HIStalk Interviews Carrie Kozlowski, COO, Upfront Healthcare

Carrie Kozlowski, MBA is co-founder and COO of Upfront Healthcare of Chicago, IL.

Tell me about yourself and the company.

I started as a clinician, practicing as an occupational therapist in the first one-third of my career. I worked in a number of care settings and saw the opportunity to impact patient care at a bigger level. I toyed between going into public health or into business and made the decision to follow the business side. I did my MBA and have been in the healthcare IT space for almost 20 years now, mostly involving workflow applications, making things more efficient and easier for providers, care managers, and now patients and the operations teams that support them at the health systems.

Our company started about five years ago. Our focus has always been, how do we help make sure patients get the care they need? We started this company as technologies continue to evolve and as health systems continue to evolve in their adoption of technologies. We think about digital health — how can we iterate on our approach to make sure that we are helping patients get necessary care?

Health system marketing used to involve renting billboards and bragging on awards to bring patients into profitable service lines, while clinical and administrative engagement was minimal. How do you see those areas changing or perhaps converging?

The biggest change is the evolution of how we think about consumers across all industries. We are seeing that now being applied in healthcare more specifically, which is the need for personalization and to tailor the communications to the needs of the individual patient. That’s the shift that folks are making. Obviously the more relevant the information is, then the more engaged the consumer will be, the patient in this case. That’s a big change that we are seeing, going from these broad billboards and radio spots into these specific patient engagement solutions.

Most people live their lives without a lot of health system involvement, which may or may not affect brand loyalty. Are health systems segmenting infrequent versus frequent patients and communicating with them differently?

I don’t know if they are communicating to them differently. I think you are hitting on that explosion of the retailization of healthcare and what we have seen in the last five or seven years in that regard. People were focused on acquiring patients, but not keeping patients. We did a lot of analysis on that about five years ago with a couple of engagements with some big health systems, and you could see it obviously lay out in the data.

But what we have seen since then is increasing competition. That has made them rethink what loyalty is and how you build it. Going back to the personalization aspect, how do you help this person by making it easy for them to get the care that they need? And offering specific direction on how to get that care from your health system, as you have offered more services and you think about the explosion of the front door. Folks have moved in that direction on the health system side, but people don’t know which front door to walk through sometimes.

Health systems may think that most patients want ongoing engagement, while many of those patients are looking for unconnected, as-needed care episodes and to be left alone in between. Can the health system meet the communication needs of both kinds of patients?

You’re getting at, what is my relationship? Is it transactional, or is it interactive content where you’re sourcing all your information from the health system, in which case those ginormous marketing websites are super helpful?

This goes back to using the patient data. Understanding what they need to do, but marrying that with engagement data, and then this third leg of the stool — which I’ve just come to understand better over the last two or three years – of health communication. More than health literacy. If you are a person who doesn’t want that information – “just tell me what I need to come in for” versus “I need help and support because I have a chronic disease” — you are motivated differently. The information that you want to consume needs to be organized differently. How do you leverage that health communication, understanding the person and marrying that with the personalization of  “this is the thing you need” so you are providing it in a highly relevant way? I think that it is that segmentation. It’s important to take those persona-oriented segments and then bring them all the way down to the personal level so that it is a one-to-one kind of experience.

Are health systems competing for the patient’s attention with similar health messages from large, technologically savvy players such as chain drugstores and insurers?

Well, that’s a loaded question. It’s a yes and a no, right? If it takes multiple teams of people to make sure that patients get the care they need and they are focused on the outcome and the care, great.

I do think it is confusing for the patient the way our health system, our healthcare in general, is organized in the United States. Everyone can think you are their patient. To your point, I think that messaging can get a little bit mixed up. The idea, and I see health systems and digital transformation officers pushing it around, is, how do we think about this as a hub? We want this experience to be a holistic one for the patient. We want to make sure that all of the communications that we need to send, or all of the digital health tools we’ve invested in, are organized in a hub so that it is feeding the patient what they need when they need it, but then directing them where to go.

How do we avoid turning technology such as chatbots into this generation’s PBX system, where we intentionally make it hard to reach a human even if they need empathy or lack technological comfort?

I don’t support taking the humans out of healthcare. It’s important to scale the human interaction and apply it in the right places. If we have humans doing all of the tasks, those people who need the most empathy, the most concentration of discussion, and the most support will be underserved. We can digitally communicate, “Hey, Carrie, it’s time for your mammogram.” I’m fine with that transactional kind of communication in that case. But that human piece needs to be there.

I’ll go back a little bit on the last thing I said, going back to personalization. We can make an empathetic experience that is personalized and relevant and can be delivered digitally. But we’re not going to ever go — and I would never support that we go — 100%. It’s all about the best modality to reach the patient to help them get the care they need. In many cases, that might be a human being, and should be.

Are hospitals trying to make their automated outreach messages seem more human given the intimate nature of healthcare services?

It goes back to that health communications piece. Communicating with empathy and making it personalized. It’s a broad message.

We all get the exact same letter mailed to us, auto-generated about, “You need this thing.” It’s not specific to where I live. It’s not specific to other circumstances. It’s not specific to where I went last year when I needed that same care. It’s obviously some auto-generated technology.

Health systems have rich data sets that can be leveraged for these needs. You can take that rich data set, process it, and apply it in a way that says, “It’s time for you to take this action, to get this care, and here’s where you had it last year. Let’s make it easy for you. Here are some options for scheduling that care at that location right now.” Then it is actually serving me, making my life easier. I know you’ are talking about me and you know me. Then you are complimenting that human experience with that personalized experience that is delivered in a digital fashion.

How important is it to focus the messaging on “here’s what you need to do next?”

It’s the most important. It is the key. We are all doing this because we want patients to get quality care and have the best outcomes. As the incentives are realigning in the same way, with quality and value-based care, that’s great news, but ultimately we are here to make sure patients continue to get the care they need. That should be the focus.

This is where I see a lot of health systems building strong bridges between their digital transformation and digital innovation with their integrated care networks, their medical groups, and their operations leaders. They want to apply innovation and digital engagement in a way that serves the needs of the patients. I just love seeing those connections being made more and more, especially with the clients that we work with, but across the board in general. That’s where you start to make good use of technology.

We talk about a unified patient record, but that doesn’t always include communications, especially those messages that were created in a mass campaign or as a patient response to one. Should we expect to have all messages from all modalities incorporated into the EMR or a patient CRM-type system?

That’s where we sit as an organization, as we see that need. It is marrying the data from the EMR and engagement data and bringing it all together in this unified patient view of, when did they engage? What was the outreach? Who did they communicate to? Did they attend the visit? When was the visit? It’s all about the interest, again, of making sure patients are not only scheduling care, but getting the care, and we can support them.

To your point earlier, are humans going to come out of it? No. So if a human needs to interact, they should know, “Hey, Carrie, we tried to message you a couple of times. It’s really important that you get this care.” We need to apply those same things we are doing on the digital side to the human side, making sure that the patient feels like we know them and they are a member of a health system that is connected and unified in the way that we are communicating to help them get care.

Should the messages encourage people who don’t see the value of having a primary care provider to engage with one?

Having a primary care provider is a key part of ongoing health. However, I also don’t think there’s anything wrong with a young person who’s healthy using the urgent care twice a year for a UTI and a sprained ankle. That’s where the data is important, looking for trends in the use of other care settings outside primary care to identify when someone needs to elevate into a primary care relationship. 

We are doing this with one of our clients. We are looking at how many visits the patients are having with urgent care. At what point do we decide, “It looks like you’ve been to the urgent care quite a bit. It might be better for you to establish a primary care relationship to help coordinate and oversee your care.” 

But creating that relationship and forcing those visits into primary care consumes limited primary care resources. We are going to compromise the patients, whether they are older or have chronic conditions, who need that capacity to serve their needs. Retail exists for a reason. It’s a valuable part of the entire ecosystem for urgent care or whatever word you want to use to describe it.

Where do you see the market and the industry moving in the next few years?

We are supporting clients who are trying to drive patients to get the care they need. Outcome-oriented population health is a portion of that, but adhering to those visits is an important part. We are then building in how we coordinate closely with the human interaction, allowing, for example, a bi-directional chat to support making sure that the patient gets what they need and making sure the outcome is actually achieved. That is what we are focused on. All of that is grounded in making sure we have a sound, relevant, personalized patient experience. But the experience isn’t the end goal. The end goal is the outcome that the patient has, a good quality of life and an excellent health outcome.

Do you have any final thoughts?

I’m excited about where we are in healthcare. I’m not excited that we’ve been through a pandemic for the last two years, but I feel like it has been the catalyst or the accelerant to think about how we deliver healthcare differently in a way that is patient centric, but supports the patient in succeeding at being there at the center of their care or their quarterback of their care. We are enabling that in a way better way. The speed at which we are seeing change right now makes it an exciting time to be part of all of it.

HIStalk Interviews Ashish Shah, CEO, Dina

Ashish Shah is co-founder and CEO of Dina of Chicago, IL.

Tell me about yourself and the company.

I started with Dina six years ago. I was previously the CTO and head of product for Medicity and was there eight years, before and after the acquisition by Aetna. Dina offers an AI-powered care-at-home platform and network that supports hospitals and health plans as they transition to monitoring patients in the home and other post-acute settings. We call this Care Traffic Control.

We’ve talked before about my father, who passed away suddenly shortly after Aetna acquired Medicity. I was a healthcare executive who had helped thousands of hospitals connect to ambulatory care sites, but that didn’t improve my dad’s situation. He had home health aides and spent time in senior centers, but those caregivers had no way to share information.

What effect has the pandemic had on the demand for at-home care as well as the company’s business?

The pandemic shined a bright light on what we need to do and accelerated it even further. Prior to the pandemic, Dina was 100% focused on organizing all of the resources outside of traditional facility-based healthcare, whether that was post-acute rehab facilities or in-home services. We knew we needed to do a better job to support the silver tsunami, the 10,000-plus people each day who are turning 65 years old. 

We would get a lot of head nods, and that was important, but COVID unfortunately accelerated that tsunami and gave us a glimpse of what it’s like when the traditional healthcare system is overrun. That cemented our place in the market. Clearly, complex things will continue to happen in the high-quality facilities. That’s never really going to change. There may be some automation and further optimization that takes place, but that’s still the right care setting for the right types of things.

Virtual care, whether it’s telehealth or some combination of remote patient monitoring, became critical. But these things need to be complemented by a third important delivery vehicle, which is in-home care. Not just traditional home health, but mobile lab and imaging, courier services, and a host of other capabilities that can be brought to you. The world was trained on things coming to you through the pandemic, not just in healthcare, but in all aspects of life. So in many ways, it made it super obvious for everyone. Now the race is on to equip the industry as fast as we can.

How do you see that shift away from the four walls of a hospital or a clinic being a threat, an opportunity, or both to the traditional health system?

It’s tricky. It’s hard to be a health system leader today because you have your feet in two different boats, two different business models. It’s hard to look away from how healthcare has been financed to date in a fee-for-service world. That creates some real challenges. Many health system operators were challenged in COVID by not having a consistent revenue flow, either through capitated payments or other at-risk payments.

It was interesting that in a industry that doesn’t have enough labor as it relates to physicians or nurses or other support staff, some organizations had to contemplate reducing headcount. I guess it was necessary to make the money work, but it was definitely challenging to witness that.

The opportunity as we hopefully come out of COVID is to accelerate health plans and providers having conversations around creating predictable revenue streams that are more based on value-based care type programs. The art is to make sure that there’s no attrition in revenue. In many ways, it’s the same type of conversation from 10 years ago when I was at Aetna. But now that we’ve had COVID, that took it from a theoretical concept to something that we need to solve as an industry.

What does the typical care network look like for a senior who has one or more chronic conditions and how do the members that participate in that care network coordinate or communicate with each other?

It’s very, very complicated. A typical senior or somebody whose health is complex could be on seven plus medications. They may need support with activities of daily living. That’s a non-medical home care service, which is different than a certified Medicare home health type service that may provide skilled nursing and physical therapy, really an extension of a service that you would get in a facility, but now being delivered in a home. So complex med management, personal care support with activities of daily living, perhaps some skilled needs that are required. That’s not even including primary care and specialty interactions as well.

A lot of what we are looking to do is to coordinate all of those logistics so that you can match or exceed the experience that you would receive in a facility. The market definitely wants it, but it’s easier said than done.

How does that care team structure or those care decisions differ for someone who is covered by a Medicare Advantage or a Medicaid Managed Care plan instead of traditional Medicare or Medicaid?

When I work with many folks on the home care side of things, they’re so passionate and they are wonderful organizations. But one of their biggest challenges and obstacles that they face is, how do we ultimately get that care financed that they know that the market needs and that creates value? I love what Medicare Advantage plans and Managed Medicaid plans are doing right now.

I’ll start with Medicare Advantage, because it’s a little bit more progressive and new relative to Managed Medicaid, which has been doing some of these things for some time. Medicare Advantage has introduced the concept of supplemental benefits — the extras, if you will, above and beyond Medicare fee-for-service — that will allow the Medicare Advantage plan to innovate and introduce new offerings like non-medical home care, nutrition support, transport, or other types of things that are not covered by a traditional Medicare plan. In the effort of delighting the member, addressing in some cases social determinants of health or other healthcare needs that can bend the cost curve, but also help that member meet their healthcare objectives. Really neat programs. We are in the early phase of this, but this is bringing online non-medical services or social determinant-oriented services that are being paid for, that are attracting members, but also change the outcome story.

Medicare, and CMS in particular, were wise to hatch the program years ago and then continue to invest in it and then allow the free markets to innovate. They have a  program called VBID, value-based insurance design, that is a vehicle for registering and testing for new types of benefits. If they work, then they ultimately graduate into the scope of things that MA plans can reimburse for. So it’s a really neat program.

On the Managed Medicaid side, in-home services, for example, are covered under what’s called LTSS, long-term support services. This is the goal of trying to meet the member in their home and community and unlocking alternatives to traditional long-term nursing home care. It’s a neat program that has been around for a while, but there’s some complexity in trying to manage that.

We’ve seen insurers that range from tech-heavy startups to Optum go big into Medicare Advantage, and some of those companies are providing health services directly. How will that change traditional hospital care, home care, and long-term care?

For Medicare Advantage plans, it’s bringing members online in a race or land grab moment that hasn’t existed before. The only option if you were a senior before was to be on Medicare fee-for-service. You could have bought your own private health plan, but now with Medicare Advantage plans, there’s a race to go manage outreach to these members, unlock a superior experience, and turn on new benefits that we know can change the arc of healthcare and the finance of healthcare.

Three years ago, 25% of Medicare-eligible members enrolled in a Medicare Advantage plan. Now we’re north of 40%, so it is growing rapidly. Many solid organizations are innovating. I think it’s wise that they are trying to establish a direct connection with the person to better understand their needs. Some go as far as delivering the care themselves, while others have invested in care coordinators or counselors who take a more proactive role in navigating that member through all of their needs. It is neat to see.

There are a lot of innovative organizations out there. Not just on the MA side of things, but organizations that partner with MA plans, like Oak Street Health, for example, or Iora, showcasing for the market a brand new community or home-based delivery model. I think we will continue to see that scale because it makes sense. Not to mention that people like it, which is sometimes hard to say about things that we do in healthcare, to get people to actually say that they enjoy the experience.

