviews Jim Causon, CIO, Memorial Hospital

February 19, 2018 Interviews 3 Comments

Jim Causon, CPA is CIO of Memorial Hospital in Stilwell, OK.


Tell me about yourself and the hospital.

Memorial Hospital is a 50-bed acute care hospital. It has a 10-bed geriatric psych unit and a physicians’ clinic that has anywhere from 12 to 16 physicians, depending on who comes and goes at any given time. It’s in rural Oklahoma in Adair County.

The clinic sees about 3,000 patients a month. The total population for the county is 3,000. [laughs] You know everybody. We draw a lot of people through the clinic. We see a lot of frequent flyers. It’s a nice little facility. It’s about an hour or hour and a half from the next-largest facility.

I am a partner in an accounting firm, Causon & Westhoff CPAs. We provide the CIO function for the hospital.

What technologies does the hospital use?

It terms of patient care, billing, and admission, discharge, and transfer, we use Medsphere OpenVista CareVue in conjunction with Stockell Insight CS. We just bought the clinic live on the EMR in August. We bought the hospital up first, got everybody comfortable with it, and then brought it into the clinic.

How has Medsphere worked out?

It has worked out well. That was a big concern up front when we were looking for a product. We were probably a little later to the ball game in selecting a vendor, mostly because we wanted to see how other implementations went at other sites with different vendors.

Then, of course, cost was a big factor. The government didn’t do anybody any favors by publishing what they were going to pay. Everybody was at the top of that rate for what they wanted for their product, which left little for implementation, hardware support, and that kind of stuff. We were fortunate to find Medsphere. The pricing worked out well for our small hospital and we were able to get it up and running easily. It was really an easy process, or as easy as going from paper to electronic can be. The technology part was easy compared to the people transition.

I assume your doctors are community based. Did you get good buy-in for physician order entry and other direct physician use of Medsphere?

We did. We have one doctor who probably does three times the volume of anybody else. He was a big concern for us in terms of being able to keep up. Are we going to have to hire additional staff to support him?

He was the silent champion when we came online. He picked it up real quick, didn’t have any problem with it, didn’t really get behind significantly in the beginning. He does well with it. We’ve got a couple of doctors that see a third of the patients that he does who still struggle with it a little bit.

When we went live in August with the clinic, for probably the first four weeks following go-live, we had a dip in the number of people we saw and charges going out. But by Month 2, we were back up to where we normally are. We saw very little decrease in productivity when we brought the clinic live.

You had no unexpected impact on revenue or accounts receivable?

Our days in AR went up a little bit when we first went live in the hospital. It really wasn’t significant. We did it sort of backwards. Most people bring in their ADT, billing, admit-discharge software first. We didn’t. We started with the clinical side. We kept all of our old billing software in place, and once we were up and running on the clinical side, we brought the admit, discharge, billing in on top of it. We kind of did it in a backwards order, but it worked out well for us.

When you look at hospitals paying huge maintenance costs for Epic or Cerner even as they’re trying to cut costs, are you glad you chose a less-expensive product?

It was more about, we have to get this right, because if we don’t, we can close the doors on the hospital. There is not a lot of big budget in there for getting it wrong. [laughs] We were very careful in our choice and the way we implemented it to protect the revenue streams as we brought it online to make sure we didn’t get a very big drop at the beginning.

What kind of technology staff do you have?

Until we implemented Medsphere in the hospital, I was the only IT person for the facility. We had a maintenance person that had some computer experience that I would recruit to restart this machine, fix that printer, run this cable, that kind of thing. I was it. Probably a year after we were on CareVue, we brought Insight up and added a fair number of new machines. We decided it was time to bring a person in house. We hired a person to be in house to take care of user issues. I maintain the servers and all of the larger issues. That’s the way we’ve run it since then. Really, it’s just the two of us.

Does it scare you reading about malware and having just two people to protect the systems?

Scares the pants off me. [laughs] Our biggest risk is what that end user is going to click on in their e-mail that’s going to cause us problems. We have had one laptop that was infected with ransomware, but it was a non-critical machine. It was identified almost immediately and we dropped its connection within a couple of minutes. We didn’t have any problems with the rest of the system, but that’s a worry every day. What is going to pop up that you’re not protected for that you don’t know about yet?

We do as much as we can in terms of firewalls, monitoring, protection, filtering, and education, but you never know. Our people are getting better. They send me e-mails that say, “Hey, this doesn’t look legit. Is it?” Most of the time, it isn’t.

We are getting ready to implement a process where we send fake e-mails to employees to see if they click on it or not. A lot of other people are doing that. That is our weakest area, the end user. Plan for the worst and hope for the best, is that how it goes?

Do you have other systems you would like to implement but can’t justify financially?

With current market, everybody is holding onto their dollars the best they can. Medsphere and Stockell have been very good to work with. If we need something or want something, they will help us figure out a way to do it at a relatively low cost, or a lot of times, at no cost at all. If it’s something someone else has, something they were going to do anyway, or something that would be a nice feature for some other hospital, they will help us get it done.

Stockell Insight CS has a large user group. They donate a certain number of hours every year to the user group. We meet in June every year to recommend the enhancements. They tally up the number of hours the enhancements that were submitted will require and they do as many as they can. We vote as a group on which ones we want. We have taken a large delegation this year and just about every year. Almost everything we’ve requested, they’ve been able to provide for us. I really can’t complain with the additional expenditures to get us what we want and what we need.

What opportunities and challenges do you see in using technology to align more closely with patients?

The biggest challenge for us is the consumer. We are in a small, rural community. It is primarily a Cherokee Indian population. A lot of people don’t have cell phones, don’t have computers. As we started rolling out our patient portal and trying to meet Meaningful Use by getting people to sign up, they’re like, I don’t have an e-mail. I don’t have a cell phone. OK, what do we do? [laughs]

Even down to our employees. When we tried to implement direct deposit for paychecks or self-service for payroll, where you can print your own W-2 and stuff they, didn’t have a computer. Some didn’t even have a bank account. Those are the kinds of issues that we face, more so than people saying, why can’t I do this online? It’s more like, please, will you try this online? [laughs]

Do you have any final thoughts?

I saw other hospitals is that were picking a vendor for pharmacy, picking a vendor for lab, and then trying to integrate all these vendors through interfaces. When something didn’t work, these guys were pointing at those guys who were pointing at somebody else. Getting it fixed and reconciled is almost impossible because everybody is pointing fingers at each other.

When we selected this system, all of those departments were integrated. We don’t have 10 different software products that are trying to do this work. Pharmacy, lab, and radiology are all in one software. The only interface we have is the interface from Medsphere to Stockell, and since they’re under the same umbrella, we have one throat to choke if things don’t work.

Their support for both sides is first class. They are very professional and quick to respond. If something is not working and we’re concerned about it, then they’re concerned about it. With other facilities and some other products, I don’t get that feeling. We’ve had a good working relationship with their support teams. There are times where we lean on them more than a large facility might because we don’t have the IT staff on site to do it. I can’t say enough good things about the support coming out of these guys.

We have been happy with our choice. Irv Lichtenwald is top dog at Medsphere. He has a monthly call with each client, so we talk to him directly at least once a month. If we have problems or concerns, 30 minutes after the call, someone is calling me back to say, heard you talked to Irv today. Yes, where are we on this? You don’t feel like you’re just a number. When I call and say who I am, they don’t ask me for my client number and have to look me up. They know who we are. That’s nice. That says something.

HIStalk Interviews Curtis Watkins, CEO, Parallon Technology Solutions

February 15, 2018 Interviews No Comments

Curtis Watkins is president and CEO of Parallon Technology Solutions of Nashville, TN.


Tell me about yourself and the company.

I’ve been in the healthcare IT industry since 1998 as a hospital IT director, vice-president of large corporations, CIO of a large health system, and deputy CIO of a very large health system. Most of my career has been on the provider side. I’ve been CEO for about three and a half years at Parallon Technology Solutions.

Parallon Technology Solutions is a healthcare IT services delivery firm. We provide EMR implementation, optimization, and full and partial IT outsourcing or managed services. We have a pretty big staff augmentation business as well, providing contract labor to health systems. Those are the three main pillars — EMR implementations, IT support, and staffing.

Is the mix of your business services changing because of provider consolidation or other new trends?

You certainly hit on one of them right off the bat. The acquisition and divestiture process, both of them. Somebody is buying something and somebody else is selling. Both sides of that equation are creating a lot of work, primarily in infrastructure refresh and EMR implementation as the hospital system is brought on board. We’re seeing a lot of activity there.

Another big shift has happened over the last couple of years. In the wild and woolly days of Meaningful Use and EMR implementations, everybody had a lot of money and a lot of incentive to implement these systems, doing it fast and at any cost. It was a pretty easy time to be in our industry. As those systems sink in and become important to operationally support, we’ve seen the costs in healthcare systems and healthcare IT shops dramatically increase. Especially if somebody’s going from, say, legacy Meditech to Epic or Cerner. It’s a lot of operating cost increase.

Over the last couple of years, uncertainty – about reimbursement models, the exchanges, and non-clarity from the Trump administration about where hospital reimbursement is going — has created a drawback on non-essential investment in hospital IT systems. The focus is on looking at the sustainability and cost of keeping IT running.

We’ve seen a lot of opportunity present itself. We’re having a lot of discussions with a lot of health systems about how to reduce operating costs, whether by some type of outsourcing or by creating some type of shared enterprise-scaled environment. Especially when you look at small hospitals or small health systems. We view that as a big opportunity. They just don’t have the levers to pull to get the most cost-effective support mechanisms in place.

Has provider technology innovation suffered as high EHR maintenance costs eat up an even bigger percentage of IT budgets as they are cut back?

Yes. I’ve seen a shift into haves and have-nots in the health system. The medium-sized health systems, small health systems, smaller hospitals, community hospitals — most of them aren’t thinking at all about population health or business intelligence. To the extent they can get that from their package vendors, sure, but they’re concentrating on operations and looking at broader uses of data and broader uses of collaboration. Interoperability and integration have taken a back seat. That’s not a universal, but in a large number of hospitals, they just don’t have the dollars to invest in those types of tools and the resources to run them.

Are health systems using more remote contract IT workers?

Yes. It’s one of the things that we do. A mid-sized or small hospital system can take advantage of economies of scale. Our central remote team can support several hospitals at once in a shared environment. Hospitals get greater expertise as their share of a high-level person who they need only once in a while.

We put together groups of hospitals, understand their operations, and support them remotely. We’ve seen people increasingly be OK with that, especially if the company has good communication tools and the ability to talk with customers and report on actual experiences and actual outcomes. It’s more a case of having a good view of how your providers are doing as opposed to having to have them right in front of you.

Elbow support has to be there, especially for end-user support or to manage the unique things about a hospital or a health system, but I think remote support continues to be important. People are getting more comfortable with it.

How will consolidation of providers and insurers affect health IT?

You’re seeing a couple of trends there. Health systems, in particular, are trying to vertically expand their systems with LTACs and urgent care to provide more of the continuum of care for a patient across their life cycle. Providers, health insurance companies, and drug companies are starting to merge to try to gain competitive advantage in areas where they have the economies of scale to do that.

It’s really interesting to see discussions about corporations like Berkshire and Amazon. What are they going to do there? What’s in their mind as big companies and corporations try to define some part of that healthcare experience and manage more of the cost structure associated with their employee health? That’s going to be interesting. It’s really about just gaining economies of scale or getting cost advantage via strength in numbers or via some kind of shared services approach.

Do you have any final thoughts?

It’s a great time to be in the industry. A lot of things are changing. I think the most important thing is for companies to be flexible, dynamic, and be prepared to meet the needs of the hospitals and health systems as they evolve. We are well positioned to do that.