A problem has always been that outside the 9:00 to 5:00 window, people who weren’t hospitalized or in a SNF had to call 911 or go to the ED to have any changes in their health evaluated, including those that turn out to not be urgent. Have those insurers who have skin in the game addressed the unnecessary use of those services?

It’s clearly a problem that people have been studying for a long time. We’ve tried a lot of different things, from raising awareness to your health plan or the ACO to let them know that when somebody is in a emergency department. But in many ways, that’s too late, even though it creates intervention opportunities.

I’ll give you an example of a company like Dispatch Health. We know some of the folks there — we overlapped inside of the Aetna portfolio companies going back, so we are fans of them, the company, and the model. They took a new approach. They started by bringing urgent care to you rather than having you come into an ER, which was costly and had a lot of other ramifications. Not to mention that maybe you didn’t actually need to be an emergency room. They’ve started to chip away at the problem by redeployment of almost like a paramedic model to your home to manage triage for routine things, then escalate and navigate you to another site of care if it’s needed. In some cases, it may not be needed. In some cases, it may translate into something that leads to a telehealth encounter with a specialist that they bring into the mix.

There’s a lot of creative solutions that are coming into place. It’s not one size fits all. It’s not whether it will be telehealth, or in-person visits, or home care. The challenge for us as an industry over the next five to 10 years is to bring the best of all of that together with the right care at the right place at the right time. It sounds cliché, but that’s the challenge that we all have, and that’s what Dina is working on.

How do you see the company changing over the next several years as these market conditions change?

We no longer have to convince people why we exist. In the early days when you start a company, that’s a lot of the discussion. Tell me about the problem that you’re trying to solve, tell me why is it a really big problem, and tell me why it’s a big market opportunity. It was clear to many, including our early investors, when we talked about the aging demographics in the country and globally. COVID has expanded our market opportunity to include all people that are struggling with some sort of healthcare-related need. 

For us, it’s really about execution.To simplify our story, we use terms like “care traffic control” to create a visual of equipping hospitals and health plans with the infrastructure to be able to move from monitoring patients in ICU units and in hospital beds and shift that paradigm to coordinating, navigating, activating, and monitoring patients in their homes and communities. The solution we put into the market is a network of resources that are medical and non-medical in nature. We’ve got lightweight technology that allows us to engage with patients and families and understand what’s happening when a healthcare person is not in front of them. We do a lot with data. We bring all that information back to create opportunities to proactively delight that person and meet their needs on a continuous basis.

The organizations that are attracted to that today are health plans, like MA plans or Managed Medicaid, but also large provider groups that have started to go down their path to value-based care. I think that in five to 10 years, this will be everywhere. I don’t think it’s farfetched to think that every home is going to operate like a virtual primary care clinic, where it’s not just your residence, but an actual site of care that the healthcare ecosystem knows how to interact and work with.

It’s exciting. It’s what I wanted for my family before. I can see the convenience for it in this day and age. Our challenge is to make it happen now.

HIStalk Interviews Justin Dearborn, CEO, PatientBond

Justin Dearborn is CEO of PatientBond of Salt Lake City, UT.

Tell me about yourself and the company.

I started with PatientBond as CEO in January of this year. Prior to PatientBond, I was CEO of Merge Healthcare from June 2008 through October 2015, when Merge Healthcare was acquired by IBM and formed the basis for Watson Health for a while until their next big acquisition. I took a pause after that in healthcare, went and did a few other things in different industries, and then found my way back to healthcare.

I took your 12-question Patient Classifier psychographic segmentation survey. What are health systems learning about using consumer insights in their outreach and messaging?

I saw you took the classifier, so thank you. You and I are both priority jugglers at a high rate. You fall into multiple categories, and then we segment you based on the highest category, and you are very high and I’m very high on the priority juggler spectrum of the model.

What a health plan, payer, physician group, or specialty pharmacy is trying to activate in their client, member, or patient determines how they start using the psychographics and segmentation platform. Ultimately it is to trigger and activate positive behavior, such as keeping an appointment, filling out a survey, or all the way to collections or the financial side. It is triggering that process.

What all of our clients and most health systems are starting to realize is that they need to treat their patients similar to a consumer. One size does not fit all. Some segments of the population react well to physician-based messaging, where your doctor wants you to do X, Y, and Z. That segment of the population will do that without any other prompting or any other pushing needed. But a large portion of the population that doesn’t react the same. 

A lot of healthcare is messaging is towards the one segment. We dynamically personalize it based on what segment we’re speaking to. The customer doesn’t need to understand the concepts, but they are seeing the results in better engagement with the patient, more engagement, and getting across the spectrum of things from marketing outreach to medication adherence to really involved specialty pharmacy workflows.

It really depends on the workflow you are trying to achieve. But the bottom line is better engagement with your patient or member because you are speaking to them in a modality they want to use, in language they want to hear, and in words that they need to see to be activated.

Do providers ask their patients questions specifically to create a more accurate psychographic profile, or do they infer it from existing information?

Our system learns. We think you want to be communicated this way, in this frequency, and using these words. If it’s an ongoing communication path, our system will learn. We thought you would like text messaging and you need to see one message a day to activate this behavior, but it turns out now that one message a week in an email is better. We can learn from that and personalize the communication path based on that.

Health systems have done a great job, and are getting better all the time, at using AI to harvest their claims data. If it’s an existing patient, they have that data. They might have some socioeconomic data or social determinants of health data. If the health system has those components, we say, great, let us append the psychographic segmentation model to that – it will be even smarter, better outreach because you’re going to have historical data, which is informative for sure.

But what psychographics really gets to is the why and the how. It doesn’t focus on the historical. The historical can be informative, and there are certain things you can tell from a ZIP code or a salary that might impact payment ability, but really what the psychographics does is get behind the why and the how. This came out of Procter & Gamble and a number of high-quality, consumer-facing companies have used this for decades to segment consumers on a mass scale, as well as individual, and we can do both as well.

The classifier allows us to segment you with 91% accuracy. If we didn’t have that relationship, or if you were doing a marketing outreach to attract patients that you don’t know, we would take a national compiler’s database and append our model to it. That would be three times more accurate than chance on segmenting you properly, but it’s still not the number we get if you do the 12 questions.

Many people heard of psychographics in relation to Cambridge Analytica or Facebook collating a lot of data without user knowledge or permission to study their behaviors. Did these examples teach us that psychographics does or doesn’t work, especially in healthcare where the results would be used to improve the individual’s outcomes instead of trying to influence them for less-noble purposes?

I’ll start with the last piece of that. We believe in the health systems that we are working with. We believe in the payers. It’s really about activating positive behavior — making sure you take your medication, making sure you do your annual physical, or prompting you the best we can to get your colonoscopy. I think we would all agree that these are healthy behaviors. We’re not showing the data. In that case of Cambridge and Facebook, if the hospital did license the Facebook data — which we did at Tribune Company, for instance — that would still be separate data. That would go more to the social determinants of health datasets, and we could still use that and append psychographics to that.

To the first part of the question, part of our challenge with PatientBond has been awareness. Since I came in with the Series C investment round, we have been doing more on the outreach, more brand-building. We have started engaging with KLAS and Advisory Board and things like that. Frankly, the company didn’t have the budget to do it in the past. Half of our engagements are evangelizing, so a couple of calls will involve explaining the psychographics model, the history and genesis of that, how we get the data, what the clinical efficacy is, etc. 

Usually light bulbs start popping on. The client, the health system or payer, will start coming up with use cases. Could you do this? How do we operationalize it here? It’s a little bit of, I’ll say, free consulting and evangelizing. But once we get into a pilot mode, it pretty much takes care of itself. Then someone from the marketing or strategy group typically owns the project.

Absolutely awareness is still a challenge, but we’re working on that daily. There was a great paper put out by McKinsey about a month and a half ago that mentioned psychographics a number of times and the way they engage patients more effectively. That was unprompted by us. They found us and did the research and didn’t call us on it. Same with the Advisory Board. They put out a good case study with TriHealth and we were not contacted, but we were named. They both had some great results. So it really is about awareness.

Last year, of course, it was difficult to get mind share with the obvious situation at hand with the pandemic. This year is around awareness of PatientBond and the mission. It’s hard to say in healthcare IT. I was at Merge Healthcare and we had great products, but it’s hard to differentiate yourself. Most of the segments in healthcare are pretty crowded with vendors, but I can say there is no other company doing psychographic segmentation modeling and has our platform. 

There’s a lot of M&A on the AI side that do claims data analysis. Systems will recommend what they think would be the outcome based on historical, which is good stuff as well, but really nobody uses psychographics. A lot of the situations we are in are not competitive, but involve evangelizing and explaining in the first couple of calls.

Are health systems reluctant to apply marketing techniques to patient relationships that are more intimate than just consumer awareness campaigns? Or have their marketing folks not been involved and that will change with the new emphasis on consumerism as overseen by C-level executives?

I truly believe it’s the latter. It’s just coming of age. I’ve spent 10 years in healthcare and I can remember growing up that you didn’t see marketing from health systems, your doctor, or your hospital. I grew up around Northwestern Hospital and they didn’t advertise, but they do now. They have marketing budgets. They have data scientists.

That has evolved for the better. How to engage. How do people want to be communicated with, like text messaging versus email or IVR? Or, do you need to talk to a human being? We are informing them on how to best communicate.

That has been going on in CPG, consumer packaged goods, for 30 years. CPG used it effectively. Proctor & Gamble are masters at consumer marketing, but they don’t necessarily have the one-to-one relationships that can be built at health systems. You’re not as intimate when you’re buying Tide detergent, so when they are applying psychographics to something like Tide, it is more of a carpet bombing. They’ll profile an area and say, this area is over-indexed for priority jugglers, and here’s the messaging, here’s the labeling, and here’s what we need to do to resonate here.

But with health systems, it is truly one to one. Once they are a member or patient client, it’s one to one, and we truly personalize it for each one. That’s a huge, huge upside and more productive.

I truly believe it is awareness. In none of the calls that I’ve been on in the past six months — and there have been a lot —  did the chief marketing or chief strategy officers not get it, not believe in it, or decide that “we’re good with what we’re doing.” It’s more of, this is really intriguing,. How would we operationalize this? How does this work with our CRM? How does it work with our EMR? There’s has been a lot of great commentary, feedback, and follow-on loops.

I would say it’s coming fast. We probably would have seen a bigger uptake last year but for the pandemic, but as hospitals get back to normal a little bit, it is all about treating the patient as if they have choices, which they do. Probably this year or maybe next year, people will be paying 50% out of pocket for their total healthcare costs. We’ve been talking about it for 10-15 years, but the patients will be in charge. They are starting to make decisions somewhat based on price, how they like doing business, and how they like the relationship. That has been evolving for a while, but it’s going to cross the 50% threshold here very soon, and patients will act like consumers. It’s coming and it’s going to come fast.

We’re seeing that increasing COVID-19 vaccine uptake isn’t a simple as informing people who are uninformed, so now we are trying to understand their beliefs and nudge them accordingly. Has that raised awareness that targeting patients who meet some criteria and hitting them with cookie-cutter messages probably won’t work?

That’s a great analogy. We surveyed 4,000 people with 400 questions around motivation for vaccination. We came out of that with a ton of data. It is coming to light right now that you can’t treat everybody the same. It’s not all about just being an anti-vaxxer. There are other motivations and other things you can point out, and it’s information. Some people need more information. Some need to have their clergy talk to them about it. It’s all starting to come out as we hit the wall. We predicted four months ago that we would hit the wall in June at about 65%. We were spot on. We had this great data built into the platform as how to basically get people who are close over the hump and off the fence.

We have been trying to get that data out there. The challenge is who ultimately is motivated and incentivized to get people who aren’t vaccinated to get vaccinated. Now it has become more of a public service. For health systems, it’s for the common good, but do they even have a relationship with people who aren’t vaccinated their community? Not always. Early on, employers were being hands off because it was a hot potato. It was hard for us, and it still is hard for us, to find a group that has the incentives to get behind this.

We are willing to share the data and share our insights on how we feel that you can move the needle on that. But that has been a challenge because there has been no ownership. The federal government is supportive of it, but other than making it free, there’s really not much else. To your comment, we are absolutely, definitely informed that you can’t treat everyone the same. You can’t have one billboard. That’s not going to resonate with all the groups.

What will the company’s strategy be over the next few years?

It’s about marketing awareness. We’ve tripled the go-to-market team, the sales team, in the first six months of the year. We’ll grow 100% this year, and I think we’ll continue that path. The really attractive piece for me coming in was that we have a somewhat “friends and family” board of directors. There’s really only one entity of professional money, which is First Trust, who has a legacy investment and is a great partner. The rest are family office and individual. It allows me to manage the company for growth and to see this thing through.

We have a huge runway ahead of us. I don’t have any investor pressure. There’s no timeline. We have enough of a platform, and it keeps growing weekly, that we can remain private and self-funded for eternity. Eventually we’ll come to a decision point in a couple of years about an IPO or something else, which is the natural evolution of an early-stage growth company, but the good piece for me was not having external pressure from traditional venture capital investors.

An HIT Moment With … Steve Shihadeh

An HIT Moment With … is a quick interview with someone we find interesting. Steve Shihadeh is founder of Get-to-Market Health of Malvern, PA.

What advice are you giving clients about participating in HIMSS21 and HIMSS22?

I am very hopeful that HIMSS22 will return to a more normal trade show to meet the pent-up demand on both the vendor and provider side. 

With all of the COVID churn, mask debates, and travel challenges, we are advising clients who want to go to HIMSS21 to be surgical about their investment. By this, I mean that they should have a narrow list of who they want to visit and what they want to accomplish and generally be in and out in a day or so to keep expenses to a minimum. 

I get the sense that vendors are being cautious about investing, and a quick look at signups bear that out. If vendor attendance is light, I would have to guess that provider participation will be down significantly as well.

How are companies changing their marketing strategy?

With in-person trade shows effectively non-existent since March 2020 — by the way, every client we have talked to has felt that the virtual shows were a bust — companies have adapted marketing significantly to keep their businesses vital.

A few clients have upped their webinar game with real thought leadership and way more nuanced selling than in the past.

I continue to be impressed by how much mileage our clients are getting out of social. They are making use of multiple channels and keeping it edgy and interesting. The really sophisticated companies are getting participation across their employee base, which is greatly amplifying their messaging.

We have participated with our clients in a number of focus groups, and while you don’t get the reach of large-scale events, you certainly get to go way deeper. It seems like picking the right attendees and having a solid structure to the events reaps the most reward.,

How has the sales process changed post-pandemic?

Value prop, value prop, value prop. With in-person meetings dramatically reduced in both number and time allowed on site, companies need to more than ever translate their bells and whistles into things that matter to the client. How exactly does it save money? How exactly does it positively impact clinical workflow and outcomes? How exactly does my taking a meeting with you help my organization dig out of this COVID hole?

What are the most important things you look at when asked to perform due diligence for a potential health IT investment or acquisition?