HIStalk Interviews Bruce Cerullo, CEO, Nordic

February 14, 2018 Interviews No Comments

Bruce Cerullo is chairman and CEO of Nordic of Madison, WI.


Tell me about yourself and the company.

I’m a Boston-area guy, growing up in a blue collar Italian family. Hospital secretary mom, high school janitor dad. What they taught us, since they didn’t have any money, was the power of love, education, and service to others. I’m back in the game because when I got a look at Nordic, they have a mission of service in the healthcare IT space.

In the 1990s, I led a workforce solutions provider called Cross Country TravCorps that is in the nurse, physician and allied health space. It was all about finding really great people who had a mission to service and deploying them to clients that had a need. Then Vitalize Consulting Solutions in the mid-2000s — same mission, same modus operandi, good people, mission-driven, deployed at hospitals in the healthcare IT space.

I straddle the light and the dark sides, “light” being running companies and leading companies and “dark” being private equity investing. When I was wearing my black hat, I ran into Nordic and said, this company has an interesting take on the healthcare IT consulting space. The more I learned, the more I liked. I was lucky enough to be able to invest and assume the leadership chair. So here I am, I’m doing what I like to do.

Being from Boston, what’s your perspective on Madison?

As a family-oriented guy, it’s a really nice, family-oriented place. Madison, as I’ve learned, is driven by the intellectual capital of two hallowed institutions, the University of Wisconsin-Madison and Epic in nearby Verona. I used to be the young person in all my companies. Now I’m the old dude walking down the halls. Nordic is about 850 strong, which is fairly remarkable for a company that’s only seven years old, and most of the folks are under 40 and the big population are under 35. As a 58-year-old feller, I’m like, OK, it’s a young place, it’s a dynamic place with a lot of smart people.

I think there’s a social mission here. It reminds me a little bit of Cambridge, Massachusetts. Smart people trying to do good work, and in our case, trying to do good work in the healthcare IT consulting space.

What is changing in consulting now that the peak of EHR implementations is over?

The good old days of brute-force implementation have passed. Consulting firms rode that wave. Those like Nordic that have evolved beyond that into what our clients’ needs are today and hopefully tomorrow will continue to thrive and succeed.

Nordic was once a high-quality, Epic-focused staff augmentation firm. It has involved into what we like to call a customized end-to-end solutions provider. Which is a nice way of saying that we do a whole bunch of things along the continuum that leverage the EHR and to help our clients finally get to the promised land, which is a return on a significant investment. Whether it’s optimization, rev cycle, training, population health, data analytics, and managed services that follow, those are services that organizations that are going to survive and thrive, like Nordic, will have to be able to provide clients. That’s where their needs are today.

What characteristics of a company allow it to react to such a dramatic change in market demand?

As my mother used to say, “God gave you two ears and only one mouth for a reason.” If you listen to your clients, it’s remarkable what they’ll tell you. In the case of Nordic — and again, I’ve only been the leader for two and a half years or so — Nordic has always been really good at listening to what the clients’ needs are. That’s hard enough. Then having the courage to spend some money, because it takes money to make money, so to speak, to invest.

For example, our managed service offering. If you asked me a year and a half ago, should we spend as much building out a physical plant as we have? Would the customers be ready for it? It’s amazing. All of our customers have a mandate today to do more with less. To locate the Holy Grail of better quality at a lower cost, with happy patients and happy docs. To do that, they need to take their best and brightest staff folks to do the interesting work so they don’t lose them to a competitive hospital. They’re leveraging folks like Nordic to outsource the application support — very important, but less-sexy, less-interesting work to do. That’s one of the fastest-growing parts of our business. You see hospitals adopting strategies that, up to now, other industries have had in spades, but hospitals tend to be a little behind that curve.

What has changed as EHR vendors have deepened their hosting and IT services offerings?

Our work was changing, not necessarily because respected organizations like Epic are moving into the hosting space. They’re doing it for the same reasons that we are evolving, because the clients’ needs are evolving as well. Once upon a time, hospitals ran their own food service, laundry, and security. For very good reasons, they brought in partners who could do it theoretically better for less money. Now that they’ve spent tens or hundreds of millions of dollars on a very necessary investment, their EHR, they have to find ways to get full value from it and to reduce their ongoing operating cost. Epic is probably driven by some of the same business decisions that we are, and that is, what does the client need?

What impact have you seen from the tax law changes, including the possibility that individuals such as consultants might gain an advantage in billing under a 1099 arrangement instead of being a consulting firm’s W-2 employee?

I would say nothing directly yet. We are employee-owned and we’re privately equity-backed. That’s part of Nordic’s special sauce. All of our employees become owners of the company through our employee stock option plan or our consultant equity participation plan. What a concept — if you want someone to act like an owner, you’d better treat them as an owner. All of our folks have a vested interest in our clients’ success, because if our clients succeed, in theory, we grow. At the company level, we’re not doing anything different because every free dollar of cash that we generate, we’re plowing back into evolving our model.

We offer a “freedom to choose” employment model, which is very different than the Big Sixes or the Big Fives, whatever they call themselves these days. The international outsourcers and the Big Sixers tend to have an employed model. We offer our consultants the opportunity to be employed “in a permanent capacity.” We offer what we call fixed-term, temporary engagements. But in both of those cases, they are our W-2 employees. The people who would be most impacted by the tax law change, the independent consultants who are either 1099 or what we call corp-to-corp, are a very small percentage of our population of people and that’s by design.

What was your reaction when Tech Mahindra acquired The HCI Group? What does it mean when a big conglomerate from India buys a US healthcare IT consulting firm?

I’ve spent a good part of the last 20 years investing in companies. I’ve never had an original idea, but I’m pretty good at picking good people with a pretty good business idea. Since life is too short to work with a-holes, the “good people” part of the equation matters a lot and the work that they do matters a lot.

Most of the time, when the big gobble the medium-to-small, over time what made the medium-to-small special tends to go away. The history of healthcare IT landscape is littered with firms that were very special in their own right and became less so when they became part of somebody else’s business model.

It’s not surprising to me that the international outsourcers would like a real stake in the US healthcare IT game. It’s a pretty gigantic pie. Some of what has made them great in other sectors will make them a formidable competitor to a Nordic-like organization in healthcare.

But at the same time, how many firms have tried to get into healthcare — whether it’s Google or Microsoft or whoever — and realized, oh, it really is different? As our esteemed President said, “Who knew healthcare was so complicated?” I understand why the international outsourcers are interested in firms like HCI. Having been at this game a long time, we are choosing an independent, US-focused path.

As someone who has been both a leader and an investor in the health IT market, what are the most interesting things happening in it?

It is a time of convergence. You’ve got technology converging with infrastructure converging with innovation and converging with human collaboration. To find that Holy Grail of healthcare, which is higher quality, lower cost, happy patients and docs.

But what people forget is that convergence happened because Uncle Sam spent money and Meaningful Use dollars. The functionality of the major EHRs — Epic, Cerner, and Meditech are the three survivors — would not have happened without them. But people are really quick to criticize either the Meaningful Use Program and/or the leaders of these important EHR vendors.

The reality is, without the money and the innovation, we wouldn’t be where we are today. Health systems have what they need to develop credible digital health strategies. Up to now, you could talk it, but you couldn’t necessarily walk it. So I’m bullish. It’s that time of convergence. Finally, the CIO and the CMIO, arguably, have a real seat at the table. I get chest pain when I think of their jobs, because for them to be successful, patients, family members, clinicians, and hospital employees have to be happy. How’s that for pressure?

Summation Health Ventures is a private equity firm in LA that is funded by MemorialCare and Cedars-Sinai. MemorialCare is Scott Joslyn, the CIO there, and you know Darren Dworkin. So Darren Dworkin, the CIO at Cedars-Sinai, Scott Joslyn, and their respective CEOs have formed their own private equity firm. That’s how much convergence has occurred. You have hospitals that are not only driving innovation, but actually funding it. That’s exciting.

I’m associated with a Boston-based firmed called SV Health Investors. SV probably gets 20 business plans a month. They’re from some really smart people with really innovative ideas that a client would never spend the money on. But if they then called Summation to say, “What do you think?” and if Darren or Scott say, “Hey, great idea,” then that’s where the decision should be made. Because great ideas are great, but if no one will pay for them, you’re not going to be in business very long.

That’s a real-life example of how much convergence is occurring in healthcare. I think it’s good. We’re finally at a point where we have what we need to try to advance the cause. That’s why I got back in the game.

Do you have any final thoughts?

Actually, with your permission, I’d like to promote something that is very important. I don’t know if you’re aware, but CHIME has formed an Opioid Task Force. I’m a volunteer with that organization and I’m trying to raise its profile. The effort is being led by who I consider a very courageous guy in Ed Kopetsky, who’s the CIO at Lucile Packard Children’s. He lost a son to an overdose just a couple of years ago. He’s trying to turn a bad thing into a good thing.

Jim Turnbull, who’s the CIO at the University of Utah, and Russ Branzell, who’s the CHIME lead, came together and said, “Hey, CHIME Foundation members — what can we do as a group that’s uniquely qualified in the IT space to try to help combat this scourge?” Fifty or 60,000 people die every year of opioid overdoses. It’s like the Vietnam War every year. My thought is, to the degree that there are folks who read this interview who have a special talent, treasure, or time on their hands who can help us, we’re still looking for a few good people to join. We would love for them to reach out to the folks at CHIME to volunteer their interest.

HIStalk Interviews Michael Barbouche, CEO, Forward Health Group

February 13, 2018 Interviews No Comments

Michael Barbouche is founder and CEO of Forward Health Group of Madison, WI.


Tell me about yourself and the company.

I’m a husband and I’m a dad. We have three kids. If you have answers on managing teenage social media, I would appreciate it. My wife is a practicing general internist. I run a company based in Madison, Wisconsin named Forward Health Group. We’re in the analytics space. Some might call it population health.

Our solutions work. I’m proud to say to you and to your readers that we have the platforms that today are helping to fix healthcare and deliver the outcomes that all stakeholders are seeking.

Has interest in the company increased following the recognition in KLAS’s recent population health management technology report?

You bet. Let me state a foundation point for this company. We look at the market and say, these EHRs are important. We need to build upon them. We need to make them successful. A big driver for us was always around clinician engagement. We saw clinician trust as this gateway to the ACOs and to the hospitals.

I can’t sugarcoat it. This is going to be an amazing transition for all of us in the US healthcare system. We will go through a reimbursement change. The feedback we’re getting, though, from groups like KLAS that you mentioned, affirms what we’re seeing. Our clients are having success. They are able to pioneer in their markets where they want to go. We love it. It’s great.

We have this energy-filled relationship with every one of our sites. We say, what are we going to solve today? What are we going to go after? The challenges that they face – other than the normal ones on the financing side and on the growth side – are still around the same things we’ve been talking about – the data. It’s messy. What do we do with our technology? How do we get it into the workflow?

The KLAS report validates, and certainly our experience with our clients reveals, that we’ve helped them figure that out. We have helped them figure out how to maximize – in their world, their own pieces – how to do this right. How to do this efficiently. How to have a strong impact on the outcomes of their patients.

What does that mean in real life?

We have this long-time client – a very rural delivery network, poor, underserved populations, lots of challenges. Sparse access to specialists, scant resources to hire additional staff. It’s the sort of system you might not expect to become the poster child of EHR success. The EHR is truly working for the care teams, not the other way around. As one of our physicians at this site always says, “We count the things that count.”

We installed PopulationManager three or four years ago, and because of very clean data and clinician-understood analytics, they’ve advanced their key metrics through the roof. Colorectal cancer screening almost doubled to over 60 percent, which if you do the math on a largely rural, mostly African-American population, greatly reduces the risk of colon cancer. That’s a lot of prevention in the population when there is limited access to screening services.

It goes on. Greatly improved pneumococcal vaccine rates, but also diabetes control, hypertension control, and more. They’re doing all this by leveraging the data we deliver to improve the data capture and the workflows in their existing EHR platform. They are making such a difference in patients’ lives. That’s pretty cool.

The KLAS report concluded that EHRs aren’t very good at population health management. As a not-huge company, how do you use that information to find new business?

The first thing that I would say to any prospect is, what data are we talking about here? Invariably they’ll speak about an EHR or two or three. But what’s so powerful for many of our clients today is claims data.

I’m an old claims guy from the 1990s. I was a shaggy-haired data guy running claims data. Claims data is enormously important to every health system, but they don’t know how to use it. It’s so important. We’ve naturally expanded to the health plan market because they’re sitting on this untapped asset of rich data.

We say to any prospect, look, you can’t get there, anywhere, with just one of those buckets of data. The EHR is rich. It’s enormous. It’s a data source unlike any we’ve had. But if we don’t bring in other clinical data, other outside labs that you haven’t yet interfaced, and, most of all, if you haven’t brought in the claims data, you’re not going to get anywhere.

The value proposition for us is straightforward. Let’s talk about your market opportunities. Talk about your market pressures. We weave together clinical and claims so we can make sense of their performance in a manner that they can leverage the data, take action, and ultimately drive outcomes.

Our initial focus in this market was around harvesting, curating, and presenting very clean, very trusted clinical data. But in the back of my mind, we were not maximizing claims data. We would incorporate claims into our builds and populate measures and metrics for our clients based on claims data as a source, but there was a richer solution to uncover.

Beginning in 2012, we began to sketch out a new path for claims data. The move to value-based reimbursement, no matter the final form of any CMS program, would place a richer emphasis on the performance and really the behavior of the clinical network. Think of where the country has spent the last 15-20 years building out the revenue cycle. Value-based care and contracting requires an x-ray vision lens on how that network is actually behaving, where the inefficiencies occur, where the care is not coordinated.

We built that x-ray vision. In 2017 we softly launched a very cool new visual platform that addresses the problem of our time. Whether you want to call it leakage, or keepage, or steerage, it is happening. We view this as a lens on the patient’s care journey. We named the platform PopulationCompass because so much of a patient’s care journey occurs outside the four walls of their PCP’s clinic. Which also means the care is often outside of the PCP’s EHR. Your clinically integrated network’s flows, in and out, come into very clear visual focus. Risk-bearing delivery systems are going to need a compass to find their way around out there.

Do you think providers know how sloppy their data is and how hard it is to move it around in a meaningful way?

I cannot begin to tell you how eyes have opened in the last three or four years. Years prior, we had some intuitive tools, some beautiful visualizations that were basic and simple. I call them poor man’s QlikView. We thought the user was a medical assistant or a nurse or whatever.

But now you can’t get into a conversation with any system without immediately being challenged on data quality, data completeness, and other data integrity things. When we first started hearing those questions in the field, we were jumping up and saying, “Hey! Who told you about all of our speaking points?” It’s wonderful. It’s refreshing. We teach all of our clients about data quality. Teach them about this beautiful asset in their electronic record and say, we’re going make this thing hum.

We’ve got sites — and I’m just tickled by this — visited by the NIH and CDC so they can learn how they’ve improved outcomes so quickly. Trying to learn so these big organizations can help the country learn to maximize health IT. They say, how the heck are you screening this many people in this rural area where there’s no access to colorectal cancer screening? Well, for some of our clients, we have mapped 187 different nooks and crannies where we can find a hit on a colonoscopy or a FIT test or what have you in their EHR. And that number will only go up. We’re weaving in data from the three different health plans to say, somebody was screened over here at this other hospital. “You need to get that properly registered in the patient’s record in the EHR.” Continually helping them narrow in on this smaller and smaller cohort of patients that they need to target and that they need to bring in.

It’s refreshing and exciting as heck to have a prospect challenge us and say, “You know what, buddy? Our data’s a stinking mess. How are you going to make sense of it?” That’s where we stand up and thrive.

Where do you think we are in the trajectory to value-based care?

We’re in a period that we haven’t had for quite some time. I will call it a period of the least uncertainty we’ve probably had in 10 or 15 years. The move to value is certain. The path to value is fraught with unknowns.

I can tell you candidly from my observations from working in multiple markets that the delivery systems, the health systems are not at the forefront. They’re struggling with this. It’s difficult. And by the way, they’re still making too much money on fee-per-service. So what do they need to change?

We’re seeing more and more that market pressures are being introduced. Health plans are getting more anxious and getting more involved. We’re involved in numerous incentive programs, Medicaid waivers, and other market shifts. The pressures are growing, but the delivery systems are not making rapid progress.

This is probably the most exciting time that we’ve ever had as a company. We are now positioning every one of our clients to take action. We tell them, “You don’t get to wait around. You signed up. Now step up. We’re working together. We’re going to play offense here. We’re going to be the aggressor.”

We have clients that are meeting with the biggest of the big, hairy health plans, the scariest national ones of all. And saying, “Hi, I’m from an FQHC and I want to set incentive terms with you.” Do you know what the response is every time? “Let’s meet quickly.”

We tell the health plans that the gating item is the claims data. Send us the claims so everyone can go to the meeting and talk to about how attributions are all screwed up. About how assigning a bunch of patients in a vacuum isn’t working. About how prior auths are occurring in all the wrong places. And by the way, these are the quality incentives that we should be looking at. And by the way, these are the diabetes patients both sides should support and the health system needs your help managing them.

What we see right now is a window, probably three to five years, where health systems can call a meeting with their health plan partners, roll up their sleeves, and say, let’s do this together. Let’s sit at the table. Let’s talk about what our priorities are. Let’s figure out how to coordinate the improvement journey.

Will the announced healthcare cost reduction focus of Amazon, Berkshire Hathaway, and JPMorgan struggle with getting data out of potential partners?

I’m a Minnesota native, I grew up in the Twin Cities. I went to grad school there. The Minnesota Business Group on Health was talking about this stuff in the early 1990s. I welcome it. I’m excited.

Tell the Amazon folks they should give us a call. We’ve solved it. We want to visit with them and tell them how to do it. JPMorgan as well will be very interested. This is an important event, along with the craziness about Apple’s recent announcement, which isn’t so crazy. The data is still a mess and we’re not aggregating the data and using the data to drive decision-making to drive the markets.

The Amazon, JP, and Berkshire announcement represents a stake in the ground, a shot across the bow to a lot of the incumbent analytics players. The reports you’ve been sending them in the three-ring binders? They’re not right. We can tell you they’re not right, because when we look at the data and we peel it back, we are able to identify risk and identify exposure in a way that says, “This list right here of 61 people? That’s what you guys need to be working on.” Anything that helps us see the purchasers exert more and more interest and influence in demanding outcomes is for the better. I’m glad they’re here.

Do you have any final thoughts?

We’re optimistic about the future for our clients. We’re excited that they have the opportunity to go after change in this value world and do what’s right for their organizations. And, do what’s right for their insureds or their patients and have at the forefront a focus on improving patient outcomes.

We’ve known for decades that we need to go there. We’re excited to see that happening, day after day, for all of our clients.

HIStalk Interviews Lissy Hu, MD, CEO, CarePort Health

February 12, 2018 Interviews 4 Comments

Lissy Hu, MD, MBA is co-founder and CEO of CarePort Health of Boston, MA.


Tell me about yourself and the company.

I started the company as I was pursuing a joint MD/MBA at Harvard. I had always been interested in healthcare, but I became very interested in some of the more foundational problems around healthcare. I was in the hospital. I was seeing patients get discharged and come back in 30 days from nursing homes, where we had no visibility into the quality of care. All I knew was that there was a lot of variation in quality of care.

I left medicine to build CarePort to address some of the variations in post-acute care, to help patients make more informed decisions about the types of care that they can choose from. Also, to provide more visibility to their caregivers as they transition, often multiple times, across different nursing homes, home health agencies, and hospices. A lot of people,  even in the healthcare industry, don’t realize that these settings are an integral part of the healthcare system.

From the hospital’s point of view, what are the most common transitions of care to post-acute care settings and what challenges do patients and families experience?

Patients get very little information about their post-acute care options, of which the two most common are skilled nursing and home health. Generally what happens in a hospital is that someone hands you a list of names and addresses and you have to pick. The case managers who are supposed to be guiding you are hamstrung by the vagueness of regulations around how they can get involved in patient choice. They are afraid to recommend one provider over the other. That’s something they really can’t do.

For a long time, we didn’t have much information about the quality of post-acute care providers. Patients were making important decisions literally based on just a name and an address. Most of them were choosing purely based on geographic proximity.

What you see in the Medicare data is that there is huge variation of quality of post-acute care providers. Just to give you one example, the average home health 30-day readmission rate is around 28 to 30 percent. But when you look at the bottom quartile of providers, it can be double. Even after you risk-adjust for different patient populations and all of that, you still see variation. It’s important when patients and families are making these decisions to think carefully and to have that information, because it can have a big impact on their recovery course.

What accountability do hospitals have for what happens when the patient moves to a post-acute care setting?

For a long time, there was no real accountability. In a fee-for-service world, you’re focused on throughput and trying to get your patients out in a timely manner. People started to think about post-acute care with the advent of readmission penalties. As we’ve moved toward bundled payments, accountable care, and risk-sharing with commercial plans, people have looked at those types of arrangements where they’re at risk. They have started to think about not only where they are discharging their patients, but also how they are doing in those settings.

Five years ago when I started this company, I would walk into a hospital and ask them, have you thought about your post-acute care strategy? It was crickets. Even doctors would say, all throughout medical school, I didn’t learn much about post-acute care or what that even is. Nowadays, when I walk into a hospital and we’re talking about their post-acute care strategy, it’s in the top three or five things that they’re thinking about. How do we have better control and management of our patients who are in this intermediate level of care who aren’t ready to go home just yet?

Should hospitals who claim to be managing population health have some control over what happens in post-acute care facilities? Are they expanding that idea into owning or managing those other providers?

The question of who owns the patient is a hot topic in population health right now. I think it’s the responsibility of the hospital to offer guidance in choosing that post-acute care provider. It’s not really much of a choice if you’re just giving the patient a list of names and addresses. At worst, it’s just totally uninformed and almost random. Hospitals have the responsibility to guide that choice and make sure that the patient is set up for success. That they’re going to a facility with lower readmission rates, higher star ratings, and all those factors that folks should be looking at when they’re choosing a post-acute care provider.

For ongoing management of the patient, it depends on who is bearing the risk for that patient. From what we’ve seen, hospitals that are engaged in ACOs or bundled payments are staffing out with care coordinators who are managing that patient across different settings. They need to have information from these nursing homes or home health agencies in real time about how those patients are doing. We make sure that the patient is set up for success, but we also continue tracking them once they’re in the post-acute care setting.

A lot of people don’t even know that nursing homes have EMRs. When I was initially talking to hospitals about giving them tools to track their patients in real time rather than just having retrospective data, a lot of them were skeptical. They thought that nursing homes were on pen and paper. We had to validate early on the hypothesis that most skilled nursing facilities are on some type of system, and often cloud-based systems where you can build APIs and pull this data rather than having these painful, one-off integrations that sometimes you encounter in healthcare.

How do you describe the benefits of your product to hospitals?

I emphasize that they need to have visibility into what’s happening to their patients in post-acute care from a readmission perspective. Also from a cost perspective, because if 40 percent of their Medicare patients are going into some type of post-acute care setting, that’s a big tranche of patients and they need to have that visibility from a readmission perspective. There are wide variations in how long people are in skilled nursing facilities. The average cost per day in a skilled nursing facility is between $500 to $700, so it’s a big chunk of change. Also to prepare themselves, as they are managing larger and larger patient populations, for having a sense of how their network is performing from an analytics standpoint and having that holistic view.