Value prop, value prop, value prop. Just kidding, but not really. Investors get this more than anyone and want to deeply understand a company’s storyline and associated ROI. Investors at different stages – seed, venture, growth equity, private equity, strategic — will have different expectations, but they all need to understand how you truly differentiate and how you truly help a provider with a key challenge.

What clues will the HIMSS21 exhibit hall provide about the direction of the health IT market and the companies in it?

The health tech market is coming back red hot, in my opinion. The pandemic has broken the status quo and providers are finding new ways to use technology and new problems it can solve. Hopefully HIMSS21, albeit with a lighter attendance than in the past, gives us a glimpse at how companies have responded to the many opportunities presented by the COVID crisis.

HIStalk Interviews Vik Krishnan, GM, Intrado Digital Workflows

Vik Krishnan, MBA is general manager of the Intrado Digital Workflows business of Intrado Life and Safety.

Tell me about yourself and the company.

I live in Boston with my wonderful wife and three children. I studied biomedical engineering at the University of Pennsylvania, then earned my MBA from Harvard Business School. I entered the digital health market 12 years ago through a company I founded. I have the probably unique distinction of having run two of the businesses in the market today that offer something similar to Intrado HouseCalls in terms of patient engagement.

Intrado’s HouseCalls business is a market share leader by far in automating mass patient engagement workflows. We serve 17,000 healthcare providers, including 400 of the largest hospitals that are using Epic and hundreds that are using Cerner.

Dental practices have offered just about every form of patient engagement technology for years. Why did it take practices and hospitals so much longer?

If you think about the longer tail of healthcare providers, small physician practices and dental practices, there is no disguising the revenue impact in a given week or in a given month of even a slight variation in patient volumes. A dental clinic is going to feel that. They may even go under with a couple of bad months. That’s probably why they were quicker to adopt. Also, any smaller institution in any market, including healthcare, is usually more willing to have a quicker and more simple sales cycle. There are more levels in the decision and more integration into the solution and the current systems at a larger healthcare provider.

All of those factors will come into play. I think that they have gotten there now, though, but you are right, it has taken longer.

What do patients gain as a benefit when you integrate a patient engagement platform with an EHR like Cerner or Epic?

We have to understand patient preferences. Certainly they vary by demographic type, and age, but essentially what a patient is looking for is a seamless experience. Surveys find that 90% of patients want automated patient engagement communications. Nearly 70% say that they want more communications and reminders that help them be compliant with their own healthcare needs and their own requirements.

What they don’t want to do is get a reminder — for example, about an appointment — and then realize that the scheduled time doesn’t work for them, but the only available follow-up action is to call the contact center. That’s a laborious process, not just for appointments, but for a recall campaign, for example. If somebody knows that they need to schedule an annual wellness visit, but now they have to call in and wait, that’s a challenge and a burden that can ultimately disengage the patient from the process.

What a patient would like — and this can only be achieved through deep integration with the EHR – is to solve that workflow through SMS. If the appointment I have tomorrow doesn’t work, why can I not just reschedule that through SMS through real-time integration with the EHR? If I know I need a colonoscopy and I’ve been reminded of it effectively, that’s great and I want to schedule it, too. Why can’t I just do that in an automatic way without talking to a human being?

Last point on this. This matters a lot for underserved communities as well, because there are a variety of differences to consider there. Some of those differences are around a preference that studies suggest for using SMS versus phone call and email. Some of it is around language. If a platform can use over 100 languages, you are more likely to deliver the patient experience that somebody wants if English is not their native language. That will improve communication health and patient satisfaction.

How do you capture the categories into which a given patient falls, such as those with a preferred communication method, a limit to how many messages they want to receive, or those who want to opt out entirely?

That is done effectively through both a solution philosophy and a support philosophy. The solution philosophy needs to be to use the hospital or health system’s EHR as the single source of truth. If the hospital or health system is using the EHR as a single source of truth, these toggles, these preferences, this information will be in there. It’s just waiting to be used.

Then the next step is a solution philosophy that leverages that data, integrates through real time like we do through APIs into the system, and is empowers that system and that hospital to get the most out of their EHR. Any hospital CIO or CMIO will tell you that they want the EHR to be the single source of truth. It’s harder to do that when many other solutions on the market don’t integrate through API as the way we do and instead use HL7. This creates a parallel EHR-like system of data and rules that live outside of the EHR.

That makes it more complex. It makes it harder for the hospital to manage this and these insights on the patients and their preferences. It also exposes the hospital and health systems — going a little off-topic here, but it’s important to mention — to data breaches and other risks. You use the EHR as a single source of truth, and you help through support the hospital or health system to do that. That’s ultimately how you achieve what I just described in my previous answer.

Everybody’s buzzword is “digital front door.” Do health systems that haven’t solved longstanding patient pain points – employee friendliness, parking and wayfinding, and accurate billing – create digital expectations that their physical reality can’t match?

We see a lot of hospitals navigating what seems like a simple concept. Digital front door seems like a specific concept, just like patient engagement seems like a specific concept, but ultimately it involves a more comprehensive solution with lots of departments and stakeholders at the hospital involved. We typically see hospitals and health systems find this process, both front door and digital engagement, to be complex and difficult.

The concept of digital front door can encompass many things. It could encompass what the website looks like. Is there a chat bot or web bot on the website? That’s for inbound. Patient engagement is often thought about as being outbound, but the way we think about it is two way. We want to facilitate, and we do, two-way patient interactions. Sometimes these will be around something specific that is happening. We want to inform a patient about an annual wellness visit, the need to get a mammogram, or something pre-post-procedure, appointment, or thereafter. But sometimes these things will be inbound. It’s not because of something the hospital wants, it’s because of something the patient is seeking. They may be on the hospital’s website, for example, and want to be able to take an action that doesn’t involve calling the hospital contact center.

We see complex RFP processes. We see hospitals engaging consulting firms to solve these problems. I certainly have recommendations on how to solve these problems, but I want to acknowledge it is a complex process and decision that is difficult for hospital decision-makers to navigate.

Is it possible to address all these patient needs, including pre- and post-procedure instructions and communication with the patient’s family, through a single technology or vendor?

It is. This is an important concept to mention. We see an evolution underway right now in the market in terms of how hospitals and health systems are viewing patient engagement. Virtually all understand that they need to send SMS reminders, for example, about appointments and related communications. Many today still view those particular use cases as point solutions, or value may be measured, for example, through no-show rates or through transactional pricing.

Some, to your point, have understood that they need a patient engagement platform, not a point solution. More broadly, a solution, a platform that is not just solving any one of those things, but that integrates, for example, in real time, not just with their EHR, but with other systems like the contact center. One that truly automates a wide range of two-way patient engagement workflows.

When you think about making a solution decision versus a platform decision,vit can be a more complex decision. But the ROI for that platform will be measured by increased revenue delivered, decreased operational costs that the hospital has to bear, and increased community health and patient satisfaction. Some hospitals and health systems are going through that process, and that frankly is the solution that we provide. Those are the types of customers that we serve and the needs we try to solve, but that’s how you get there, and that’s the difference between the solution and the platform.

To what degree are hospitals using patient-reported outcomes, such as automating a daily inquiry about the patient’s pain, medication effectiveness, or mobility?

Let’s talk about a mass notification solution and then a patient engagement platform and what the difference is.

Let’s say a hospital has a mass notification system to inform patients about the need to have an annual wellness visit. They have some success rates. Great. They get some revenue and community health has improved. Nice job.

Now if they have a patient engagement platform that truly integrates in real time, it can automatically identify which patients need to be informed about an annual wellness visit. It can drive those interactions, but it can also capture those patients, for example, who say, “I actually declined, I don’t want to have an annual wellness visit.” You can record that information and report it in real time back to the EHR.

At some point, that patient will come in and  talk to a physician, maybe their PCP, about something else. The PCP, through a platform — not just a mass notification system — will have that information in the EHR that will allow them to know the decision the patient made and have a conversation with them about why they made that decision. This is about holistic care, which ultimately drives patient satisfaction and improves community health. Doing that actually also improves the hospital’s satisfaction scores and care quality scores, just knowing why if somebody didn’t want to do something, why that was and what happened after.

Do health systems and practices do a good job of not overwhelming patients with poorly designed or poorly targeted messages?

For our solution, we adopted a concept of augmented intelligence. You can broadcast every message to every patient about everything, which will probably create the dissatisfaction and disengagement that you just described. You can also ask a patient to go log in somewhere to a portal, download an app, and go log in there and get whatever information that the hospital wants the patient to get. Every study shows that if you ask a patient to log in somewhere, they’re less inclined to do it. They probably don’t know their login and they will never get that message. The message may not even be tailored to them.

An augmented intelligence patient engagement platform integrated into the EHR knows when a patient needs to hear what and when. Once one of those automated workflows is set up by hospital staff, it runs. It can be monitored and reported on, but it doesn’t need to be manually managed. A platform like that will reach out to patients about the right thing at the right time and collect responses. That makes it more tailored, more personalized, and ultimately more effective.

What changes do you expect to see in your business over the next few years?

We have adopted a process of continual innovation. The biggest hump to get over — and we are increasingly doing this in our new logo deals and also our customer base —  is that it’s not a point solution that you need. What you’re getting from us now and what you need to adopt from us now is a true augmented intelligence patient engagement platform.

But once they make that leap, and many of our customers already have made that leap with us, then it is not hard after that to continue to add new workflows that increase automation and ultimately help healthcare providers, hospitals, and health systems do three things — increase their revenue, decrease their operational burden and costs, and improve community health and delight patients and increase their satisfaction. Once the customers we serve and the customers that we are adding are over that hump, they will continually add more and more automated workflows that we are delivering.

Do you have any final thoughts?

I’ve described the concept of a point solution and a platform. While we excel at delivering some of those point solutions, our mission in this business is to offer the platform. If a healthcare provider in your audience is interested in a true platform that digitally transforms their organization and does what I’ve described, I would urge them to reach out to Intrado or to me personally.

HIStalk Interviews Don Woodlock, VP of Healthcare, InterSystems

Don Woodlock is VP of healthcare at InterSystems of Cambridge, MA.

Tell me about yourself and the company.

I have been in healthcare IT my whole career. I went to school next door to where I am now, at MIT. I joined the company IDX and worked there for 14 years building applications, basically billing, scheduling, and managed care. I joined GE Healthcare for 14 years doing imaging IT –radiology, cardiology, and labor and delivery type imaging. I’ve been at InterSystems for four years.

InterSystems focuses on two areas. One is a data platform. We have software companies, maybe most famously Epic, that build their applications on our technology. Then we have an interoperability product line called HealthShare that many of your readers would use. We have an EMR that we sell outside the US called TrakCare.

Northeastern companies such as InterSystems, Meditech, and IDX had a lot of influence on today’s health IT market going back into the 1960s and 1970s. What does that impact look like from the inside?

There’s a technology similarity, but the most important similarity — at least in the original IDX – is the private company, customer-obsessed model. Epic still has that, InterSystems still has that, and IDX had that while I was there. It was a small group of individuals who were really excited about health systems and were focused on that. They didn’t want to bring their companies public. 

That model and culture is familiar to me. I had a 14-year deviation when I went to GE Healthcare, but when I joined InterSystems, it completely reminded me of IDX, that same kind of friendly, customer-focused outlook. Maybe there’s a Boston-y culture to the whole thing. It’s a nice place to be.

Technologists from outside of healthcare may know little about Caché. Can you explain its benefits?

That market has come around a little bit more. This multi-model, key-value store wasn’t popular at all in the early days when the technology got started, and was not popular during the relational days. But in the last five to 10 years, there has been more variety in the way people see databases and different models. Caché’s power comes from this key-value model, which makes it scalable and efficient. You can build an application that scales and micromanage the way your data is actually stored. That’s part of Caché’s secret sauce.

How are the company’s integration and interoperability solutions used?

Our integration engine is used by 39 of the top 100 hospitals and health systems. Your readers may know it under the name Ensemble, but we market it now as HealthShare Health Connect. It translates from HL7 to FHIR to X12, from whatever format to another format. It scales really well and is the next generation of that category.

The broader HealthShare is a data aggregation, unified care record platform. It got started in the state HIE market a long time ago. We more often use it for health systems that want to aggregate data across all their different EMR systems. We also market it to payers, life sciences companies, and regional health authorities outside the US. It focuses on unifying patient data and making it useful for point-of-care, analytics, research, and many other use cases.

With interoperability, we are in the middle of a nice, big change from HL7 — which is more of a “copy data from here and put it there” model, that copy-and-paste model — to FHIR, where you have applications that can work together and can request information from each other. It’s a much better interoperability model and it also opens up a lot of innovation, where you can treat your EMR data as a FHIR repository and build applications on top of that more easily. We are at the beginning of a next era in interoperability that will be quite fruitful and useful to our industry.

What market exists for helping life sciences companies use provider EHR data for research, real-world evidence, and product monitoring?

We’ve had a lot of increased activity with life sciences companies. There’s the research side, which is running successful trials. Using real-world data helps you with study planning. I’m looking for diabetics over 50 on this medication — how many people can I find in my population that is used for site selection? What organizations should I approach to run my trials? Then there’s the patient recruitment process, having real-time interoperability of information so that my principal investigators at the different sites can identify patients as soon as they enter the system.

This market has been aided by more healthcare information being digitized. It has also aided by regulatory agencies that are more open to real-world data being part of a research submission.

Then there’s the commercial side. You have a drug or a therapy and you want to get it out to the market, so you need to understand that market. A broader array of data helps you understand where your patients live, what other medications they are on, and what other problems they have. Having this data enables a life sciences company to more effectively operate these days, and I think that most of pharma is recognizing that now.

How has product demand and the company’s strategy changed with healthcare’s move to the cloud?

The cloud enables innovation. On-premise is like our waterfall software development process, while cloud is more like agile, lean, and a minimally viable product. It enables you, as a health system that wants to innovate, to spin up a FHIR repository, spin up a development stack, and try a proof of concept. To build a small application and not necessarily have to have pre-thought all of that and to buy a lot of hardware. You can focus on that stable environment.

You can more easily innovate and adapt in a cloud-based environment. That’s in addition to operating a data center better and more effectively with a cloud partner. The interesting part of the cloud is the innovation and the ease of starting up and taking advantage of newer technologies.

Our predominant model of healthcare applications, like HealthShare, is to offer it as a service. Customers may choose on-prem, but generally speaking, most of our new projects are us managing the entire environment for a customer. Then we are starting to introduce cloud-based services. Earlier this week, along with Amazon’s launch of HealthLake, we launched our HealthShare Message Transformation Service, which allows HealthLake to speak HL7. You can see it in the AWS marketplace. You can spin it up today and start using it.

We anticipate that more and more of our offerings will look just like that. We’ll offer it in the cloud stores. Customers can spin it up and start using it. The amount of friction needed to get started with InterSystems technology will be lower.

Healthcare users may not be aware that InterSystems has customers in other industries.

InterSystems is a multi-vertical company. We have a lot of experience in healthcare, but we are building up a more robust financial services business. The majority of trades that happen in the US stock exchanges go through InterSystems technology. We have another interesting customer who is basically the NASA of Europe. The European Space Agency tracks all the bodies in the sky using InterSystems technology. We have a lot of neat customers in other verticals as well.

TrakCare is a fully functional EHR that is in the top three in the world. We sell in 28 countries. The root of that business was a customer of ours named TrakHealth in Australia that had built an application on our technology. We became closer and closer with TrakHealth and eventually acquired them and made them part of InterSystems. We have a big business in the UK, Italy, Australia, New Zealand, China, the Middle East, and Chile. We enjoy having a global EMR product, but having a level of what we call local editions that tailor it for these specific markets.

Would you ever develop or acquire domestic healthcare applications, or do you have agreements with customers such as Epic to avoid competing with them?

We don’t have an agreement, but we feel like the EMR market in the US is pretty well saturated and pretty well taken care of, including by our good partner Epic. We don’t have any plans to launch TrakCare in the US. I don’t think it would add a lot to the market, honestly.

It must be unusual for a company that is approaching $1 billion in annual revenue to be owned outright by a single person, Terry Ragon in the case of InterSystems. What are the advantages of that form of ownership and how does it influence the company’s long-term plans?

There’s nothing like the private company model when the company is profitable and doing well. I enjoyed my time in GE Healthcare, but you have this other stakeholder, which is the shareholder and quarterly earnings concerns. That’s another kind of stakeholder that you need to worry about, please, and perform for in addition to customers, which is this other sphere. That was the only sphere I ever cared about, honestly. It’s nice to be in a private company with the one owner. It’s a simple model, where I can focus on customers all day long and not really worry about the rest.

We don’t have any concerns about the long run. We haven’t made it a priority to figure out the long-run transitions. We’re happy now. My boss, the CEO and owner, comes in every day. I just met with him earlier. We have a fully staffed senior leadership team, a 1,600-person-strong company, and a great customer base. We are enjoying ourselves pleasing customers.

How will the company’s healthcare strategy change in the next few years?

We are migrating more and more to analytics. That is natural in our industry. We’ve collected all this data, we’ve digitized our workflows within health systems and providers, and now we want to get more out of that. A lot of our customers are migrating to using their data for analytics. The types of things we do around interoperability, data aggregation, and normalization are all useful for the analytics use case. We have been focusing on a lot of projects and offerings in that respect.

Even our underlying data platform historically has been that online transactional processing system, and more and more customers want to build analytics solutions on it. We’re adding a number of features around self-service analytics, Python, integration, and embedded machine learning, a number of things that are more analytics-oriented to our product line. That is a big part of the future.

The other would be what we talked about concerning cloud. Having more and more of our offerings be click-click services that you get in, start up, and start to use instead of larger decisions that involve a larger monolithic type of implementation.

Do you have any final thoughts?

It’s not InterSystems related, but I wanted to thank you for publishing HIStalk. I’ve been in health IT for 33 years and I have been a dedicated reader of your publication since it started. Healthcare IT is such a community, and while my former colleagues and I from other companies run into each other all the time, it is nice to read about folks and see what is happening across the industry. HIStalk is one of the most important things that bind us all together. It has been a joy to read, and I look forward to it every day.

HIStalk Interviews Tom Skelton, CEO, Surescripts

Tom Skelton is CEO of Surescripts of Arlington, VA.

Tell me about yourself and the company.

I’ve been in healthcare IT for a long time now. Believe it or not, it has been 40 years. The focus of my career has been digitizing healthcare, predominantly from the perspective of providers. Over time, it moved into different segments.

Surescripts has been around for 20 years now. It was stood up to solve some of the nation’s most significant problems. That was e-prescribing at the time, but we’ve expanded and broadened since then. We have never wavered from our purpose, which is to serve the nation with the single most trusted and capable health information network. Our focus remains patient safety, lower costs, and higher quality care.

How did use of the Surescripts network change with the pandemic?

Our focus has always been on either the prescribing process or informing care decisions and providing information to the caregivers, usually at the point of care. We saw a number of things occurring during COVID. There was a huge change in the telehealth landscape. Lots of new entities were springing up, and even within established entities, large health systems were innovating in the world of telehealth. We saw a much greater use of the network.

The other thing that happened was there was a greater focus on public health type information and the need to inform federal, state, and local agencies what was going on in the world of COVID. Folks repurposed some of our solutions to do that. For example, our clinical direct messaging offering was never intended to do that type of reporting, but that’s what people did with it. 

We think that that’s an example of how innovation is going to occur in the world of interoperability. We are all accustomed to certain use cases. We think that the consumers of those use cases are going to make those things valuable in ways that maybe we didn’t anticipate or intend.

What has the company learned in not just allowing healthcare participants to exchange information, but making the external information actionable?

It used to be that establishing a connection was a huge issue. It still takes a lot to do that and get it right, but that’s getting easier and easier. As it does, there’s a greater focus on the quality of the information that is being moved and how it appears in a natural workflow for the consumer of that information. Surescripts and our network alliance are focused on enhancing the quality of that information.

It’s making sure that the standards that exist — and there are many of them – are being implemented in a way that everybody agrees on how to utilize them and how to populate the individual fields or to populate the data elements. So that when it hits the workflow of a physician, pharmacist, or any clinician, it is appearing in a way that they can consume it and use it to enhance the care that that patient is being given. We see a lot of time and energy being put in to that.

Direct messaging seemed like it was going nowhere for a long time. How have you seen the Direct concept as well as your specific Direct platform progressing?

It’s interesting that you make that observation. That solution has been around for a while. It’s one of the few general solutions that exist in the world of interoperability. You are right that when it first came out, because it wasn’t use case space specific, people weren’t sure what to do with it. Over time, they are finding solutions here and finding that it can be an effective way to share information, provided that the sender and the recipient are on the same page in terms of what’s being said. We certainly saw that during COVID.

We are seeing a lot of work with that as we are working with health plans and helping them to do outreach to the physician community. These are the types of solutions that we are bringing to bear to help inform those care decisions that the prescribers, providers, and clinicians are making.

How do you see the information exchange market between providers and life sciences companies evolving?

Those companies have a a significant role to play here. They are major players in what goes on with the patient. They are obviously very interested from their own standpoint about what’s happening with the brands that they are putting out there. They want to know how their products are being used and what the adherence rates are. They want to make sure they are communicating with the prescribers. In many cases, they want to have access to the patient.

They have a great interest in the whole world of interoperability. We see that and understand that need. That’s one of the challenges we will face as interoperability grows. Life sciences wants access. Health plans want access. PBMs want access. One of the challenges for clinicians will be to make sure they are getting the right information without being overwhelmed with information.

How do healthcare networks add value?

An individual network can add value in many places. A lot of networks in healthcare are doing great work, whether it’s in the clinical world like we are, or whether it’s in the administrative world like some of the other folks.

Moving that information and helping to connect the ecosystem is a pretty daunting task. We have two million healthcare professionals. We are sharing actionable intelligence for 320-plus million patients. We are processing over 17.5 billion transactions a year. The role of the network continues to be not only facilitate that connectivity, but to ensure the reliance, the resiliency, the quality, basically the trust between the sender and the recipient and making sure that people that are requesting information are who they say they are and are entitled to that information and really do represent the patient that they’re requesting the information about.

There’s a lot that goes on there to maintain trust across the ecosystem. All of that contributes to how networks add value.

What influence will the Trusted Exchange Framework and Common Agreement have?

There’s a variety of mechanisms that the regulatory bodies are putting out there to help facilitate interoperability, whether it’s increased focus on standards, something like TEFCA, or whether it’s the information blocking legislation that was put through and is out there. All of that has value and helps to move it forward. It’s incumbent upon all of us in healthcare that are moving this information to tell our stories effectively as well.

One of the great challenges in the market is that each of us has an anecdote that we can tell that indicates that interoperability is not perfect. But we’re all moving a lot more information than we ever have, and it’s on us to share that information so that everybody understands how far along in the journey of interoperability we are and how far we’ve come. There’s still a long way to go, but a lot of good progress has been made.

The creation of those networks also creates business value. We’ve seen high levels of health IT investment activity and company valuations, but Surescripts has been quiet in terms of acquisitions or market transactions. Why is that?

We were founded to stand up one of the earliest networks in the market, particularly as it relates to clinical. Our goal here is a bit different than the goals of some of these other folks. We’re not chasing EBITDA. We’re not chasing an exit. That’s not what it’s about.

What it’s about for us is establishing, operating, and innovating on an existing platform that is neutral in the ecosystem, that is designed to facilitate the movement of that clinical information. Our growth has been driven by organic investment and continues to be driven by organic investment. We think that that’s a fabulous way to go. We think it also gives us the ability to take the long view and to make investments that other organizations may not be willing to make, and we think there are advantages there.

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

We are looking at what’s going on in the market and seeing many of the same things as everybody else. We’re seeing an increase in chronic conditions. We’re seeing the impact of high-cost specialty drugs. We’re seeing doctors facing ever-increasing rates of burnout. There’s a lot going on around us.

Our focus will be, number one, to sure that we optimize the prescribing process. We’ve got a lot of work to do in the area of specialty. We need to stay focused on that. We need to remove friction. We need to do things that advance and improve adherence and make it easier for all Americans to get the medications that they need.

The second thing for us comes back to that getting information to the provider community at the point that they need it. Solving that need for informing care decisions by giving them the actionable intelligence that they need and continuing broad-based connectivity for clinicians all across the market.

We remain purpose-driven. That’s who we are and we are very comfortable in that world. Our goal is to continue transforming these interactions among clinicians, pharmacists, and patients.

Do you have any final thoughts?

We’ve seen a lot of investments in the market. We’ve seen a huge influx of capital. We think that shows the amount of opportunity that there is here.

We think there’s a tremendous amount of room for innovation. We are excited about that. We see a continued acceleration of the trends that enabled virtual care. We think there’s going to be a lot of innovation to come that will help further information sharing across the healthcare ecosystem. The pandemic accelerated that and we look forward to continuing that over the next three to five years.

HIStalk Interviews B.J. Schaknowski, CEO, Symplr

B.J. Schaknowski, MBA is president and CEO of Symplr of Houston, TX.

Tell me about yourself and the company.

I’m a 25-year software veteran. I was with big publicly traded companies like Intuit, Sage Software, LexisNexis, CA Technologies, and Vertafore prior. I had done primarily go-to-market roles. I’ve done operations, M&A, strategy services, almost any job you can have inside of a software company. I spent about 10 years in the last two companies prior to this in vertical software. Legal for about four and a half years with LexisNexis, trying to help large and small law firms run better, and then the last almost four years at Vertafore, trying to help independent insurance agencies modernize their technology.

Symplr felt like an obvious opportunity, because at least from my diligence, there’s no more inefficient operational entity than some of these big healthcare systems. I thought it would be a great opportunity to bring my technology background and help modernize what is effectively the healthcare operational landscape at Symplr. 

That’s really what we do. We cobble together, consolidate, and standardize everything between ERP and EMR, where today there are hundreds of point product solutions, small companies all over the board on data migration, data security and privacy, and look and feel. We believe we can consolidate that into a single operational platform that allows CIOs, CMOs, and COOs to better run their healthcare systems to the benefit of not only the top and bottom line, but also operational efficiency as well as patient safety.

Can a company that has grown by acquisition keep all of its three constituencies of customers, employees, and investors happy?

It’s the imperative. The investment thesis for Symplr from our sponsors is exactly that. At the end of the day, world-class run companies with successful, happy customers are the ones that get world-class valuations. Our backers literally have a vested interest in making sure that we are solving for our healthcare systems. 

There are only 1,900 acute care systems in the United States. We have 85% of them as Symplr customers. If we’re not providing extraordinary value, if we don’t have good customer Net Promoter Scores, if they’re not really happy with Symplr all day long, this thing isn’t going to work regardless. Believe it or not, I 100% stand behind the fact that we as Symplr and our sponsors have to make this work for customers. If not, our sponsors won’t get the financial results that they want.

The company is looking for a financial transaction at a multi-billion dollar valuation. How would you characterize the health IT investor market?

You have three or four driving forces relative to the healthcare IT market today. The first one is that the pandemic shone an absolute spotlight on the fact that healthcare operations are wholly deficient. You’ve got physicians who can provide COVID care that can’t get tagged in from the sidelines because they can’t get credentialed for three or four months. You’ve got nurses on the evening news who are working 12- to 15-hour shifts without lunches because their staffing and scheduling systems don’t talk to their HRIS system, and that’s criminal. So now you have this imperative because of the spotlight on healthcare operations, and as a result, you’re seeing those companies inherently become more valuable.

The second thing is the cost of capital is still relatively cheap, and healthcare has always been a great place for investment. You are now seeing this modernization initiative take hold and consolidation within many of the largest systems, which will be good for technology providers.

Third, you’ve got some market conditions relative to what likely will be perceived as enhanced regulation, which typically is addressed with software businesses, particularly the governance and compliance area.

Those three areas are driving what is an incredibly hot healthcare IT market right now. Frankly, we don’t see that slowing down. It’s interesting because it’s making multiples meaty, to say the least. But Symplr’s strategy is to look for the right companies that add additional value to the portfolio that we’ve already built and strengthen our position in healthcare operations. We’re taking the more long-term views, and sometimes we might be willing to look into investment differently because we can look at it over time, not just in the next 12 to 18 months in terms of our returns.

Do those meaty market multiples give you an urgency to act quickly to find a buyer or investor?

The short answer from my seat is no. I have the benefit as the CEO of Symplr of making it the best healthcare IT software vendor provider in the world. If our sponsors look at high multiples and say, now’s the time to look for a new partner to change hands, I leave that in their hands, frankly. But I will tell you that I think it’s more indicative of the value that software modernization, technology modernization, can provide to healthcare systems. 

I don’t see healthcare technology multiples fading, because there’s so much value to be brought here. We are just cracking the surface on the potential of improving operational effectiveness of healthcare systems. I think that will only continue to rise as these systems truly embrace what technology modernization can mean for them. They start to stitch it together. They don’t have the data security and privacy risks any more. They have the data and insights to make intelligent decisions. They understand where they fit relative to other systems and peer community. I only see them going up.

People keep expecting technology to reduce costs, reduce inefficiency, and improve outcomes in healthcare, but somehow that never seems to happen at a macro level. Are prospective customers becoming more demanding?

Yes. People were still looking at this whole middle infrastructure realm in a point product way. The reality is you can keep investing in point products all day long, but if you don’t have better interoperability, if you don’t have a common look and feel, if you don’t have a common data layer that gives you better insights in how to run your healthcare system, you’re not going to see the benefits.

We’re seeing these top-down initiatives that are starting with some of the biggest healthcare systems in the world moving down into what I’ll call the more mid-market or mid-tier size healthcare systems. I’ve talked to some CEOs and CMOs who would reinforce this. As recently as seven or eight months ago when I joined, the theme was, we just let our facilities and our teams pick whatever solutions they want and we just make sure that we get the right price on them. Maybe there’s some data security and privacy standards, maybe there aren’t, which is frightening on so many dimensions. 

But now what you see is these large systems that keep getting bigger, they know they can’t run with 100, 200, 300 different point product solutions, many of which are trying to achieve the same outcome. They are now driving this consolidation standardization, not just as a technology, but of workflow and processes, such that you can  have a facility in Oregon and a facility in California and you can transfer an employee. A lot of those systems and tools are made the same way, so you can onboard them immediately and they’ll understand the look and the feel and the healthcare system’s way of doing things.