What patient information do skilled nursing providers and hospitals want to exchange?

I see this almost like a two-sided network. You need the engagement of the hospital, but you also need the engagement of the post-acute care providers to want to share that data.

When I was starting this company, one of the things I wanted to validate and test was the willingness of a skilled nursing facility or home health agency to share data with the hospital. It wasn’t a completely clear-cut answer. From what I had seen in the hospital, there was definitely some trepidation in sharing their own data. When we went out and spoke with a lot of these post-acute care providers, one of the things that they said to us was that they are being asked for specific care protocols to take care of ACO patients, for example, in a certain way. Often they have no idea who those ACO patients even are.

We need to add value, not only to the hospital, but to the skilled nursing facility and home health agency. We can collect data on when a patient is admitted, when they’re discharged, and some of the clinical factors, like the medications that they’re on in the nursing home. We can pass that, for example, to a hospital care coordinator. But at the same time, while the post-acute provider is not paying us, we add value by giving them things such as the name of the patient’s care coordinator and whether they are an ACO or a bundled patient. We add value to both partners.

How has the Allscripts acquisition affected the company?

It wasn’t something that we were looking for. It’s not like I started this company and had it in my mind that it was going to be acquired in a couple of years. We had supportive investors who were willing to put more money into the company, so we had multiple options. This is my company, my baby, and I wanted to make sure that whatever the decision was would set us up for long-term success.

When I jumped out of medicine, it wasn’t because I didn’t like taking care of patients. I saw this as a problem that needed solving. I was passionate about it and I wanted to make an impact. I didn’t want to just get sold. You hear stories of products getting shelved and never seeing the light of day again. It was important to me that we were able to operate independently and that there was strategic value in the acquisition that would allow us to scale quickly.

I could have gone two ways. I could have raised a boatload more money, hired out a sales team, and sold on my own to hospitals, health systems, ACOs, payers, and all that. Or, here was Allscripts, which has a product called Allscripts Care Management, which was formally known as ECIN before they acquired it. This product was in 1,000 hospitals and 70,000 post-acute care providers – SNFs, home health, LTAC, rehab, transport, and DME – are receiving referrals from it. We were encountering it over and over again as that nexus between the hospital and the community. When I thought about scaling this product, it provided a real strategic advantage for us to be able to link up with this discharge planning product. Because the other thing I hear constantly in hospitals is, I don’t want to go to another platform. If I’m using this for discharge planning, I don’t want to log into another platform.

From a user perspective, the discharge planning product sends the referral from the hospital to the post-acute care provider and CarePort bookends that process. We help with the selection and then we continue to track that patient. From a platform perspective, it made a lot of sense. That being said, most of our customers are Epic or Cerner. We’re fairly EHR-agnostic in terms of our client base.

Do you have any final thoughts?

This is a really exciting time to be in healthcare. People are finally paying attention to this whole area of post-acute care that for a long time was largely ignored. I’m hopeful that with these payment changes and the focus in post-acute care, we will finally be able to deliver to patients a better post-acute care experience. It is a critical part of their recovery and I’m glad there’s an awareness around that. I’m glad there are financial incentives around that. I’m really excited in terms of where the next five years is going to take us as an industry.

HIStalk Interviews Rob Culbert, CEO, Culbert Healthcare Solutions

February 5, 2018 Interviews 1 Comment

Rob Culbert is founder and CEO of Culbert Healthcare Solutions of Woburn, MA.


Tell me about yourself and the company.

I started my career in the mid-1980s with a company called IDX. I had the pleasure of watching IDX grow by leaps and bounds over a nine-year career. I’ve been in the consulting world for over 20 years, starting Culbert Healthcare Solutions in 2006. We are just entering our 13th year, having a blast, and trying hard to help customers through all these crazy times of healthcare.

How is consolidation in health systems, software vendors, and consulting firms affecting your company and the industry as a whole?

We’ve seen it as well. It’s hard to avoid it. In some ways, it’s positive because it’s an opportunity to gain efficiencies through economies of scale.

The areas where we have seen it the most have been around organizations coming together and either consolidating billing operations or creating centralized billing functions. Also with IT opportunities. In many cases, organizations are able to make better IT decisions when they can spread the cost over a larger population to pick the technology that makes the most sense for the newer organization. It’s a win for the patient, obviously, the more centralized an electronic health record. From a billing and efficiency standpoint, organizations have great opportunities to do their job easier.

What is the impact of Epic and Cerner offering systems appropriate to smaller hospitals?

It helps the vendors get a customer that they might not otherwise get. The need and the interest in being able to outsource IT for organizations that don’t have the bandwidth to hire the technical talent in-house — it makes it a tougher decision if they have to own that responsibility. If they can leverage a larger organization that can provide security and disaster planning, then it’s the difference between selecting a system vendor and not selecting a system vendor.

People have always said that it’s hard to sell small hospitals pre-packaged software that was designed to meet the more complex needs of larger hospitals. Do you get calls now from some of those small hospitals that are implementing Epic and Cerner who need help with implementation, maintenance, and optimization?

We do. You’re right, it is amazing that smaller hospitals that you wouldn’t have thought of as being a traditional Epic or Cerner customer can now take advantage of that technology like the big boys. We see it quite a bit, whether it’s through an affiliation with a larger organization or becoming part of a larger organization. It really does help them to be able to get access to a system.

The content that has been provided by the vendors, in addition to the software, helps organizations make the right install decisions. There’s a whole lot more tools to help them through that process than there used to be. The timetable of how it takes to implement a hospital on these systems has narrowed quite a bit to make it a win-win.

Are hospitals with less-certain margins questioning the ongoing cost of maintaining these systems?

I would say it’s the number one worry that they have. Trying to balance the user’s need for functionality and technology to do the job and the costs associated with providing that technology and supporting that technology. There’s always a balance.

The challenge in looking at it compared to earlier times is that systems are more integrated now. Typically when we were involved in a practice management implementation or a hospital billing system implementation, you didn’t get involved with people outside of those departments. That can’t be the case now because so much of what clinicians do, in terms of entering medical data for electronic health systems, is going to ultimately feed the billing side of the house. There has to be a whole lot more coordination.

If you look at total cost of ownership and take out the non-pure IT costs that can be eliminated if you set up the systems correctly, the cost of expensive systems comes significantly down.

Are hospitals looking back at the cost and effort of implementation to decide if they got their money’s worth?

A number of customers that have asked us to help them take a look at what they’ve already spent. Many times it’s because they have board members or C- level folks who are reading the newspaper and find a horror story that talks about costs of implementing a system, the challenges that came out of the early days of that system going live, and the disruption it caused to the physicians and to the organization.

What we have found is that typically when you let the dust settle — because everybody starts out all thumbs on a brand new system regardless of the system — and you get to the point where they’re using it the intended way, the costs settle down. In many cases, we’ve been able to show customers that their investment turned out to be a very good one. That helped justify their willingness to move forward to a Phase 2 or Phase 3.

We typically don’t see a ton of big-bang implementations of every application across the board. We’ve seen an awful lot of cases where it’s been staged. There’s been nervousness around, did we spend too much? Did we get the value? Is the system doing what we want it to do? We’ve found that often that investment has proven to be invaluable and helped make the decision to move forward to completing the enterprise-wide system. It’s made it a “go” decision more often than not.

A lot of what passes for interoperability involves entities within a given health system connecting their respective systems. How much interest do unaffiliated health systems or practices have in exchanging information with those potential competitors?

The reason we typically see the challenges of trying to share all of the patient data within the multiple systems that one organization might have has more to do with the business need to grow faster, add more physicians, or help hospitals into the fold so that they can do their job better of managing costs and helping patients across a wider spectrum. The business decisions around needing to implement those acquisitions quickly happen far faster than the IT systems can keep up with changing them over. That business need is what has driven some of the system integration pieces to lag behind, where everybody would prefer to start right off the bat with a clean system that is fully integrated across the various entities that have come together over time.

After that, in terms of sharing with others outside of the particular organization, the interest is there and the need is there, but we see a mixed bag of success in that happening. It is dependent on what each of those organizations use for technology as to whether or not they have the mutual interest and the ability to afford the resources to put into sharing that data.

What factors should health systems check before hiring a firm to do major implementation work?

What is the goal at the start and the end of an implementation? In some cases, if an organization has a system software license that’s going to expire in 12 months and they have no interest or ability to extend that license, then they might be under the gun to do an implementation in that time frame, regardless of whether the organization is ready and able to handle all the change management that goes into making that implementation successful and do the change management and the re-engineering of work flow to best change advantage of what the software can help you with.

That’s where we see the missed opportunities — if there are pressures above and beyond just doing the ideal implementation. Some of those organizations, whether they like it or not, are making the strategic decision that they have to move forward, get the system up and running, and then do a wave of optimization after the fact in order to make sure that they round out all of the bells and whistles and the features that could go in place.

Any time you do a big bang implementation of this size, you are hitting people over the head in terms of the amount of change that they are going to have to absorb in a short period of time. You typically try to push out your training until the very end for almost any of your users, because whatever gap in time between the training and the go-live point is going to hurt their ability to remember what they learned in training and take advantage of all the tips and tricks that they’ve been taught.

Once users get used to the system, in some cases finding themselves to be using their thumbs more than they want to, optimization waves provide a great opportunity to reinforce best practices that may have been taught in the beginning but that were forgotten. In other cases, the organization has the ability to turn on features that didn’t go on in the beginning, or maybe they turn them on because they see challenges, opportunities for improvement, or the chance to make users’ lives easier. That never changes. Constant, ongoing training to help users take full advantage of the technology. It doesn’t happen overnight. Sometimes system implementations get blamed for being a bad implementation or a poor implementation when it’s really just the start of the journey.

What is the single biggest trend you saw in health IT in 2017?

The number of organizations that were looking for a partner or an affiliate to leverage their need for IT. Their need for knowledge of the IT in order to get the biggest bang for the buck for their IT dollars and spend. Why reinvent the wheel if someone has already done it very well and you can take advantage of their best practices to get you to the end game faster?

Do you have any final thoughts?

I’ve been in this business for over 30 years. I’ve watched providers come together, go apart, and come back together for lots of reasons. The most exciting part is that there’s an opportunity to use data to make the provider world so much better, allowing them to do their job for patients in new ways. We are only seeing a fraction of the benefit of EHR installs today because we’ve been so busy getting people to take advantage of structured notes and following a structure that can now turn into data that we can use to do great things.

It’s scary and it’s frustrating because it’s a much bigger pie than we’re used to when focusing on clinicals, financials, hospitals, or ambulatory business, but all of that now has the ability to come together. We’ve never had access to that information. We will have better ways to help the patient and run an organization more efficiently than we’ve ever seen.

HIStalk Interviews Niki Buchanan, PHM Business Leader, Philips Wellcentive

January 31, 2018 Interviews 1 Comment

Niki Buchanan is PHM business leader of Philips Wellcentive of Alpharetta, GA.


Tell me about yourself and the company.

I am the PHM leader for Philips Wellcentive. I have been in healthcare IT for over 15 years. I came from the EMR world and have done implementations in a clinical setting. I’m an Epic-certified consultant and have spent time with at other EMRs throughout my healthcare experience.

Philips Wellcentive is focused on value-based care and population health management. We believe we have the tools and the capabilities across our broad business to help healthcare outcomes, help our customers reduce cost, and look at that on a patient population basis.

How would you describe the population health management technology market and Philips Wellcentive’s place in it?

My gosh, it’s so positive. There continue to be opportunities for organizations such as ourselves to leverage what’s happening, both from a legislative perspective and industry and compliance perspective.

Value-based care is here to stay. There are so many initiatives in Congress, on the Hill, as well as happening within the commercial payer organizations that are continuing to drive the opportunity for us to improve clinical quality in our healthcare settings, look at what we’re seeing as far as costs go, and help reduce those costs. But still striving towards quality as well as expanding our views beyond the fee-for-service mentality towards bundled payments and opportunities where we control the costs, but we still provide that high quality of service.

I am very excited about what 2018 has to offer us. When you look back on 2017, all of the data is coming out about how many ACOs formed last year, how many of them chose and opted into extended contracts with Advance Payment Models, and how many are looking to do Advanced Payment Models, specifically around ACOs. We’re heading into our first year of MACRA and MIPS reporting. Now we’re pivoting and evolving even more towards opportunities with value-based care. We see it as a continual business transformation opportunity, not just for our customers, but for everyone in healthcare to drive the change and the effective change we’re looking for to improve patient quality, experience, and reduce costs.

What are the primary technology components of population health management and what does Philips Wellcentive offer?

We tend to base our decisions and our strategy on partnerships that we have in the industry, specifically KLAS. KLAS says you should be evaluating your pop health partner or your value-based care partner upon six driving factors.

When you look at the Philips portfolio and the opportunities that we have to help our customers consume value-based care, it starts with the most simple of simple. We’ve got the data aggregation tools, the data analytics tools. You can do advanced insight and reporting, which meets all of those basic compliance and governmental regulation type submission programs.

We expand into even more analytics and opportunities to do proactive outreach, proactive care coordination. We provide opportunities and tool sets that allow our customers to do chronic care management, which is new in the value-based care world. Opportunities exist to do that care coordination and care outreach and get reimbursed for it, which is the key with value-based care.

So many of the organizations we’re working with are trying to figure out how to maximize their fee-for-service opportunities through wellness visits, get-healthy visits, well checks, etc. Yet at the same time, they’re balancing risk in some of these ACO or Advance Payment Model contracts with their insurers. We believe you need tools that help you with the financial side as well as that care and care coordination or clinical side.

KLAS also added the criteria in the past two years that says that if you are focused on value-based care and improvement for patients and clinicians, then you need engagement tools that allow the clinicians and the patients to have communication beyond the regular hospital walls, beyond their primary care visit, beyond their specialist visit. You need to have communication opportunities between these two entities because they are the driving force of healthcare.

We believe we have the right patient monitoring tools as well as the right partners. American Well is a great example of that, to enable us to bring the technology, software, and the patient experience even closer to the healthcare system.

Philips acquired Wellcentive about 18 months ago, explaining that it was a good fit with its other businesses, such as telehealth and home monitoring. What’s the vision for tying those businesses together?

We continue to progress through our strategy on that very front. Bringing the businesses together, the various groups you mentioned, is an exact reflection of how we see the market going in order to support customers with these value-based care contracts.

We have strong initiatives on the Hill right now, where we’re hoping and advocating that providers can be continually reimbursed for the telemonitoring opportunities and these patient monitoring opportunities. We see that as a direct reflection not only of the tools we provide, but that opportunity to engage the patient beyond the clinical setting. If providers can’t be reimbursed specifically for those fee-for-service visits, or a limitation of fee-for-service visits, they need alternate ways to not get negatively impacted, but yet still provide the same level of care as before.

Bringing together Philips Wellcentive, bringing together our hospital-to-home, ambulatory business, and even other components within our organization to allow us to expand and deliver medication management within the home, collect that data, and bring that back into our system and EMRs. We see these all as a continual part of our strategy for tackling all areas of value-based care and pop health management.

Philips confirmed layoffs in the population health management business to me a few weeks back, with the spokesperson explaining that it was due to “the dynamic nature of the population health management business.” What forces are in play that required changing the workforce?

There are always opportunities for us, whenever we’re revisiting our strategy, to stay focused on what’s important for our business. That opportunity for us is always in gaining our efficiencies as well as aligning our strategy toward what our customers need. We are pleased with the strategy that we’re rolling out in 2018. We see us as having all the components we need to be successful. I appreciate that you’ve covered that topic with our PR department. Obviously, they’re the ones to provide the standard response to that.

Philips recently announced several acquisitions, with the one that seemed most relevant to me being VitalHealth and its outcomes measurement. How does that fit?

We see it as absolutely critical and pivotal to our business in both the European market and the Asian market. VitalHealth is well known, with a great customer base. They’re a creative group of individuals, now part of our larger pop health strategy. Yes, we absolutely see it a part of our key business going forward. There will be opportunities for the market to hear more about them at HIMSS this year as well. We’re excited to be able to expand the global footprint and meet our customer’s demands and needs across the globe with having this acquisition and this new family member as a part of our business.

Does Apple Health Records have a place in population health management, or is it only of consumer interest?

Oh gosh, isn’t it exciting? I love the age we’re living in right now. It feels like every day I wake up and there’s a new article about some consumer-driven business that is having a positive impact on healthcare. Yes, I absolutely think there’s a place for that kind of innovation and technology. I see organizations such as ours, Philips, being able to capitalize and partner with these types of entities.

Pop health 10 years ago was a strategy in and of itself that was segmented by healthcare organizations. It is a business transformation opportunity now, and it’s being visited and seen that way over and over again in the market. I get excited at the CVS mergers and the new ways of thinking about bringing people in for their yearly immunizations, because this is the opportunity. If we’re able to leverage consumerism at this level and at this scale across North America, and of course the globe, we’re going to allow providers, when they have the patient in the office, to practice to the top of their license. They don’t have to worry about all the routine things that occur for a patient every year.

When I think of the impact of EMRs, I spent a career helping set them up across different organizations. I love the fact that there’s a digital record — for me, for you, for patients across the country — that reflects the care that they have received. But I love that we’re taking that data out of the patient record now and we’re deciding on proactive opportunities for caring for them. We’re pivoting away from sick, we’re pivoting towards well care, which is a hugely opportunity for all of us. In addition, because our providers and our clinicians are now used to using an EMR, there is the opportunity for data aggregators such as Philips Wellcentive to take that same information and display it back at the clinician’s fingertips in their EMR.

We are opening up our partnerships. We are opening up our technology. We’ve always had an open platform, but we’re doing so in a strategic way this year to say, do you want to keep your clinicians working in their EMR? We have the data you need for them to make some clinical decisions while the patient is in your office. Let us take care of that for you. Let us create the technology and merge with the technologies out there so that you have banners or pop-ups that tell you what you need to do at the point of care. Don’t worry about how the data got there — just know that it’s valid, it’s clinically relevant, and it’s the right data at the right time. I’m excited about the future there.

The term “population health management” sounds a bit paternalistic, something providers do to faceless groups of patients because they get paid to check boxes when electronically prompted to do so. Does a conflict exist between what providers want to offer and what consumers would like to have?

Absolutely. I don’t think “conflict” is the word I would use. I see it as a coming together. I’m a patient. I’m a consumer. It drives me insane that I have to make a physical phone call to be able to get in and have the care that I want available. I have a son who has been through many medical treatments over the years. The opportunity to get online and schedule a visit, a follow-up visit, for him, to be able to do all that online or from my smartphone seems like the most logical thing, and the way the consumerism market and expectation is driving towards.

Does it put it in conflict with some of our older, established technologies in healthcare? Maybe. But, with innovative companies like Philips and others that are out there, we should be able to build simple tools, simple applications, that allow all that robust technology that we already have in house to simply get connected. When you talk about consumerism, I immediately think it’s all about connectedness. It’s all about us having access to seamless care and opportunities for us to interact even more so with our providers in the way that makes the most sense for us. Granted, I’m a 45-something year old person, I love my iPhone, and what I’m saying may not play well for a 70-year-old or a 17-year-old. But the whole idea around access, patient engagement, and me — where I am at my stage of life — being able to interact with my well care, my sick care for my children, it just makes perfect sense to me. I think we’re all on the right path. We just need to do it better together.

Do you have any final thoughts?

Everything in the industry is going our way right now. Everything in healthcare, everything as far as policy, everything as far as reporting, it is all aligning. The planets are aligning and we have spent so many years as a business planning for this coming together, this tsunami of value-based care that’s on its way.

We feel like we are well positioned to help our customers, prospects, and partners leverage the tools and the data they have to make the right decisions, provide the best care, be efficient around their costs, and strategically plan the business transformation that they’re undergoing. So many are new to risk and risk contracts. We are helping, in partnership, prepare them for that next level of risk, their ACO or MACRA Year 2 reporting. We are excited and we feel like we’ve got everything in the portfolio we need, as well as the partnerships, to be successful in 2018 and meet our customers and our prospects where they are.

HIStalk Interviews Jonathan Baran, CEO, Healthfinch

January 29, 2018 Interviews 2 Comments

Jonathan Baran is co-founder and CEO of Healthfinch of Madison, WI.


Tell me about yourself and the company.

The fundamental problem in healthcare is there is far more work than there are people to do it, particularly to care for patient populations. Healthfinch closes that gap by automating routine work that’s associated with patient care. We accomplish that with software that sits on top of electronic medical record systems.

The company is just under 50 people. About half of those folks are based in Madison, Wisconsin. The remainder are remote all across the country. We have 5,000 physicians on our platform and 1.5 million patients that we interact with in some form or fashion each year.

Do you worry that EHR vendors could add similar functionality to their core product?

A core premise of the business is that the next wave of healthcare IT will be built on top of electronic medical record systems. I started a PhD at the University of Wisconsin on building tools on top of EMRs to automate work back in 2009. At that time, it was particularly crazy to think about building on top of EMRs. It just wasn’t heard of at that point.

There has been a significant change in thinking that we’ve seen across the industry. We like to think of Madison, Wisconsin as ground zero for healthcare IT. Now you’ve seen every single EMR vendor open up and start to support companies that are not directly competing, but are doing ancillary things to improve their functionality. I believe it started with Allscripts and Athena and now Epic is part of the game.

While there’s a whole bunch of things that EMRs do, I think they are coming to the conclusion that there are far more smart people outside their organization than are in it. The more that they open up their platforms to enable people to do cool things on top of it, the better for everyone, their customers and the vendors themselves.

Healthfinch products are offered on the third-party app marketplaces of Allscripts, Athenahealth, and Epic, so you are relying on their openness and ongoing cooperation. What’s the benefit and the challenge of working in those EHR vendor marketplaces?

It’s not always easy. We knew early on that if we wanted to introduce technology to support providers in any way, it was not going be via a separate user interface or something that caused you to get outside of the EMR workflow. It was going have to be contained in the EMR for it to make sense.

We started this company with the premise that if the electronic medical record doesn’t exist, then we don’t exist. We don’t have a standalone system. We only exist in those EMR markets. That puts us in a unique position.

Certainly there have been challenges over the years. There’s been a big shift in thinking from how companies like us integrate. There was a dominant way of thinking a while ago that HL7 gives you everything you need. But when you start thinking about the world in the context that I just proposed, an API-driven approach needs to be much more prevalent for that to become real. There’s been a change in thinking and technology changes that have come along with it. We’ve had to follow that wave.

The market is not used to buying from these marketplaces. There’s a whole bunch of reasons for that. But you’re starting to see vendors promoting openness a lot more, because they understand it as being a key piece to the business moving forward. They need to talk about their innovations, the cool companies that are sitting on top of them that are doing things that are interesting that might not otherwise be possible. That’s creating a lot of market awareness, but people aren’t used to buying in this sort of way.

You’re going to see this follow a similar trajectory to what you’ve seen from other enterprise systems like the Salesforces of the world. It will take a few big proof points to prove this, but they will come. It’s just a matter of time now that the EMR vendors have started to embrace it.