That’s going to be better for business. Number one, you get the obvious financial impact of system consolidation. But beyond that, it’s going to be so much better for the frontline workers who live in those in those tools for a couple hours a day who need to be as efficient and productive as humanly possible. When you’ve got a nursing leader who spends three to four hours a day of his or her time in systems instead of providing care or mentoring younger nurses, that’s horrible for your system. The ability to reduce that to an hour or hour and a half a day provides meaningful time back. That’s why you’re seeing a lot of these top-down down initiatives that previously had just been left to a fragmented, decentralized decision-making process. That’s the way of the past.

Has Symplr’s acquisition and operation of Phynd given you an appreciation for the challenges involved with the seemingly simple task of provider data management?

It’s so strange coming in from the outside. It’s a plumbing problem. If your pipes are set up the right way, your data flows. This shouldn’t be that hard. But because of the way credentialing takes place, because of the way a lot of these systems do provider data management, it’s been wholly inefficient. We look at Phynd as another part of provider management, which is one of the core categories that Symplr operates in as part of healthcare operations and GRC. If that front door doesn’t work, it  impacts the entire downstream operational landscape.

Phynd was so obvious for us. What had been Cactus and all the other provider applications we have that – Symplr Provider – and we saw the opportunity to bolt Phynd — now called Symplr Directory — into that and extend the operational wherewithal and competency in through the digital front door. Systems are now able to identify and convert more of those patient opportunities. It just made a ton of sense to stitch the whole thing together. It’s one plus one equals seven with those products together. It was a great opportunity for us to add a lot of value by simplifying something that shouldn’t be that hard.

You’ve said that companies need leaders who can stop debating and instead take action based on the 80% of information that is known. You’ve also said they must get along with each other. Did that mindset come from your military experience?

It’s this whole concept of task and purpose, and it really comes down to alignment and goal setting. If you have an organization that is trying to do too many things and doesn’t understand collectively what winning looks like or what success looks like, that’s when you get these rogue individuals who are well-intentioned, but are off doing their own thing. 

At Symplr, we have three strategic priorities — grow organically, become one Symplr internally and externally, and then win with mergers and acquisitions. The individual goals of everyone in the company, including me, ladder up to those three objectives. If you have continuity and consistency of purpose, the organization is able to better win together and remain aligned. We also have to know what right looks like, such that if someone is off doing something, the rest of the organization has a mandate to say, wait a minute, I think we’re out of balance here. How does this align back to our common objectives? 

Whether it’s in the military — where you basically have tasks and purpose, you have very specific missions with a specific purpose and clarity around mission intent – or in business — where you have three strategic goals, here are measures for each, here’s how your job ladders into each of those, here’s how we collectively in a system achieve those — it’s much easier to create organizational alignment.

I say I joined Symplr for four reasons, and one of the primary ones was the culture of Symplr when I walked in the door. This was a company that had grown up through acquisition. I was shocked to learn that the employee engagement was as high as it was. We had world-class Employee Net Promoter Scores the day I walked in the door, which told me you’ve got a workforce that wants to actually understand and solve for customers. That it’s looking for singularity of purpose, if you will. We’ve done a pretty heavy internal transformation to become one Symplr — our own infrastructure, our own processes, a common way of doing things. We do EMPS every quarter and we’re still world class. The organization was hungry for that kind of goal-oriented management and I think we have thrived as a result.

You are early in your first CEO job, but have already been involved in acquisitions and presumably some discussions about the possible change in company ownership form. What are you learning as the person who has to make those big decisions?

The two observations that I probably reflect upon the most are, number one, you can’t undervalue the importance of having an incredibly strong executive team. Do the leaders of the functions of our organization all understand what the goals are? Do we ladder up against them? Do we have the right culture on the executive team such that the organization sees us working together, challenging each other, but always being professional and having a ton of fun doing it?

I probably believed this before I took the Symplr job, but now I very much understand it because I own it as part of my job, but having the right executive leadership team, senior leadership team creates wonderful opportunities for engagement, for alignment, and for internal employee mobility. That’s what it looks like done right.

The other piece is that you never know, until you sit in the chair, how amazingly complex and varied the different parts of the business are. In the same day, I’ll go from evaluating our return to travel and the office COVID policies — relative to vaccinations and who is, and who isn’t, what do we do — to incredibly important diversity and equity and inclusion initiatives that we’re overseeing, to product strategy, to facility rationalization, to sales bookings growth. You get everything in the same day. If you’re not intellectually curious enough to be able to pivot five or six times in a given day and focus on different things, this could be exhausting. If you enjoy that, and thankfully I do, it’s exhilarating. But until you sit in the seat, you have no idea the amount of variety that goes into the day-to-day.

Some technologies found their way to success being led by top executives whose temper, insults, executive turnover, and micro-managing control were legendary. Does that approach still work, where one person’s force of will pushes the company forward even while alienating many of the people who work in it or with it?

A majority of those examples involve founders and majority shareholders, so they could get away with it. I would argue that nobody wants to work for a jerk. There are too many options, particularly in technology. If you are good, you can go work in a million different places and be treated really, really, really well. Our philosophy as an executive team is that we are ruthless in our decision-making, but we’re nice to everyone all the time. Because why would you not be? No one wants to do this if it’s not fun and enjoyable and if you don’t trust the people that you work with and for.

That other way may have worked. It may still work for some folks. It’s never been my style. You learn early on in your career that you can rattle your saber, shake your fist, and pound the desk and nobody cares. You’ll end up seeing higher degree of turnover and maybe the enterprise will be successful, but at what cost? As opposed to a place that is welcoming, nurturing, and accepting of all. That has high standards for performance, but just as an expectation of the role, never an indictment of the individual. 

We don’t yell. We don’t scream. Sometimes people work really hard, but hopefully it’s never all the time. This is not sustainable. I believe that the better financial outcomes come from happy and engaged employees, because then they’ll take incredibly good care of our customers, write great code, sell really hard, and market really well, and that will lead to the financial outcomes that you want. I hope those days are gone and you see more of a accountable, but accepting kind of leadership in technology.

Where do you see the company in the next 3-5-years?

I get this question a lot because of our size, growth trajectory, and profits. The financial profile at Symplr is just wonderful, so we have a lot of options. We might go public in a few years. We might remain privately held via a private equity sponsor. We may find a home with a very large strategic partner that thinks we can be accretive to their healthcare IT strategy.

More than anything, we’re focused on creating incredible healthcare outcomes for our customers, driving great growth as a result of that, and maintaining our financial discipline relative to the profit that we put off. If we do those three things, the options for Symplr will be unlimited. But the reality is that we’ll continue and maintain and extend our market leadership position within healthcare operations.

My dream is the day where healthcare systems, CMOs, COOs, CIOs, wake up and say, you know, we’re a Symplr shop. We use Symplr for provider management, workforce management, contract and spend access, compliance, quality, and safety. We’re a Symplr shop, which means we’re a best-in-class healthcare operation or healthcare system with our operations. If that happens, Symplr’s corporate outcomes involve a ton of different options, but that’s how we think about driving business.

Do you have any final thoughts?

It’s funny that probably 90% of the folks today are using a Symplr product and may not know it because we’ve grown through acquisition of brands like Cactus, API, TractManager, HealthcareSource, and ComplyTrack. We have all these wonderful point products that for years were best-of-breed in each of the categories they served. What we’ve now done at Symplr is to begin to stitch them together and create common workflows across systems, a common look and feel, and interoperability, We are making game-changing operational improvements. 

I would encourage folks to come talk to the business and come talk to Symplr to learn a little bit more how we can benefit them, because it’s probably not the same collection of point products that they once knew. There’s meaningful value to be had.

HIStalk Interviews Sonny Hyare, MD, CEO, ReMedi Health Solutions

Sonny Hyare, MD is CEO of ReMedi Health Solutions of Houston, TX.

Tell me about yourself and the company.

I was born and raised in Houston, Texas. I did my undergrad degree in Europe and then started medical school. I finished up my medical training in Chicago. I’ve been in the EHR space for about 11 years now. I worked for some pretty big consulting companies through 2017 and then started ReMedi Health Solutions, so we are five years in now.

What post-pandemic changes are you seeing with the company and its customers?

When the pandemic hit, we saw everything change, either going virtual or shutting down certain aspects of what was happening in the hospitals. Rightfully so, because of everything that was happening, especially with some of our clients in the Northeast that were being hit with COVID a lot harder than we were down south at that time. What I saw was quick adoption of tools that already existed. I didn’t see anything new come up. I just saw a bunch of people take platforms or technology stacks, put them together, and create what they needed. 

Post-pandemic, we assumed that we would have a hybrid model, or even not going back at all to what the norm had been. But I feel like we are getting more back to normal than we had originally anticipated. Some of the workforce wants to be back in the office. They’re trying to get out of the space that they’ve been in for the last 18 months. People are also seeing a different type of productivity versus at home or in the office.

Many health systems are operating under a budget that was created during the pandemic’s bleakest times. Are they reconsidering their priorities or just making it up as they go?

A little bit of both. They were making it up as they went, but now I l feel like the budgets are coming back into the plans they originally had. It is all coming back as if it hadn’t taken that 12- to 16-month pause.

How do you combine the value of a remote go-live with the benefit of having people wandering the halls looking for puzzled or frustrated clinicians who probably won’t open a help desk ticket?

That’s one reason that our virtual model includes a live video feed. It gives the feeling that somebody is there. But your example is why we need some folks to be on ground. We need this hybrid model to engage the physician who we won’t find sitting on a computer or being in a newsfeed, where you could see frustration in any end user. The live feed makes sure that we maintain that emotional connection, but you could have five tablets with one resource supporting all five of those clinics at the same time. The support model will definitely change post-pandemic, and instead of bringing 1,000 resources, you figure out how to bring in a hybrid model of on-site versus remote.

Are you seeing health systems that are worried less about physician EHR satisfaction and instead see the EHR as a way to implement corporate decisions that may take away individual physician choice?

I do see it, but I’m also seeing  more physicians getting involved in the administrative side of things, making sure that the right decisions are made for the physicians. That was one of the reasons we came about — we essentially understood both sides of the playing field. It was our job to be that liaison, to help the physicians understand why these decisions were being made from an administrative level. Then on the flip side, help explain to the administrative side of things of why physicians needed certain things.

It is getting harder for physicians to what they need, but it’s also getting more complicated on the IT side as well, where you see both sides of the story.

Are you seeing physician EHR dissatisfaction that is driven by local implementation decisions rather than core product design?

That definitely is one of the reasons. Sometimes what I see, and have seen in the past, is having the knowledge of what the tool can do and how it can drive the efficiency that we are all trying to achieve. Sometimes it starts as simply as that. We’ve seen this across the board. You don’t know what you don’t know. Physicians who I’ve known and worked with have dug into these systems over the last decade and could probably answer any question that a physician might have on what and how they need to do something. They have the inefficiencies in both ways.

When we talk about certain changes, we know there’s a lot that goes behind getting something changed like that. Nine out of 10 times, the physicians will be satisfied, but they just don’t know how to do it. That comes back to, are we talking about training, or upgrades, or new additions? These systems have the capability of doing a lot more than the way the physicians are using them now.

Health systems have said in various recent KLAS reports that they wish their software vendors would take a more active role in telling them how to implement and optimize their systems. Are you seeing more demand for a prescriptive approach that takes advantage of broad vendor experience?

Absolutely, and it makes sense. Why would we not explain these certain milestones or scenarios in the implementation in a better way? We were working with a client 18 months prior to them hitting the switch on the EHR that they had selected. The EHR vendor had a list of items that they were going to run through, but at the end of the day, there was no explanation or details in what needed to be done. Some of these bullet points were engagements that would have taken one or even two months. That is misleading the client.

The consulting company and the EHR vendor have to help them guide and understand the decisions that they are making to maximize satisfaction as a whole for everyone. Not only the end users, but the people who made the decision to bring that EHR vendor in.

Are metrics used to identify users who are struggling or functions that aren’t being used optimally?

We live in a data-driven world. Every metric and every data point that we can grab helps us make a better decision. It helps us explain to our clients, as well as to the vendors, why and how this is happening and how we can mitigate the issue. I don’t look at it as a ticket, but something more detailed than that, that has helped us get success. We have to collect information from one-on-one sessions and at-the-elbow support to get a bird’s eye view and understanding of what’s actually happening.

What changes do you expect to see in the company and in the industry over the next 3-5 years?

Three to five years ago, I thought all of this implementation and conversion activity was going to end. But it seems to be constant due to mergers and acquisitions and systems deciding to replace or upgrade software. We may see the same types of engagements in 3-5 years that we are seeing now. I only hope that we are getting better and better as a whole, the EHR vendors, the hospital organizations, and the consulting companies. How can we make this process better for the actual end users who are going to be using these systems on a daily basis? Can we get rid of the term physician burnout?

Do you have any final thoughts?

We are thankful where we’ve gotten to over the last five years. We’re thankful for all our clients that have trusted us. We are still working with our first client, all the way until our last client. Our firm appreciates that, knowing that we’re giving the value that we said we would. For that, we are thankful for the hospitals that took a chance on us.

HIStalk Interviews Richard Caplin, CEO, The HCI Group

Richard “Ricky” Caplin is CEO of The HCI Group of Jacksonville, FL and CEO of healthcare and life sciences of Tech Mahindra of Pune, India.

Tell me about yourself and the company.

I’m married to Danielle and we have three children — Callie is eight, Rilen is six, and Brooks is three. I started the company 12 years ago at the height of Meaningful Use. We began in strategy implementation and training on electronic health records. We grew to be one of the largest firms in our space. 

I sold the company about four and a half years ago to Tech Mahindra. which is a leading firm in the digital transformation and managed services space. At the time we sold it, we were about 1,000 employees plus a bunch of contractors. The idea was that we could bring their services and use our domain expertise and clients. We have done that successfully. We are one of the largest consulting firms in healthcare. We still do a lot of implementation and strategic roadmaps, but it’s more project-based work or large-scale managed services. As a matter of fact, we just closed one of the largest managed services deals ever in the application space. 

We also do a lot in the digital transformation space, such as robotic process automation and digital charters. We do automation as a service. We have launched a new company called HealthNxt, which is an enterprise-wide virtual health platform. So we started in the strategy and implementation space and today we are known as one of the leading innovation and visual transformations firms in healthcare. At the end of last year, ISG, Forrester, and Black Book all had us at the top in innovation and digital transformation categories.

What do you think will change with whatever the post-pandemic normal looks like?

I think we have already started to see change, both in health systems and in big cities. You might have had 500 employees in your IT organization in New York City, Chicago, or San Francisco, and all of a sudden you went virtual overnight. A lot of those people are never moving back into the cities and the office space isn’t needed. I have talked to many organizations that are working on new design layouts that are more of a hoteling system with innovation and collaboration space.

Once you have a relationship with someone, it’s a lot easier to conduct virtually. But still, as you are hiring new employees, you need to build that rapport and chemistry. People are emphasizing that team-building aspect in the way they are laying out their office space. But it also changes the way you pay your employees and where you recruit from. You can be in New York City and hire someone in Mobile, Alabama, so it is readjusting the entire pay school for people in big cities and small cities since all of a sudden you’re in a more national and even international hiring environment.

The way we work and interact day to day are also changing. When you look at how healthcare is being delivered, there’s all of a sudden a window to do things that really hadn’t been focused on before. A lot of organizations didn’t have digital charters and roadmaps, and all of a sudden that’s the way of the future. You are seeing huge upticks in telemedicine, and while we know it is coming down some, there will be a new normal. You’ve seen organizations do remote patient monitoring. We’re going to see a lot of stuff around virtual hospitals and eICU. A lot of organizations are focused on their digital front doors and you are seeing that in the way healthcare is delivered. Health systems are becoming more like technology companies first, and they have to be to compete in the new world.

You offer a fixed-price digital transformation strategy. What results are you seeing?

The first category is the operations of an organization and how they can do things more efficiently. What processes can be automated? There is a lot of opportunity in HR, payroll, revenue cycle, and even facilities and maintenance to automate processes and run more efficiently.

Beyond doing things better and cheaper, you look at the delivery of healthcare. What does your current landscape look like? Organizations may be using multiple telemedicine platforms or may not be doing remote patient monitoring, or if they are, only for a very specific use case or two. A lot of them got into it around COVID, but there’s so many different disease states with use cases for remote patient monitoring. Very few use virtual hospital, eICU, or virtual physical therapy. Many organizations are just starting the journey of deciding what their digital front door will look like and how they will engage with consumers outside the walls of the hospital. That’s a huge part of the strategy.

How are you seeing health systems using robotic process automation and what benefits are they realizing?

I’ll give you a basic example. When you are onboarding a new employee, you may have a bunch of paperwork that needs to be done. You may need several approval signatures. That’s a lot of manual work and a lot of processes. You’ve got orientation, things like that. You might have seven, eight, maybe even more people who touch that process and it takes up a big piece of their time. There’s a lot of paperwork and approvals moving back and forth. If you can automate that process from start to finish, where humans don’t need to even touch it but instead maybe click on an approval button when it pops up, things will be done faster, cheaper, and more efficiently.

That’s a basic example. But think about any process where people are involved — especially things like revenue cycle and facilities – and the size of some of these hospitals and health systems. You have many people monitoring and touching their electrical and lighting facilities, and a lot of those processes now can be automated as well.

Outside of healthcare, I’ve had a conversation with the CIO of the state of Florida, which has a budget of about $100 billion. He gave me an astounding number. He thinks that through automation, we can take something in the neighborhood of 30% out of our state budget. I also got together with a gentleman who is running for mayor of New York City, Andrew Yang. He’s a former presidential candidate. I had dinner with him last Friday, and we talked about the city’s permitting process. For anyone who has dealt with big government, how long does that take and how many people have been doing it for years? You can automate that entire process. Andrew Yang thinks there’s significant savings, similar to the state of Florida, that could be achieved in big government.

We have always had screen-scraping tools and basic automation tools. What has changed from a technology perspective to suddenly make RPA a hot topic?

That’s a really good question. I’m not an expert by any stretch of the imagination, but from my high-level view of what’s possible now, I think there’s a willingness for organizations to try it out. You have a lot more automation companies as well. There’s a whole bunch of them that have emerged and grown. The technology is advanced and there’s tons of applicability. We are winning some of these large-scale managed service projects, but a big piece of what we’re doing isn’t just the labor arbitrage, it’s the process transformation. We are taking a forward bet on what we will be able to automate.

How do you see health system C-suite roles changing now that chief digital officers and chief experience officers are joining CIOs?

We looked at the transformation over the past five or 10 years. The CIO has become a much more important executive role, really one of the leading executive roles in any senior leadership team. Technology touches everything. But now we are seeing the same thing occur, where this consumerism that you talked about, or this chief digital officer role, is driving everything. It’s a strategic role, it’s an operational role, and you have technology. So you will see one of two things happen. The CIO is either going to become a functional role reporting to the chief digital officer, or chief information officers are going to evolve into chief digital officers and they are going to own IT. But it’s a more strategic role where IT is a component of the digital strategy.

Health systems are outsourcing their IT work to offshore firms and in some cases to Optum. What trend do you see?

I think you hit on this earlier. There may have been some movements earlier in automation, but now you are seeing a much bigger uptick. The majority of technology has migrated to the cloud and it is more readily available. I think you will see a permanent shift in large-scale managed services or outsourcing. COVID shed light on that. Organizations had new pressure to decrease operating expenses and run more efficiently, and you saw a big uptick in these large-scale projects.

We won a couple of large deals. We’ve been able to save organizations in excess of 30% of their operating costs while giving them a better service level agreement than they were doing internally. As I speak to CFOs and CEOs — not just CIOs — they don’t want to be in the business of commodity IT. They want to be in the business of delivering world-class healthcare. It has been proven by from organizations like ours and others that you mentioned that the savings is there, and if we can deliver a high-quality product, there’s no reason for them to go back to want to run IT, especially with the pace that technology is involving.

You can’t keep up with some of the things that are happening with cloud. With the cybersecurity risk, it may not be the best thing for you to do. You may want a partner that has a balance sheet that’s going to own those processes, even just from a de-risking standpoint. But I think the pace of change, the amount of risk, and the opportunity for savings are all permanent changes that we didn’t see before. The adoption of technology in 10 years has been tremendous. I don’t think a lot of that will go back. We will see more and more of it.

Do you have any final thoughts?

It’s going to be exciting to watch. Tech Mahindra is positioned very nicely to be a leader. We are hopefully going to continue to grow our managed services business and deliver value, but we are also all in on being a digital leader and with our virtual health platform HealthNxt, which I see becoming one of the largest platforms in this space. Time will tell. COVID served as a catalyst, where we saw a lot of innovation happen in one year that might have otherwise taken multiple years, and that will continue. As the new normal comes back, technology is going to lead the way in how we deliver healthcare.

HIStalk Interviews John Gannon, CEO, Blue Spark Technologies

John Gannon, MBA is president and CEO of Blue Spark Technologies of Westlake, OH.

Tell me about yourself and the company.

I’m CEO of Blue Spark. I have been here for about 10 years. I am an aerospace engineer by training and have spent time in banking and venture capital. 

Blue Spark is a medical device company. Our primary product is TempTraq, which is a wearable, continuous temperature monitor that is designed for patients in clinical settings or remote patient monitoring environments. It’s an FDA-cleared device that is used by pharmaceutical companies and hospitals for early detection of fever.

What is the clinical value of having a patient’s temperature continuously monitored?

Temperature is the only vital sign that is not continuously monitored outside the intensive care unit phase. Temperature taking has been done globally the same way for about 150 years. It is done intermittently, taking the temperature once every four hours. In a number of disease states, patients deteriorate more quickly than within that four-hour window. That is where TempTraq plays a role, such as in oncology, where you have immunocompromised patients, or post-surgery where you are looking for infection, sepsis, or infectious disease.

The American Society of Clinical Oncology’s guideline for the US is that neutropenic fever should be treated within one hour, but they still only take their temperature once every four hours. The benefit of doing something continuously, as is done with pulse oximetry and blood pressure, is that identifying that fever early allows you to intervene sooner.

How does integration with other systems work, such as turning the stream of temperature data into something actionable?

We have designed the system to feed data into an electronic health record. EHRs are records of truth, but that is “records” as opposed to “monitoring devices.” We have a HIPAA-compliant cloud architecture called TempTraq Connect. We provide the hospital with a dashboard for real-time monitoring that can monitor either inpatients or those in remote settings, or we can push that information to their own internal systems. For example, it can go into an EHR, but we’re bringing a process live now where we are pushing data to the Vocera badging system so that nurses who are specifically aligned to rooms are getting actionable data in real time. It’s a flexible system.

What is the task management that is involved in changing a patient’s disposable patch?

Doctors we talked to at the outset of the design cycle asked for two features. The patch needs to be uniquely identifiable so you can associate a dataset with a unique ID, and then further associate that with a patient. Second is disposability. We are measuring the axillary temperature of an infectious disease patient for up to 72 hours. They don’t want to sterilize that device.

We have two versions that we sell into the hospital setting. We have a one-time use, 24-hour device and a one-time use, 72-hour device. When it’s done, you dispose of the device. The system will give you an alert 30 minutes before the end of its run time that it’s time to change that patch.

Is battery life the life-limiting factor?

Interestingly, it is not. It was a surprise in the development cycle that one of the more difficult things to get right was the adhesive. We wanted FDA clearance for all ages, which we have. We use a very gentle adhesive that is silicone gel based. That allows us to use that patch on all ages. But at the same time, we found that, particularly in adult patients wearing the 72-hour patch, the very gentle adhesive drives the end of life at 72 hours from both a hygiene and adhesive perspective. We certainly could design a patch that would run longer based on that battery, but the adhesive and hygienics were the limiting factors we found in our clinical studies.

What does the connectivity to the patch look like?

We use Bluetooth Low Energy. We are sending that signal in a hospital setting to a Bluetooth gateway that we install. It is specifically listening for TempTraq devices. That data is sent back to TempTraq Connect, our HIPAA-compliant cloud. For patients in an outpatient setting, they download our patient application to their device or use a device that is provided by the hospital or the pharmaceutical company that is running that software. Then the same thing happens to data. Once it gets Bluetooth from the patch to the phone, it is transmitted to TempTraq Connect.

Some consumer wearables, such as the Oura Ring, can measure temperature. How good is the reliability and accuracy of those devices versus TempTraq, where you had to prove your capabilities to the FDA?

The FDA is very prescriptive in terms of what is required to use a device as a clinical thermometer, which is the category we are in. FDA requires being compliant with the ASTM E1112 standard, which is plus or minus 0.1 degree Celsius within body temperature range. Beyond that, we also did clinical studies to show accuracy. We did our gold standard test at the Cleveland Clinic, where they were comparing TempTraq to readings from a pulmonary artery catheter in the chamber of the heart. The concluding statement of that study was that TempTraq was in agreement with core. Beyond what the FDA requires in terms of testing for submission, we also did human testing to show that that validation occurred on patients.

We’re seen a wide pandemic rollout of thermometer guns and walk-through fever-detecting frames that seem to offer limited accuracy and usefulness. Does that make people wary that devices like yours can actually work?

I think we’ve all had the experience of somebody using a gun and measuring our temperature at 94 degrees or something like that, hoping that it is still consistent with life. We are conscious that they have been used widely and are fairly erratic. We don’t generally run into those types of devices in the clinical setting, which is our primary market, so we don’t really view those as competitive devices. We make sure that people are familiar with the clinical studies and the standardized testing that we’ve done.

The “normal” temperature of people isn’t always the same 37 degrees Celsius. Is the change in someone’s temperature as important as its value at any given snapshot of time?

Absolutely. It has been studied over time that fever profiles across disease states have a distinctive footprint. The point that you made is a really important one, which is that 37 degrees Celsius or 98.6 degrees Fahrenheit is widely considered normal. But long, large studies have found that someone’s normal can have a standard deviation of plus or minus one degree Fahrenheit. Having a baseline and being able to look at trend data can absolutely be valuable when you are working with patients.

Is the future of the company always going to be related to temperature monitoring, or does your experience with patch technology provide more opportunities?

We view TempTraq as a platform. We have developed an unique database of continuous temperature data. Given the fact that there isn’t a lot of continuous temperature monitoring done outside of an intensive care unit, that makes that data more interesting.

We are looking at two areas of expansion. One is work that we are doing relative to being predictive around early warning. We have engaged with Adam Perer, PhD at Carnegie Mellon University to help us work on doing some of the artificial intelligence work around our network.

The other is looking at moving from univariate to multivariate, taking additional sensors and sensor readings into our database to help with that early warning score concept. But the other is looking at additional devices. We have a unique form factor in the TempTraq device. We will be looking at adding additional sensors to it, likely with a different device because the placement in the axilla under the arm, for example, is not a location that you would typically monitor another vital sign. So to do it effectively, we are probably looking a second device where we could bring in data from another vital sign.

Do you have any final thoughts?

It has been a really interesting year. If you go back 15 months, remote patient monitoring and telehealth were on the horizon, but hadn’t taken a foothold in the healthcare industry. COVID certainly has accelerated that. We have seen a breakdown of regulation to allow telehealth acceptance. We have seen a greater healthcare provider acceptance of telehealth. With that acknowledgement, there is a need to do remote patient monitoring. Not just temperature, but across all the vital signs. A lot of hospitals that we are engaged with today have initiated remote patient monitoring strategies, and we are hoping to work with them as they think through what that will look like.

There is a whole continuum of possibilities across different patient populations. We are an element of that, but it is certainly a multifaceted array of sensors that are being looked at to see what particular patient populations are most effectively tracked in the home setting. If you think about remote patient monitoring, going back a year, it really was around population health and chronic care, and now it is accelerating into the acute care setting. That is important for patients and important for overall healthcare cost. It’s an interesting time to be part of it.

HIStalk Interviews Stephen Gorman, CEO, RCxRules

Stephen Gorman is CEO of RCxRules of Burlington, VT.

Tell me about yourself and the company.

Like many people in this industry, I’ve spent my entire career in the healthcare IT space. I started out working at IDX in the early ‘90s when I was 24, which now seems like a long time ago. I held various leadership positions at IDX and GE Healthcare before joining forces with revenue cycle experts from a longtime IDX customer to start RCxRules back in 2010.

RCxRules helps medical groups improve their billing and coding, which is admittedly a pretty crowded market. There are a couple of things that make RCxRules unique. The first is that our technology focuses on harnessing our customers’ deep understanding of their unique billing and coding challenges. We then take that expertise and help them automate as much of their billing and coding process as possible.

We also have a deep appreciation for just how challenging the healthcare industry is. We appreciate that successful IT projects require a real partnership with our customers to be successful. We pride ourselves on rolling up our sleeves and working closely with our customers to deliver a solution that really meets their needs.

To what extent are provider organizations using customizable rules for billing?

The short answer is customized rules are used all the time. When we started RCxRules, we incorrectly believed our customers would find our “standard” billing rules and guidelines to be most valuable. We quickly learned it was our ability to easily create custom rules that customers appreciated the most.

As we dug into this, it made sense. With the adoption of EMRs, doctors are now entering the billing information directly into these systems, and we all know doctors are not billers or coders. In the old days, doctors scribbled markings on paper charge slips to indicate billing information. Billers then performed the very valuable but underappreciated work of translating that charge slip into a set of billing codes that insurance companies would accept. The billers eventually learned the idiosyncrasies of the doctors they supported and intuitively corrected their specific issues. They provided a great deal more value than simple data entry.

To make this process work well in the current electronic and EMR-centric world, our technology had to harness the knowledge of these billers. We learned that our technology had to be flexible enough to deal with physicians’ idiosyncrasies, and that a one-size-fits-all approach doesn’t meet the customers’ needs.

What billing challenges have resulted from expanded telehealth volume?

While expanding telehealth was a great move for both patients and providers, it really wreaked havoc on the billing process, especially back in April and May of 2020 when CMS and other payers were scrambling to liberalize the use of telehealth. Pre-pandemic, medical groups needed to use certain codes and modifiers to designate a telehealth visit, and these codes were designed to downgrade the reimbursement rate. A critical aspect of the telehealth expansion was normalizing the reimbursement with traditional face-to-face visits. So literally overnight, the payers then wanted different codes and modifiers to reflect that the care was being provided via telehealth, but that the visit qualified for normal reimbursement levels.