Can you assume that those EHR vendors will promote your product? Do they have the right incentives — i.e., financial — to do so?

At least in our experience, all the EMR vendors have financial incentives in the form of a revenue share that makes them align with your business. From my perspective, that’s good thing. I want them to be financially aligned enough to make sure they’re moving in the same direction.

In terms of how they help, how each EHR thinks about that, you get slightly different responses from their teams. In some cases, it is a direct promotion. Sometimes they identify a customer that has a high need for what we offer, and they say, “You should check out this company XYZ on our marketplace.” That’s awesome. That’s great. That’s a great way for us to get visibility within the market.

In other cases, it’s more indirect. For better or worse, all these marketplaces start as just, “Look at all the companies that we have.” More and more they become embedded into the way that organization thinks about doing business. But that’s a many-year transition for these companies, so for the ones that have been there longer, you see more of it. It’s a progression.

How do you decide which areas are ripe for third-party innovation and how much effort is required to turn that into a product that works across multiple EHRs?

Identifying areas of market need comes down to understanding your end user. How they think about the world and the challenges that they face day-in and day-out. We have a strong perspective of that at Healthfinch, which is that there is far too much routine work that is overwhelming providers and their staff. That is the premise around which we think about the world.

The question is that, within that broad context, what are the specific use cases or pain points that are causing challenge today? I place an emphasis on the term “use case” because far too often, startups in particular go in with solutions that are general. They are referred to as general platforms or general purpose solutions that are pitched as, “We could solve a bunch of problems for you.” But in reality, you need to be selling use cases to your end users because that’s what will resonate.

Really quickly, the challenges become apparent. Then to the broader point of that, translating that to other EMR contexts and specifically within the EMR — that is definitely a big gap that we see. I’ve never worked at Epic or an EMR company. A number of folks in the company now do or have in the past. But the understanding of these rather complex workflows is a big barrier to innovation right now.

Take the broad concept of automating prescription refill requests. That sounds simple on the surface, but once you start digging a couple of layers down, you realize the complexity. It’s not always easy to uncover that complexity. That’s a big challenge that I think a lot of these EMR companies have. How do I take an idea and turn it into something that works at the highest level? But also something that works day-in and day-out with what we know are the challenges of healthcare IT today?

The good news is that the general themes will hold across all EMRs. The same problems you face are pretty consistent between EMRs. But there’s always that little bit of nuance that’s specific to each of them. It’s a challenge, but if you can get in there and figure it out, it represents a competitive barrier for new entrants.

How do you coordinate and test EHR changes and make sure the customer isn’t straddling incompatible releases of their product and yours?

When we are integrating with these EMRs, they are making an either implicit or explicit promise that their integration points are going to hold from version to version. So in most cases, that’s abstracted away from us and not something that Healthfinch has to worry about. We just have to make sure that we are consistently working with the SLAs that we have with those third-party vendors.

That isn’t always the case, though, and it doesn’t always hold true. I can tell you that five years ago, it was much more of a challenge from release to release. We had to double- and triple-check to make sure that wasn’t the case. That has smoothed out considerably over the last couple of years. It has more tried-and-true process associated with it as they’ve become more used to working with third parties.

Some EHR vendors are well known as having zero interest in working with third parties or offering open access points to their product. Can those vendors continue operating by walling themselves off?

I don’t think so. For the last couple of decades, there was certainly an argument to be made for the highly-integrated electronic medical record system that didn’t work with third parties, working strictly within the four walls of that organization. What’s happening now is that healthcare is becoming far too complex for just one company alone to solve all those challenges. To a certain extent, you’re facing the classic innovator’s dilemma. The approach that has allowed you to win in a previous business environment is the same approach that will cause you to fail in the current context if you continue along.

Will there be some holdouts? Sure. Will it be challenging for those folks? Yes. As these open platforms become more prolific, as customers use third parties and see the value and that these companies that are narrowly focused in given niches that can do a lot more than a company that has to build towards a lowest common denominator, as they see those proof points begin to emerge, those third parties are going be important to their business and how they run things. That’s not to say that that change is going happen overnight, but it’s a fundamental tipping point. A lot of the major players have already made that transition, so it’s only a matter of time.

Where is the company in its growth trajectory and where does it go next?

We are still very much in the growth phase, on the heels of some of these app stores that have come into existence. In the case of Epic in particular, it went live in the last quarter and we’ve seen a nice uptick in business associated with that.

For us, it’s the mindset of going out and growing the business in those areas that you identified. We last raised funding a couple years ago. We’ll be doing a little bit more fundraising, but then we’re driving towards building this thing into a big, profitable business moving forward.

Do you have any final thoughts?

I am truly excited about the time that we live in right now in healthcare IT. The type of change that I mentioned at the beginning has only become possible to build because of the introduction and the adoption of these electronic medical record systems. For the first time in the history of the world, we have an opportunity to drive some incredible change for healthcare systems, physicians, and for patients. So much is changing.

We are at this defining point in the industry’s life cycle. I’m excited to see the innovations that come out Healthfinch, obviously, but also in the industry at large. There’s opportunity everywhere to drive significant improvement.

HIStalk Interviews Brent Lang, CEO, Vocera

January 24, 2018 Interviews No Comments

Brent Lang is president and CEO of Vocera of San Jose, CA.


Tell me about yourself and the company.

Vocera Communications makes clinical workflow solutions that simplify and improve the lives of healthcare professionals and patients. We’re focused on enabling hospitals to enhance both quality of care and operational efficiency. That has direct impact on patient satisfaction and caregiver resiliency as well.

The company has about 600 employees. We did roughly $160 million in revenue last year. I’ve been the president and CEO of Vocera since 2013 and I’ve worked with the company since 2001. I spent the first six years as the VP of marketing and then spent another six years as the president and chief operating officer before taking over as the CEO.

In terms of my personal background, I have an MBA from Stanford. I have an engineering degree from the University of Michigan. In 1988, I had the privilege of being part of the US Olympic Swimming Team and won a gold medal in the 4×100 freestyle relay in South Korea, which ironically is the location of this year’s Winter Olympics. Thirty years later, it’s returning back to Seoul, South Korea, and I’m really excited and interested to see that.

Vocera has been around since 2001, the company is publicly traded, and competitors have come and gone in those years. How would you characterize the market and Vocera’s position in it?

It is an interesting market. It has definitely evolved over time — our offering into the market, how we’ve broadened our solution, and the way the market perceives us. We were the creators of the category, and for a long time, had to educate the market about the value proposition.

What we’re seeing today is a recognition that clinical communications is a high priority. More and more customers are reaching out to us proactively to help them optimize their data and mobilize their data in the post-Meaningful Use era, where most hospitals have their electronic health record deployed. They’re looking for ways to empower the mobile workers inside their buildings. Getting the right information to the right worker is a real challenge for them.

We’ve evolved from being more of a pure communications company to being more of a clinical workflow company. Much more software-centric. The clinical relevance of our solution has definitely risen up. As a result of that, the competitive landscape has evolved over the years. Initially, we were replacing pagers and in-building wireless phones. We were replacing a lot of inefficient processes, where people were running the hallway looking for the right person. 

Today, we’re much more focused around the idea of clinical workflow and how we can empower care providers to be more efficient. Also, how we can reduce the level of burnout or burden on those care providers by giving them the tools that allow them to do their job on a daily basis.

Have we figured out alarm and event notification?

It’s definitely still a work in process. Connectivity from all these clinical systems to mobile workers was a Phase I solution that created as many problems as it solved. All the research would indicate that the vast majority of those interruptions and alarms that caregivers are receiving don’t require immediate action.

A real focus for us is using intelligence, analytics, and rules engines to try to filter out only the most appropriate alarms, alerts, or messages. Then, delivering those only to the most appropriate person. This idea of the interruption fatigue or alarm fatigue that results from being bombarded by all these clinical alarms is a real concern. It has resulted in a high degree of burnout among clinicians.

For us, the key is pulling situational awareness from the environment. What’s going on with the patient? What’s going on with the care team and their care plan? What’s going on with the other data points that might be accessible from other systems in the hospital? Then, using that to filter out only the most relevant and most urgent messages to be delivered to a particular care provider.

Is it a market differentiator to offer an enterprise strategy instead of point solutions, multiple devices, or a lot of connectivity points?

Our approach has always been to try to listen to the pain points of our customers. You may not know this, but when Vocera was originally founded, we were not a healthcare company. We were a solution that could be used across a variety of vertical markets. It was a  function of listening to specific pain points within our customer base that made us more and more focused on the healthcare space.

As we’ve evolved the product over time, it’s always been driven by, how do we not think of it as a particular technology or a particular point solution, but how do we think of it in terms of solving particular clinical problems or customer problems? Even our sales approach is one of a consultative inquiry, where we actually send out clinicians. These are people who have worked as nurses before they came to work at Vocera. They do a clinical assessment, where they interview people at a customer site to understand what problems are top-of-mind for them. Then we try to apply the solutions to that. 

We’ve always had this solution mindset. I think the market is evolving in that direction. If you look at some of the more recent analyst reports, they’ve moved away from looking at it in terms of vendors that might only provide text messaging or might only provide integration. The landscape today is around who can deliver a unified platform that enables true collaboration and clinical communication across these different care providers. 

I view that as validation of the strategy that we’ve been pursuing for the last several years. I think that the rest of the marketplace is recognizing that and realizing that they need to move more in that direction.

It must have been both a blessing and a curse to have been identified so strongly with the Star Trek Communicator thing early on, and people might still associate Vocera with that communications badge. How do your other services — such as patient experience tools, pre-arrival preparation, follow-up care, and PCP notification of patient hospitalization — fit in your business?

You’re absolutely right. The Star Trek connection, the uniqueness of the badge, and the iconic nature of the Vocera badge has been both a blessing and a curse over the years. It’s driven a tremendous amount of brand awareness for the company and a tremendous amount of differentiation and uniqueness in terms of our offering. But it does tend to limit people’s perspectives on the value proposition that we’re delivering to marketplace. We have had to invest time and energy over the last several years to educate the marketplace that there’s much, much more to the Vocera platform than just the badge or just voice communication.

Our goal is to deliver across the care continuum in interacting with patients and care providers. The products that you mentioned — pre-arrival, post-discharge communication, the rounding solution — these are all software solutions that we feel like fit into our vision around enabling the real-time health system. We have to do a better job of informing the marketplace that we have that breadth of solution.

For us, it’s all about how we can simplify the lives of these care providers and improve patient satisfaction, There’s a variety of ways we can do that, whether it’s clinical communication, secure text messaging, alarms and notifications, patient experience monitoring, or analytics. These are all areas that become part of a unified platform. By tying them together, we’re able to do some exciting things that you wouldn’t be able to do if they were simply just point product solutions.

Are caregivers changing their work communications expectations because of the apps they use at home?

It’s certainly raising the expectation, both in terms of their experience on consumer devices as well as their interaction with voice interactions. Things like the Amazon Echo, Siri, and Google Home. When we were first introducing our products 15 years ago, the idea of using speech recognition as a user interface was fairly new and took some getting used to. Today, consumers are very comfortable using speech as a user interface. That has generated a whole new level of interest in our products, because people are more comfortable with that in the rest of their daily lives. Mobile technology is another area that has become more prevalent for all of them.

Having said that, we still believe that there are some unique requirements for the healthcare environment. In general, it’s very difficult to bring a true consumer device or consumer experience into the healthcare environment.  You’ve got issues associated with security and privacy of patient information. You’ve got cleaning and sterilization issues. You’ve got security on the wireless network standards. You’ve got breakage. Hostile environments are really tough on electronic devices, and most consumer-grade phones have a hard time surviving in the hostile environment.