Telehealth billing is still complicated, especially with different payers having different policies, and our product helps manage this complexity. But at least now the guidelines aren’t changing every week as they were back in the spring of last year. The next big challenge is going to come when the public health emergency ends and the payers establish their long-term policies for telehealth.

What technologies and processes, especially those involving physicians, are needed to successfully move to value-based reimbursement?

In some respects, moving to value-based care models is extraordinarily challenging. But the concept is pretty simple. Value-based care models focus on compensating physicians for spending the right amount of time with their patients to deliver the necessary care. Sicker patients need more care and attention, and therefore money more to treat. At its core, this is an intuitive concept that allows physicians to get off the fee-for-service treadmill and allocate time based on clinical need.

This simple concept becomes very challenging in a few ways. The first being that physicians have to live in two worlds, fee-for-service and value-based models, which have different incentives and drive different behavior. The second is the actuarial-like accounting and reporting that is necessary to allocate the right amount of money to groups based on the health of their patients. This is where HCC coding comes in. Older and sicker patients cost more to care for than younger and healthier patients. Again, it is an easy concept to grasp, but the devil is definitely in the details.

The bottom line is that the physicians need help succeeding in this new model. The staffing profile and technology that are optimized for fee-for-service don’t work in value-based models. The physicians need help clinically and administratively. Clinically, they need to staff care teams that can support both physicians and patients, and they need data on which patients need the most care. They can get this data either from their own population health solution or from their payers. Administratively, the priority is utilizing HCC coders and HCC technology to ensure the physicians’ good work with patients is correctly reported to the payers so the right amount of money is allocated for care.

What are the company’s priorities over the next 3-5 years?

Our customers are large medical groups. We fully appreciate the challenge they are living through balancing the fee-for-service world with the value-based care world. It’s the proverbial “foot in two canoes” challenge. Most medical groups have more priorities they want to accomplish in any given year than resources to get them done. They sometimes talk of feeling like they’re on a treadmill that keeps speeding up every year.

Our focus over the next three to five years will be the same as our focus over the last 10: helping customers get off that treadmill. We will continue to build and deliver solutions that remove as much manual effort from this complex billing and coding process as possible. We want to free up our customers’ time so they can accomplish more of their priorities.

HIStalk Interviews Carina Edwards, CEO, Quil Health

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

Tell me about yourself and the company.

I have spent my career leveraging technology to improve the clinical and patient experience across healthcare. I’ve done that at companies including Imprivata, Nuance, Zynx Health, and Philips Health.

Quil is a digital health joint venture between Comcast NBCUniversal and Independence Blue Cross. We are on a mission to help people organize and navigate their health lives. We have proven that an educated and engaged consumer leads to better outcomes at a lower cost. That has been the holy grail and we want to see that through. It’s an exciting venture and I am thrilled to be at the helm.

To what extend has widespread availability of consumer technology, as well as comfort with using it, provided richer healthcare at home options?

The home as the center of care is squarely in our remit. We purposely think about the connected home, which with devices, wearables, and the television hanging on your wall, can be truly differentiated and activated in health. But the core comes down to, why aren’t consumers activating in their health?

One of the big things for me is that we need to stop, as an industry, thinking about the patient, the member, the employee, and the caregiver. We need to start thinking about the person. We need to be thinking through how we bring health and the navigation of health together for the individual. That means meeting them where they are — whether they are in a high-tech or low-tech household, whether they are connected, how they are connected — and trying to figure out the best way to activate that persona in a healthcare journey or in health literacy.

Nobody wakes up hoping to be admitted to a hospital or nursing home. Is it hard to tell the story of care options that don’t involve particular venues?

That’s the part that is rapidly changing. My customers span providers, payers, and employers. When I speak to all of them, they see their as-is state moving very quickly. The more progressive ones get it. The hospital at home concept has been touted for a very long time, but COVID brought to life the need to do infusions at home and do cancer treatment at home. Nobody wants to come in to the city center to the amazing, beautiful, big cancer tower, because that’s inconvenient for their life and they are already in pain and struggling. 

How do we bring as many services, knowing that there is a huge cost implication of that, too? Where we can leverage people, process and technology, we can rethink many things at a lower cost and meet people where they are. I love that sentiment.

How will health systems change their business model as the pandemic winds down leaving deeper experience with delivering care outside the hospital?

Everybody realized that, and they quickly spun up the technologies. It’s an interesting perspective where both providers and payers realized where the gaps were in the other side of the pane of glass. It wasn’t so much, can I get and engage my patient, member, or employee on a digital medium? It’ more like, how does it fit into the workflow of healthcare as we’ve established it? How does that integrate to make sure that the waiting room is virtual? The thoughts are virtual? You’re keeping people engaged, you’re meeting them, and they’re not meeting some random doctor or someone that doesn’t have their health history.

As they look forward, we hear a lot about, how do you bring information sharing? Now that we are all working towards interoperability with the passage of the legislation and the activation of the legislation, how do you bring that to the pane of glass in the provider workflow? In the patient workflow? So they they can not only interact, but they know what to do pre and post, because so much is forgotten during the encounter.

That’s another stat that I love to bring to people’s attention. People forget that when you hear a critical diagnosis or even a joyful diagnosis – congratulations, you’re pregnant, or I’m sorry to inform you that you have cancer — your brain goes to a whole different place. Studies have observed time and time again that patients can’t easily recall information that was relayed during an appointment. So now in this new medium, how do you make sure they understand, acknowledge, and can continue learning and engaging post the video visit?

What expectations come with the big investments that are being made in healthcare companies that offer everything from primary care chains to employee wellness technologies?

It’s an interesting world and I’m really encouraged by it. You’re going to see a lot of starts and stops, and we’re going to get to new models because consumerism is creeping in. 

The excitement is around consumers and where we’re trying to meet people where they are. We are trying to segment the market. There isn’t one size fits all for an individual, what they need, and their health at a certain part of their life. If I am a younger employee trying to figure out basic care and navigation, things like needing to get a flu shot, that’s a very different patient persona than someone who has been given a new diagnosis, is dealing with a chronic condition, is aging, or needs to go in for a procedure. Care at that point in time becomes very local.

I love that these new models of care are springing up. Just like there’s not one department store we buy clothes in, and there’s not one TV channel that we consume information on, we are giving people opportunities to engage in mediums that might work for them, make it easier in their life, and get all of us to better outcomes. I’m encouraged by it. But I don’t think there’s one big magic bullet that will change healthcare as we know it. At the end of the day, complex care requires care coordination, testing, and all those diagnostic tools that hopefully will move over time into the home. But those towers will still be relevant in someone’s health journey over time.

How do you broaden the use of apps, wearables, or other technologies beyond the “worried well” to more effectively move the health cost needle?

We spend a lot of time thinking about care in the home — ambient sensing,  wearables, technology, and voice. Together with our parent Comcast, we’ve run a bunch of experiments, especially with the silver tsunami that is coming, the aging at home of a generation that I adore that wants to go out fighting. They do not want to go to assisted living facilities. They want to live exactly where they are and how they want to. We have done a lot of consumer research where those who are aging at home will sometimes buy some of these technologies to allow them to continue to live independently. The other thing that we see is that there are 54 million unpaid caregivers in the US, those unpaid caregivers are also managing their own lives, and 23% of them have worse health because of their caregiving responsibilities.

Finding technologies to support the care recipient and being mindful of the individual that wants that independence, but also wants that safety net, is a great segment where you will see consumerism come to life for aging and home solutions that are way better than the “I’ve fallen and I can’t get up” button. That’s where you are going to see some really fun innovation.

Some people dumb down hospital at home and remote monitoring to “can get a pulse ox into the chart?” That’s not the challenging part. It’s the figuring out what data to get, what ranges to allow, and how to make sure that when it comes into the clinical record that it’s clinically relevant. How do you start thinking through the lens of the clinicians at that point in time to say, what is useful in an encounter? What is useful for me to remote monitor? When do I actually look at thresholds, alerts, and alarms?

That remote patient monitoring world will continue to scale from simple wearables to ambient sensors. We have been playing with this concept of, can you make the bathmat a scale? Can you start using new technologies for those that are very chronically ill, that might have episodes that they might not be self-aware enough to tackle?

A new article just concluded that nurses spend twice as much time managing a patient who is seen virtually instead of in the office, mostly because they need to monitor a steady stream of data from wearables and patient-reported information instead of just looking everything over during a three-month office visit. Has the capability of sensors exceeded the ability of people or systems to monitor the data those sensors create?

It’s a workflow and insight challenge. When you start looking at data, data is data. Data is overwhelming. You can start gleaning insight from data through models, algorithms, and deep understanding, but you have to do so through the lens not just of the data and the individual generating it, but the individual who has to consume the data. We spend a lot of time on user experience and user design, and sitting with clinicians – which has been challenging during the pandemic – to observe their workflow, watch these things, and design the system around when it should alert, when it  should tell you, what’s overwhelming, what can be computer screened out, and what can be noise in the system. Then, what is actionable, and where does that action lie?

When we redesigned these versions, the process side of it, we try to throw tech at a lot of things. The process and understanding side is important. Then, there’s the financial component. Is the nurse doing some of those things because that is the right data digestion, or is it also because there is a documentation requirement to get reimbursed for remote patient monitoring? Thinking about that whole spectrum and making it a win-win for all three parties involved is key. The payer truly comes into this as well. It’s a new frontier that can only be better. When we start any new technology, it changes. When it moves the cheese, it changes the workflow, and so many times we don’t assess the workflow change and acknowledge it.

With all of the provider roles, who coordinates monitoring the patient’s data that is created by devices in the home?

The key for us is today, where we are. This is all a life cycle, and as we are progressing down our life cycle. We see convergence coming together for the individual. That’s our three- to five-year vision of how I, as an individual, get the different streams of health, care, benefits, and employee benefits all navigated for me in one pane of glass that I choose. We’re starting in the provider, payer, and employer world, with unique use cases. Learning and aggregating, and where we can collapse them, we do. If I am on a pregnancy journey that is navigating me — not just on benefits, short-term disability, talking to my manager about being pregnant, and thinking about childcare post delivery — and I am also on a pregnancy journey with my provider, those two worlds come together for me today on a pane of glass.

But each of those pieces is uniquely owned by the organization. The employee benefit side of it is going back to the employer. The clinical insight generator is going over to the provider. But the individual has one pane of glass to see the experience together. That is the nirvana as we think through data sharing, permissioning, and where all of that needs to go. And to your point, who is bearing risk on that? How do I make sure that the risk-bearing entity — because there’s many models of risk now — that you need to align around that model of who’s there in it with you, that everybody wants the best outcome? Then, who is incented for better outcomes?

Is it hard to sell an employer an app or service using metrics around employee adoption or satisfaction rather than cost savings that will deliver return on investment?

Is it difficult? No. Do you have to understand their world? Yes. All employers want the best outcomes for their employees. There are more forward-thinking ones in benefits and benefits aggregation that are thinking through better outcomes, getting people to higher-quality venues, because that’s a win-win for everybody. It’s not wasting time, and it’s keeping presenteeism. There are so many ways to measure success.

But to your point, the more progressive employers are looking for real, tangible outcomes. It’s not just about X percent engaged, X percent liked it. Clearly, there’s a point that you want a great employee experience. It has to be usable. Those are almost table stakes today. How, though, do you generate that longer-term ROI that justifies that? Who do you put in the middle of that? We have taken the approach where we are going to be focused on a digitally-forward health engagement platform, not coach-enabled. But others have taken the approach where we are coach enabled, and then through digital interaction, we can get you to a next action. We will see that evolve over time. Can we get more digitally forward so we can scale and improve outcomes across the continuum?

How can technology support unpaid caregivers of people aging at home?

I look at it pretty simply. It’s there for them and it’s there for you. For them, it’s technology that is easing the care recipient’s mind. For you, it’s also there for the caregiver. They are able to do task trade-offs with their family, coordinate things, be in one space, not have to time slice, and have one point of view on what’s going on with mom, dad, loved one, neighbor, etc. There’s also levels of caregiving. The fun thing is there for them, there for you. As the care recipient, there for me, I want to know who has access to my data, who I want to have permission to my data. 

We think a lot about the tier of caregiver you are. If you are the neighbor who might have a key to get somebody in if something happens to you, that’s a tier one relationship. If you’re navigating and supporting me for a geriatric hip fracture to home, or through hospice to home, you want that person to have access to everything. Making sure that the tool understands that it’s not one way. It’s not a caregiver tool, it’s the caregiver and the care recipient tool. I’ll leave it with there with there for them and there for you, because it’s multi-sided.

HIStalk Interviews Charles Tuchinda, MD, President, Zynx Health

Charles “Chuck” Tuchinda, MD, MBA is president of Zynx Health, EVP and deputy group head of Hearst Health, and executive chairman of First Databank. Hearst’s healthcare businesses include First Databank, Zynx Health, MCG, Homecare Homebase, and MHK.

Tell me about yourself and your job.

I’m a driven physician who is hell-bent on making healthcare better. I  want to figure out how things work and how to innovate, which applies to many things in my life. This weekend, as a random example, I actually tackled my first brake job and successfully replaced the brake pads on an old car.

I’m the president of Zynx and I still have some responsibility over FDB, and more broadly, additional responsibilities across Hearst Health. Zynx has been on a mission since 1996 to improve the quality, safety, and efficiency of care. We help people make better decisions that lead to better health through evidence. That’s something you see playing out in the world today.

How much of a physician’s decision-making can be directly supported by available evidence, and why does medical practice sometimes fall outside available evidence?

This question will continue to grow in terms of the body of knowledge and the evidence that helps us think about what we need to do. 

Let me come at it a few different ways. When you look at our process of processing evidence and synthesizing it, we search across a bunch of different literature sources and we filter these things based upon the quality of the study, the type of study. Often, we are looking at over 13,000 studies, so we read and distill them and then we grade them and prioritize them. Then we generate a core piece of knowledge that we call Zynx Evidence that helps us as a foundation for all of the clinical decision support that we make.

But if I step back away from our process and I think about healthcare overall, there’s just so much information, or I should say data, that is available now. The challenge as a clinician is that you have to synthesize it. There’s so many competing interests. You are expected to practice and handle a high volume of visits. You’re expected to practice with high quality of care. You are measured on whether you can reduce readmission or shorten the length of stay.

As clinicians, we are expected to draw upon so much data and synthesize it so quickly. That calls out for partners, information, and tools to help you be the best version of yourself, to do the best that a clinician can do. In the future, we are going to see clinical decision support continue to advance, first to support the healthcare professionals and elevate their practice, and in the long run, to elevate and empower the average patient to make the best possible healthcare decision.

People talk about gaps in terms of the knowledge base. There will always be gaps, because there’s a frontier of knowledge out there that is growing and expanding. But we live in an era now when a lot of the healthcare information can be captured, stored, and analyzed, so the body of knowledge is going to continue to grow. That will make it more important to understand what the standard is. What do we already know about how to go about and do things in a better way?

How difficult is it for physicians to assign the proper weight to their personal experience with looking at someone else’s research that covers a large population?