Our purpose-built solution has created a large degree of differentiation for us because we’ve solved the problems of how you get a wireless device to roam inside a hospital. How you create the ability to block out background noise so that you can have a clear communication in a very noisy environment. How you can share a device across multiple users while having it be fully encrypted and logged into the highly secure wireless network environment that an enterprise customer has. Those are all examples where the expectations of their daily lives as a consumer influence their technology choices, but to bring it into the enterprise environment, you have to up the game one step further.

Another example has to do with text messaging itself. Several years ago, there was a feeling that text messaging by itself was going to be a communication solution for hospitals. Today, the market has spoken and made it very clear that while it’s an interesting feature, it is not a complete solution for mission-critical, real-time environments like hospitals delivering acute care. Secure text messaging combined with real-time voice communication, alerting and alarming, and clinical integration are all required to put together a complete solution. 

The consumer offering tends to be the baseline. To be successful in the enterprise, you have to build upon that and solve for not only the environmental issues, but also the specific workflow challenges associated with a hospital.

I didn’t realize until recently how widely deployed Vocera is within the VA and DoD. Does their Cerner implementation present any new challenges or opportunities?

It really doesn’t affect our business directly. We love our federal customers, both in the VA and in the DoD with the military hospitals. They’re great customers for us. They have a tremendous level of loyalty. They’re great users of the product. They drive standardization across their facilities, something that the healthcare industry overall has not necessarily done a great job of and is moving more in that direction. People are recognizing that to drive greater efficiency and better quality outcomes, standardization is a key. The DoD and the VA are leading that effort and have done a great job of standardizing the product.

We integrate with Cerner. We have a lot of great Cerner customers that are able to send alerts and alarms from the Cerner EHR out to the Vocera clients. The DoD and the VA were very clear that it is important for Cerner and Vocera to work effectively together in that environment. To some extent, it’s another source of great data that can be delivered out to the mobile workers. In fact, the Cerner employees doing the deployment in that environment are going to be wearing Vocera badges during the deployment and rollout of the Cerner EHR.

What business lessons did you take away from your experience competing in the Olympics?

Swimming was a big part of my life growing up. Certainly the Olympics was a key accomplishment along that path. But one of the key lessons you learn as a competitive athlete that translates directly to the business world is that life is not a sprint. It’s a marathon. 

I was a sprinter. I swam on the 400 freestyle relay. I swam the 50 and 100 freestyle. These are races that last less than a minute, but you train for them for 15 years. Even though the glory happens and the media focuses on the 20 seconds or the 50 seconds that you’re in the water, it’s the preparation that goes into that ahead of time. 

The business world is very similar to that. People focus on an event. They focus on the IPO, the sale of the business, or a big customer win. But success in sports and success in business is about putting in the effort every day. Having the discipline. Having a clear vision of where you’re trying to go with your life or your company and focusing every day on making progress towards that and not letting the day-to-day highs and lows impact your progress towards that end goal.

Do you have any final thoughts?

I’m really excited about the market transition that we’re going through. I think in the post-Meaningful Use era, there is an opportunity to transition care delivery across the care continuum and to use technology to not only improve patient satisfaction and patient safety, but also improve the caregiver resiliency. We have a major problem with burnout among nurses and physicians. Technology has been a source of that problem, historically. 

Vocera is committed to using technology to restore the human connection to healthcare and to enabling care providers to go back to doing what they went to nursing school for in the first place, which is to care for patients. Our employees and our customers are passionate about that. It drives us every day.

HIStalk Interviews John Fleming, MD, Deputy Assistant for Health Technology Reform, ONC

January 8, 2018 Interviews 3 Comments

John Fleming, MD is deputy assistant for health technology reform for the Office of the National Coordinator. He served in the US House of Representatives (R-LA) from 2009 until 2017.


Describe your role within the Office of the National Coordinator.

I’m a board-certified family physician. I practiced for a number of years, going back to 1979 when I completed my family practice residency. I did six years of service in the Navy and then went into private practice in Minden, Louisiana. I ran for Congress in 2008 and served from 2009 through last year. I was appointed to this position, deputy assistant secretary of health IT reform, in March. I’ve been serving here ever since.

We have two major areas that we are working on going forward. One is interoperability. Genevieve Morris is the lead on that and that’s her specialty area. Mine is in physician burden, administrative burden, and provider burden in general. But particularly physician burden is critical and crucial at this point. Of course I work with the interoperability issues as well, but my major emphasis is on physician burden.

We’ve been doing a lot of stakeholder input. We’re continuing that process. Then, we’re going to begin working on deregulatory actions as well as fulfilling a requirement in the 21st Century Cures Act that we report to Congress or the Secretary or both. We’re still trying to elucidate that issue on the current state of things, which incidentally is not good on physician administrative burden, and recommendations on how we can move forward on that.

How do you see ONC’s role, especially since some of the burdens of documentation were imposed by the federal government and systems vendors design their products both around those requirements and what they believe the market has demanded?

In the mind of most providers out there, the burden is in some way connected to, if not caused by, the electronic health record. But the plain truth is that the electronic health record is not the fundamental cause of administrative burden. But it does, I think, worsen it to some extent, and it has not yet been capable of fixing some of the problems with administrative burden that you might expect a computer to do. 

I think it makes sense that ONC is involved. In the 21st Century Cures Act, it calls out for collaboration between ONC and CMS, because CMS is a major payer for healthcare across the nation. I’ve heard estimates that as much as 40 percent of healthcare is paid for through CMS, mainly through Medicare and Medicaid. It calls out a collaboration between ONC and CMS to do these things.

We have four work groups that are currently working in collaboration between the two agencies on the various aspects. Yes, the electronic health record does have its issues in terms of usability. The interface, we certainly think, needs improvement. But to be honest with you, it is not the fundamental problem. The fundamental problem with physician administrative burden has been an accumulation of regulations, requirements, and restrictions going back over three decades. To solve the problem, we need a combination of regulatory reform as well as improvement and enhancement of the EHR interface.

Do you see the burden of documentation that was introduced as an improvement framework within Meaningful Use unwinding, or will it just be changed to reflect contemporary practice?

I don’t think it’s going to change on its own. If left untouched, it’s going to continue. In fact, it’s actually going to get worse, because in the 2016 MACRA bill, there is brought forward the quality measures and quality reporting into the electronic health record space. Those requirements actually started up maybe six or eight years before, but they were streamlined and brought up to date into the MACRA  bill and set up for implementation.

As of last year, we began to see the implementation of quality reporting, and then payments are going to be adjusted based on scores. But the problem is, how do you work that into the electronic health record workflow without causing additional administrative burdens? The truth of the matter is it’s quite a challenge and there’s a lot written about it. MedPAC has made some very interesting comments about it as well. I would say to you that in the current trend line, it’s going to get worse before it gets better, which is all the more reason why we need to begin addressing these things.

One thing that you mentioned — I would like to adjust back on the facts a little bit. The documentation guidelines that I think are a big source of the physician administrative burdens actually began in 1995 in the pre-EHR period. The electronic health record in some ways has made that worse as an unintended consequence. In 1995, the rules and regulations came out and they were somewhat changed or added to in 1997, so there are two sets of guidelines and physicians can use either one of them. Evaluation and management codes – which are what most non-surgeons use, a set of codes as far as what level of service was provided — determine the pay to that physician. The level of payment is determined by how much documentation is provided in that visit. The point is, the more you document, the more you’re paid.

That doesn’t necessarily mean that doctors are being paid more for better service, longer time spent with patients, or even better care. Simply, the more they document about what they did, the more they’re paid. The problem that we see in the electronic health record era is that now these systems are often designed where you can click boxes and dump a lot of data or text into the progress note, much of it normal description, which then creates a huge document that becomes virtually unreadable and actually camouflages important findings. We call that note bloat.

As a result of the documentation guidelines in 1995 and 1997, which at that time required either dictation or handwriting, then you fast-forward into the higher adoption rates we have today, which are about 85 percent for ambulatory care, 97 percent for hospitals. Instead of improving that, the unintended consequence is that the way systems are designed, it creates larger and more unreadable notes. That has become quite a pain point for providers to the point that oftentimes a doctor simply refuses to read progress notes that other physicians created because they simply don’t have the time to dedicate to reading what is a lot of normal text. Often it’s a syntax that’s very hard to follow because it’s a cut-and-paste kind of creation.

Hopefully that gives you a little better idea of what seems to be the most crucial pain point. There are others, but that seems to be the one that you hear the most from physicians.

How do you see the recommendations of those committees being operationalized?

The documentation guidelines evaluate a progress note in terms of how the physician is paid based on three areas — the complexity of the history, the physical exam, and then the decision-making process. It’s very specific and arbitrary about how many systems are examined and discussed, how many tests are ordered, and that sort of thing.

The stakeholder input that we get — and a lot of discussions that we have internally from those like myself who’ve practiced medicine for a number of years — is that that needs to be reformed and streamlined. Just a couple of example ideas that we’re hearing. One is to do away with the requirements on the physical exam and the history and simply base that on the complexity of the decision-making. That can be somewhat arbitrary, too. How do you really score that? How do you determine what’s complex and what isn’t?  For instance, you may have one person with a serious disease that requires a lot of discussion and decision-making, or you may have somebody with five different simple problems. Which is considered more complex? That’s a matter of debate.

Another option that’s been discussed — and again, no decisions have been made whatsoever — would be to simply pay the physician a blended rate for the encounter and assume that some encounters are going to be more complex than others, but that by doing away with the extensive amount of unnecessary documentation that’s more red tape than anything, that the physician would have more time to spend with the patient and provide better quality care.

That’s just some of the discussion. We’re not even close to making a decision on that.

You said once that you would like everyone in America have a single, cloud-based health record under their control. Is that possible, and what would it take to make it a reality?

It is possible. There are some barriers. There are some challenges before us, but they’re technical and they can be overcome. For instance, how do you get that information to that location? That’s where we’re working on interoperability. Genevieve Morris is working on the TEFCA program – Trusted Exchange Framework and Common Agreement. We’ll have regulations that come out that are compliant with HIPAA, which will promote and implement some standards and also enforcement such that providers will be better able to share information with permission of the patients.

As we do that, there are companies out there already that have data banks, or patient record banks. They’re already accumulating those to some extent. It’ll simply be a matter of how they collect these from various providers, how they organize these records, and how they put them under the control of patients. That’s where the discussion about APIs comes in, which we talk a lot about here. Then, how do they give permission to other providers to access those records and at what security levels?

This is all coming together pretty rapidly, although we don’t have a specific goal here at ONC to create a patient-centered record. Both patients and professionals alike have a huge stake in this outcome. We’re facilitating the intermediate process of sharing that information, making sure the data is readable and transferrable so that ultimately it can be put into one single location.

That’s not to say that providers wouldn’t also have a version of records as well, but there would be a stockpile, or a single location that a patient could point someone to so that all care can be accessed to the extent that the patient gives permission. For instance, if you’re traveling in another state or another location and you have an acute illness, you could simply give a temporary password or code and that physician could access all of your records that have accumulated from a number of providers over a span of time.

How much is the lack of interoperability due to technology rather than the business problem of providers not necessarily wanting to share information?

It’s totally a mixed bag. Both of those are factors. I don’t think I have enough information to decide which is worse or which is the bigger problem. They’re both big problems.

I think that the policy side of it and the business model side is a lot easier to fix than the technical side, because what you’re looking at is all sorts of syntax issues. For instance, some programs may be set up to measure weight in kilograms, some in pounds, some may write out “pounds” and others might use a symbol instead. All of these things have to be unified in a way that when you send that information, it means what it’s supposed to mean when it gets to the other end.

There’s a huge complexity to all of those issues. We’re trying to bring everyone to a consensus on how that information is reported and what format we use, such as the FHIR standards, which seems to be the way most people are going nowadays. The standardization is something that we’re working on so that it’s easier to move that along.

The other part of it is, how do you build the highways out there for that information to flow? Then more importantly is the on-ramp to that information highway. Let’s say a solo physician wants to be interoperable with a local hospital, maybe other medical clinics, ambulatory centers, or other physicians. They may have to sign a number of different contracts in order to be able to do that with different standards, different requirements. Some may cost money in order to build APIs, an interface where one program can share information with another.

What Genevieve is working on is on-ramps where a given provider could — either through the vendor or through a local information exchange organization — get on that information highway with one login that’s sustainable. They can go wherever they need to go to get their information, whether it’s a one on or whether it’s a bulk download or upload.

All of that’s in the works. We’re trying to be not overly prescriptive about it because we want to be sure innovation continues. Sometimes too much regulation can hold that back.

But there’s also is the business model, the business case. Currently, or certainly in the past, there are vendors out there who felt it was in their best business interest not to share information or the capability of sharing information except within their own system. That gives them, in their view, some advantage in order to sell their system and its capabilities.

But I think with the evolving regulation requirements — and certainly the very stiff penalties against those who don’t create the capabilities to share information — there’s going to be a totally different business case out there that will be in the best interest of all vendors. That is to say, if you’re not able to communicate with all of the systems available out there through the pathways given, then you’re not going to have a sustainable business. I think that’s going to change rapidly over the next year or two.

How has ONC’s mission and operation changed with the leadership changes in HHS and the White House?

I can only speak for leadership as of this current administration since I really had no interaction with ONC prior to that time. The changes in leadership that we’ve had have really had no impact. Certainly the three political appointees in our agency are the same from Day One and our mission has been the same. We haven’t missed a step. We may report to a different person from time to time than we did before, but nothing’s changed about our activities or was really impacted whatsoever from the change of leadership, certainly at the Secretary level.

As a former number of Congress and a physician, what are the most significant opportunities to improve American health?

First of all, that we put patients or consumers back in the driver’s seat so that they can make decisions about their own healthcare and their healthcare coverage. Where we come in is the liquidity of data, so that information can go where it’s supposed to go and certainly for the benefit of the patient or the consumer. The reason I say “consumer” sometimes instead of “patient” is that a lot of times people want to maintain good health rather than getting well from ill health. It’s important to think of everyone in America as having the need for data liquidity for their health, even if they’re fully healthy.

We’ve  been through quite a cycle of healthcare reform, which I think continues to evolve. Whether you are very much in favor of government being in control of the healthcare system or whether you believe that the free market should be in control, I think we all agree that better access to care and lower cost and higher quality care should be the goal. That is really the goal ahead of us. We’re trying to create that data liquidity in order to help patients and professionals to delivery higher quality and lower cost.

Then on the physician burden side, if you look at it from a macroeconomic standpoint, there’s a lot written about the fact that physicians spend at least half their time and perhaps more — and we think that this is happening with nurses and other healthcare professions as well — on administrative duties. They’re spending half of their professional activity functioning below their license. What we really have is a pent-up productivity in America.

Think about the physician shortage that we have across America, particularly in primary care. If we were to unleash doctors, if they were practicing up to their full license status — that is, functioning as healthcare providers at least 90 percent of the time, much less 100 percent of the time — just think how much more care and how much time they could spend with patients, how much better quality of care would be, and how much lower the cost would be.

That’s the ultimate goal I have in the physician administrative burden space — to unleash, unlock that pent-up lack of productivity that has been created over three decades of regulations on top of regulations. I’ve only named two or three. There’s quite a number of them that sometime I’ll be happy to go through it with you to show you just how much has been done in the regulatory space over the many years that has created what is, at this point, a critical juncture in this time of healthcare such that doctors, at the highest rate ever, are having burnout or retiring early, going into other professions, and certainly not practicing to their ultimate capabilities. That’s what I hope to achieve on the productivity side of things.

Do you have any final thoughts?

Other than the ongoing regulatory responsibility that we have at ONC — which is the follow-through on Meaningful Use, which is now wrapped into MIPS, which is part of the quality measurement and quality reporting space going forward and through statute — what we are dedicated to do here in addition to supporting HHS in all of its goals and missions is to create data liquidity, lowering healthcare cost and increasing quality by way of improved interoperability and the end of information blocking. Then also to unleash physician productivity, which is at an all-time low. That is, in a nutshell, what we’re all about here at ONC.

HIStalk Interviews Dennis Dowling, CEO, Formativ Health

January 3, 2018 Interviews 1 Comment

Dennis Dowling is CEO of Formativ Health of New York, NY.


Tell me about yourself and the company.

I’ve been working in healthcare most of my life and my entire career. I have spent probably 42 of 45 years working in an organization now known as Northwell, which is a healthcare system in metropolitan New York. I held a a variety of responsibilities. I was executive director of two of their flagship hospitals, North Shore University Hospital and Long Island Jewish Medical Center. I was more recently responsible for the strategy and the management of their ambulatory care network, which now comprises over 3,000 physicians and multiple joint ventures in dialysis, imaging, urgent care, ambulatory surgery, and so forth. 

In January 2017, I became as chief executive officer of a commercial, for-profit joint venture known as Formativ Health.

How hard it was to turn Northwell’s management services into an investor-backed joint venture company?

There are clearly differences between a not-for-profit, community-based organization and its culture and that of a for-profit, commercial enterprise. The difficulty is in having both of these organizations understand the culture of the other and figure out how to adapt their cultures, missions, and objectives together.

It’s not the business so much as the personality and character of the organizations that have to be understood. If you have a community-based organization, no matter how large or complicated — a not-for-profit, mission-driven organization like most of healthcare — to understand how to function and operate in a for-profit, commercial world is a challenge. Similarly, these commercial, for-profit organizations don’t get it when they’re dealing with a community-based organization like most of healthcare.

In what areas are physician practices least prepared to meet current and future expectations?

I would start with consumerism, the advent of transparency, convenience, and the expectations that most of the population has of other industries. Whether it’s banking, retail, or airlines, when you interact with any of those industries as a consumer, you have certain expectations about service and convenience. Healthcare is way behind in having that transparency, convenience, access, and service as part of its DNA.

Hospitals, physician groups, and practices need to adapt quickly. As you can see recently with Amazon, Google, and CVS, a myriad of industries and organizations are moving into the healthcare space. If the current healthcare providers don’t understand and adapt quickly, they’re going to get overrun and pushed aside.

How will practices and hospitals that are accustomed to staying busy and profitable just by opening their doors market their services and improve the patient experience?

Just as you asked the question, that’s the challenge facing healthcare today. Some are going to be able to understand the challenge, recognize it,and adapt to meet it. Others will be swept aside.

The new patients of today and tomorrow will accept nothing less than transparency, ease of access, convenience, and good service. They will no longer accept sitting in a waiting room with a 300-page novel that they can read while they’re waiting for their physician. They won’t accept that any longer, nor should they. That’s the new expectation.

Technology is going to have a lot to do with it, just like it does in other industries. This is another challenge for healthcare — to quickly develop and adapt the technology that the consumers of today are going to expect and demand. Technology that allows them to interact with their provider without going through a phone tree and filling out dozens and dozens of forms in a waiting room multiple times. This is an antiquated system.

There are good, understandable explanations as to why healthcare has been slower than other industries to react. A lot of it is regulatory. A lot of it is privacy concerns. Nevertheless, for whatever reason, it is what it is. It’s going to have to change and change very quickly.

Hospitals have been acquiring physician practices and are now merging with each other to form what could be just a few dozen national health systems. That gives them scale to improve communication, engagement, and patient satisfaction, but with the risk of being seen as a faceless corporation that doesn’t value people as individuals. Will patients see the situation getting better or worse?

What is transpiring now in healthcare has been experienced by many other industries throughout this nation. It could be the airline industry, banking, or accounting. There used to be the Big 8, now I think there are three accounting firms left. There used to be airlines like TWA, Pan American, and Eastern. They’re all gone. They were all swept aside. Either for some of the reasons we’ve already mentioned – adaptation, meeting some of the challenges that they faced, and they weren’t able to have that flexibility to adapt — or they were swept aside through this consolidation. 

Healthcare is going through that as we speak. There are no longer these little community-based hospitals that were the local equivalent of the YMCA and a Main Street mom and pop store. They’re now all being brought together into these massive health systems. At the end of the day, there will be some number.  We can guess the number of jellybeans in the jar, but there will be very fewer healthcare organizations. Not only are they consolidating as hospitals to each other, their physicians are consolidating into large medical groups and then again into hospitals to create these health systems.

There’s also now the trend where insurance companies are acquiring providers and providers are creating insurance companies. I think the latest trend is going to be the commercial market, like the CVSs and the Amazons, getting into healthcare. You’re having the retail meets the healthcare providers and vice versa. I don’t know who’s going to be left standing at the end of the day, but the landscape is going to be dramatically different than it was yesterday.

What’s that going to mean for the patient? I’m going to be optimistic. I think what they will have is a much more open, transparent, and accessible healthcare system than they had yesterday, notwithstanding the Marcus Welby image of the kind, gentle healthcare provider — whether it was a hospital or a physician — of the past.

People need ease of access. They need high levels of service. Competition for access and service is a good thing. Healthcare needed a prod to become more convenient and more focused on the patient, satisfying their needs for both service and access. This will ultimately be a good thing. It will be disruptive to the providers, but I think it will ultimately be very positive for the patients.

What service and technology improvements do you recommend to practices?

That’s the focus and objective of Formativ. We’re looking to fill this gap — I consider it a gap — between connecting the patient with the physician. Right now, it’s a very frustrating experience for both physicians and patients. Walk into virtually any physician’s practice and it’s like walking into a three-ring circus. There are all kinds of activities. You’ve got phones ringing. You’ve got people standing and waiting to make a new appointment. You’ve got these poor people behind the desk trying to juggle and balance handing out paper and moving patients back into the exam area. The organizational skills these poor receptionists need to balance and manage are incredible.

We go in and say, there’s no need for all of this. Like in other industries and other experiences, you can take that noise out of the waiting room and out of that day, moving it to the day before. Get it done in a more relaxed and more manageable setting. You can pre-register. You can get all the patient demographic and insurance information before you walk into the waiting room. You can do it electronically. When the patient walks into that waiting room to see their physician, it becomes a clinical experience, not an administrative nightmare.

When they’re leaving and need care coordination, follow-up care, or prescription refills, you can all do this electronically or over the phone by someone who is dedicated to help that patient navigate the system rather than trying to cram it all in to the same time you are there to have a clinical experience. You can do this through technology and dedicated service.

We refer to that as our patient access service. Individuals who are sitting anywhere are interacting with the patient, have the ability to see into the electronic health record of that patient, can communicate with the clinical providers through the electronic health record, can answer patient questions, can get schedules and appointments made, can answer insurance questions, and can help coordinate that whole experience for that patient.

Do you have any final thoughts?

It’s an exciting opportunity for those that recognize the challenge and the need that the population is demanding from their healthcare providers. For those who are willing to step up and to meet that challenge, it can be a very exciting and rewarding opportunity.

I’ve been doing this for well over 40 years. It’s been a pleasure and an honor to try and meet the needs of the community of patients — who, more often than not, experience some hardship or problem with healthcare – and try to relieve them of some of the frustration and the anxiety. Through technology and  personalized service, there’s this incredible window where those that are willing can step through. I believe the receptivity of patients is going to be extraordinary.

I’m just blessed to be able to have the opportunity to see the transformation and be part of it. It is coming, make no mistake about it. Don’t think it’s not. There is a wave of consumerism that will engulf healthcare. I hope and expect that most of the healthcare providers will be able to step up to meet the challenge.

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