It is challenging. I remember medical school very well. I went to Johns Hopkins and was infused with knowledge around what the research and evidence shows, essentially defining the right standard of care, at least in the eyes of the medical school I went to. Then when I went to the floor and started meeting with patients, trying to help people do what I believed was the right thing, based on the way I was educated. That turned out to be a big challenge, getting people to do what is likely to be in their best interests for better health.

You also see that challenge with clinicians. Clinicians have different experiences. When they graduated from school, there was a certain level of knowledge and a certain practice pattern. The challenge is that clinicians and the patients they see influence what they think is the best way to practice. What’s tough is that there’s always people out there doing more research, studying more people, coming up with better ways.You have to look at that, synthesize it, make sure it’s right, and make sure it’s right for your situation. Then if you are constantly trying to improve yourself, you’re going to want to bring that into your practice and your day to day. That’s a challenge that has been described in the literature as something that takes, unfortunately, a decade plus for some new knowledge, from the time it’s discovered, to be put into practice and benefiting a large population.

It’s tough. And when you look at the differences in care and the disparities, it’s not only about knowing the difference between the standard of care and what actually happened, it’s also a lot about convincing people and changing minds and helping them access and make good choices.

Will the less-structured, more timely way that new research and clinical findings were disseminated during the pandemic influence the distribution of clinical information in the future?

Yes, absolutely. The pandemic highlighted the fact that reliable information is more important than ever. In the early days, you saw that the volume and velocity of information coming out had increased dramatically. Lots of headlines and a lot of observations. There was this urgent need for scientific or rigorous medical knowledge. You also saw public health entities trying to make decisions with the best available information they had at the time.

It was this nexus of, I want some good information, but I don’t know if it’s out there. Then a flood of information with unclear significance. That’s when it’s important to trust your process. Go back, look at the source, look at the study design, try to figure out if it’s rigorous. Once you feel like you have distilled a few things that work, the other challenge is getting it into practice. How do people apply it? How do you implement it into their workflow? The pandemic really highlighted that need. It’s a good and a bad thing.

In the early days of the pandemic, a lot of health systems sent some of their staff home. They became productive, worked on some change management type stuff where they said, hey, I’m home, I might not be able to go in at the moment, but I can work on updating the system, or I can figure out a protocol. In several health systems, we saw that people drove change at a much better and faster rate than ever before. That gives me a lot of hope, because if folks have the right information and are empowered to make a change in their practice patterns, they will.

Implementing standardized order sets was a contentious topic a few years ago. Now that the implementation dust has settled, what is the status and future of order sets?

The order set market has evolved dramatically, and Zynx has evolved to match it. We have been partnering with clients to serve their needs. The classic market, when EHRs were being deployed, was to populate the EHR with a lot of point-of-care CDS, your traditional order set, a tool and a content inside the EHR system. But now as people primarily have EHRs deployed, you see a shift to optimizing the information you have, updating it. That means a greater need for collaboration software to drive your clinical teams to work together, to examine the changes that they think that they should put into place, and to make decisions and track an audit trail. 

Zynx provides tools to help do that. We even have a platform where we can interrogate the configuration of an EHR and compare it to our content library to suggest spots where there might be gaps in care or vice versa, like some extra orders that you don’t really need that might be considered waste. Maybe they shouldn’t be done when you’re an inpatient, they should be done when you’re in clinic or in follow-up afterwards.

The new frontier for us is looking at clinical practice patterns, the actual ways that clinicians are taking care of patients. Our content team has written business logic rules to interpret that order stream and identify opportunities where clinical practice patterns may not match the standard of care or the evidence-based interventional suggestions. Those are things that we want to highlight as a way to drive clinicians to change their behavior and get better results.

What is the value of slicing and dicing the universe of aggregated data to allow physicians to do a “patients like this one” crowdsourcing-type review?

I would say that there is some utility to that, although I don’t know if that would be my go-to source of rigorous information to begin with. 

When I look at that type of guidance, I map it out in a way where I first want to look for any sources from well-known publications, from experts, from sources that I believe are free from bias with good, rigorous study designs and see if they have done their best to control and observe an impact related to an intervention. That is your traditional, solid, core, evidence-based recommendation. The reality is that there’s not an evidence-based recommendation for everything a clinician might do, and then you need to look for other ways to take care of patients and decrease variability. You might look for some expert opinion, and short of that, you might start to look at practice patterns that are aggregated.

The danger of going to practice patterns right away and crowdsourcing an intervention is that you are going to propagate common practice. Common practice presumably is OK, assuming that the common practice was a good thing. But it also then means that people are going to be entrenched where they are. If there was a breakthrough or new discovery, that won’t be common practice. That’s why I wouldn’t say you go to common practice first. You would go to whatever the latest and greatest leading evidence would suggest that’s rigorous, and try to change behavior and try to change clinical practice to that. But short of that, go to the experts, And if you’re completely lost, then I would consider looking at what else have other people done and what we know about this path in terms of helping people out.

How should an expert’s gut feeling about what seems to work be incorporated into more rigorous, evidence-based recommendations?

My hierarchy would start with trying to find evidence-based recommendations that are based on the best studies. Short of that, I would go to experts, because they presumably specialize in it, probably have a comprehensive knowledge of the disease process going on or the treatment protocol. Then the common practice piece I would put below that, because experts are outnumbered by just the number of generalists. My worry is that maybe an expert who has studied this, who does know the cutting-edge stuff, has the better way to do it, but it’s not showing up if you use an algorithm to just source common practice. Then you don’t have anything else to go with, I probably would look pretty hard, before just treating someone willy-nilly, to get a good recommendation.

It makes me think of the “do no harm.” I’d rather make sure that the things I’m suggesting are sensible rather than just suggesting random things, which then might start to fall in the category of waste. It’s a hierarchy that I think most clinicians, when they practice, come into. You saw it play out with the pandemic. We saw some early treatments look like they might be promising. I might even argue that they became common practice for a period of time. Then people studied them and realized, wait, this is no better than placebo. This is not leading to a better outcome. Those practices largely died out.

Artificial intelligence seems to be focused more on diagnosis rather than treatment, probably because the diagnosis endpoint is better defined. Do you see a role for AI in clinical decision support?

I’s really early days on artificial intelligence. I’m a huge fan of artificial intelligence, but I want there to be a lot of rigor in it. I worry a little bit about the hype around the shiny new object and the fact that that might sway people to try things before you really know how well it works.

When I look at AI in healthcare, one of the reasons we see it in the diagnostic area is that AI for imaging, in particular, is quite good. That’s built on a lot of imaging research that came from other industries, and when you apply it to healthcare, we get good results. There are thousands of studies that have been reviewed by humans and labeled appropriately, so when you train an AI system on that type of information, you can get and characterize the way it performs rather well.

When you look into other areas, especially around treatment and around maybe other diseases, it’s harder to know, because you want to have a large body of information to validate it against. This is one of the topics that we track very closely at Zynx and across Hearst Health, because we want to really understand how well an AI algorithm might perform and how you can judge that. Do you judge that by knowing the makeup or the composition of the AI algorithm, the layers of the neural network, or do you judge that by the input data that you gave it? When you look at the input data, do you want to have a diverse population of folks with a lot of differences, or do you want to have something that’s more uniform?

All these things are still not quite answered. We don’t have a great standard to prove that an AI algorithm is rigorous and it needs to work on a population that looks like this. I think we’re going to get there soon. We have that in other areas emerging. When you test new drugs, you want to test it on a specific population. They may vary by age. They maybe vary by comorbidity. We need to be doing that type of rigorous testing on the AI algorithms. It’s early days, so I think we are getting a lot of tools implemented. But I’m hopeful that we’ll come up with a good process and then have really good, reliable tools to use.

What is the status of electronically creating and sharing a patient’s care plan, and the challenge of defining who of potentially several types of caregivers is quarterbacking the patient’s overall care?

We are proud that we were recognized by KLAS as being Best in KLAS this year for order sets and care plans. That’s a great honor, and we were rated very highly across all the categories that KLAS surveyed our clients for. We have over 1,200 clients and it’s growing. These health systems use the order sets and care plans to help their clinicians work more efficiently.

When you look at how it works at the point of care with care plans specifically, we help guide the interdisciplinary team on the assessments and the goals that they should set for each patient based on the disease condition and the severity of illness. Then we help them perform the right interventions, the tasks to drive that patient to heal and to do better.

Our future and our innovation work has been around translating a lot of those care plan items to patients themselves. We think that patients could be engaged in their care, and to some degree, do some self-care. That should be aligned with the care plan from the care team. Some of these interventions seem pretty straightforward, like make sure you show up for an appointment, make sure you assess a certain thing, know the goal that your care team has set for you so that you can follow up on that.

We think that by increasing the engagement and the participation of patients themselves, people get to better outcomes and are able to receive care in different venues, not necessarily only in an acute-care hospital setting. I’m excited about that. That’s a new area for us, where we tie the two together. We are looking forward to building that and seeing where that can lead us.

Do you have any final thoughts?

Practicing medicine is pretty tough today. There are a lot of competing interests between quality and volume and reducing readmissions and shortening length of stay. The challenge for clinicians is they are expected to draw upon more data and synthesize more things than they ever have, so there’s a need for tools.

I see a future where clinical decision support will continue to advance and help professionals elevate their practice. Ultimately this is going to make patients healthier, and we’re going to all benefit from it. I wish it was as easy as replacing my car’s brake pads. I mean, that would be great. But healthcare is complex, and there’s a lot of different things that factor into getting a good outcome. But I’m very hopeful.

HIStalk Interviews David Baiada, CEO, Bayada

David Baiada, MBA is CEO of Bayada Home Health Care of Moorestown, NJ.

Tell me about yourself and the company.

We are going on 50 years as a provider of home-based healthcare services. We are based in the Philadelphia area, in southern New Jersey. The business was started by my dad who, at the age of 27, was an aspiring social entrepreneur before the term really existed. Through mission-centered, people-oriented focus on culture, connectedness, and service, we have — little by little over a long period of time, almost entirely through organic growth — become one of the largest providers in the country, with about 30,000 employees across 24 states and eight countries.

Because of our scale in a quite fragmented industry and our diversity of services, we deliver eight different types of service, depending on where we are in the country or in the world. Our long-term orientation as an entrepreneurial, not-for-profit organization is focused on long-term sustainability and continued growth adaptation to the market. That makes us a little bit different in terms in the ways that we invest in and position ourselves to continue to make an impact in the communities we serve.

What is changing about home health and the involvement of health systems in it?

While the delivery of services in the home is clearly not a new phenomenon, the societal attention and perpetual reflection on safety and health at home has been clearly spotlighted over the last 12 to 14 months. Never has there been a time where literally every single American is staring at the TV every night thinking about, how do I stay safe and healthy in my house? 

That has created a bit of an awakening for the healthcare industry. Maybe we can deliver a high-quality service at scale at a lower cost in the place that people prefer, which is their living room or their home versus an institution, where appropriate. Maybe we can use technology to deliver certain types of services and interventions virtually or by video.

All of these things are not new. We’ve been working in the home for centuries. We have been delivering remote monitoring and virtual care for a decade or more. But the last 14 months clearly have created a bright spotlight on the power and opportunity that exists with the things that we can do in the home.

What impact did the pandemic have on the home care model and on your business?

The most important thing we saw is the validation that these amazing people — nurses, therapists, home health aides, and others who have chosen a profession to take care of people in the community — rose to the occasion. They are used to walking into the unknown, whether it’s COVID-19 or any other type of illness or environment. Clinicians that have chosen this profession rose to the occasion, and it was super inspiring to watch people, when appropriately prepared with PPE and clear protocol, walk into the unknown and navigate whatever was necessary to take care of people, whether it’s the thousands of COVID-positive patients that we took care of or the unknown of what was happening in that home related to risk and potential infection or otherwise.

The business implications were all over the map. The biggest implication is that volumes are up and down for different parts of the country with infection rates. That created, and continues to create, a wet blanket of ambiguity and unpredictability of what might happen tomorrow with protocol and infection risk. Then you compound that with the ambiguity, complexity, and unpredictability of what’s happening in their personal lives, with their kids and families, school, travel, and all these other factors. Ambiguity and unpredictability has been a major force, not just in our organization, but in our lives more broadly.

Does scale help you recruit and retain employees for the hard job of going into the homes of clients, especially given the reimbursement challenges?

We have dealt with cycles of shortages in different labor markets, whether it’s geographic or different types of workforce, for decades. We have now clearly entered a phase where the cycle is no longer a cycle, it’s a perpetual of supply shortage. The demand for our services — along with other macro factors like population, demographics ,and aging – has taken us into a cycle of permanent shortage for all types of in-home care delivery, nursing and home health aides in particular.

We are spending a lot of time, using our scale as you alluded to, to differentiate as an employer, to be more sophisticated in how we find people and how we create opportunity for them. We have a diverse, large organization with lots of different types of services, which creates lots of opportunities for people that are interested in doing new things, trying new settings, and picking up new skills. Our scale helps with that for sure.

But a lot of this is about figuring out how to create an environment in which people feel supported and engaged so that they stay. That really is a part of how we think about this challenge, which again is no longer a cycle. The demand for our services will continue to increasingly outstrip the supply of caregivers for decades, so this is the heart of the matter for us.

What services or technologies could help family members who unexpectedly take on the role of primary caregiver?

Virtual care and remote monitoring are a huge opportunity for family caregivers. It reduces the burden of having to get to a doctor’s appointment and creates the ability to monitor signs and symptoms proactively to avoid risk. There’s lots of incredible technology that is emerging and being adopted more quickly in sophisticated ways for both virtual care and remote monitoring. That’s a huge benefit to the family caregiver.

Another example is what I will bucket as care coordination and transparency tools. We have worked with, and continue to work with, a lot of partners to experiment around how to make it easier for family caregivers to understand what’s going on and why and the interaction of all these different silos in the healthcare system. Everything from scheduling of appointments to messaging with providers to history and medication reconciliation. There’s just so much to manage when you have a sick, at-risk, or vulnerable parent or loved one. If you have ever had to navigate the system, it’s really complex, and some of the technology and tools out there are trying to break down that complexity and simplify it for the family caregiver. I think they are making an impact.

What levels of integration, continuity of care, and accountability are you seeing between hospitals and home care organizations?

It has been emerging for a while, but in the past 18 months and certainly the last 12, the dialog in the health system boardroom around the strategic importance of home and community-based care delivery, the extension of the health system’s brand into the home, the seamlessness of the transition from acute to home — it’s moving way up the strategic priority list. You are seeing a lot of health systems say, we need to be really good at this. Some, to the extreme, are saying, we are going to start reducing inpatient beds over time.

All this is part of a broader shift, too. Payment could unfold over time where health systems are taking on an increasing percentage of the risk dollar, in which case when at risk for total cost of care, they are now properly incentivized to think creatively about how non-acute or less-expensive remote, virtual, and home-based care can help them create better experiences and better outcomes at a lower cost. We have a whole channel, a joint venture of structures with health systems that are designed specifically in this context. How do we jointly own home and then Bayada-managed home-based care delivery capabilities for a health system to give them instant access and continuous innovation around best-in-class, world-class, home-based care?

What new technologies are important to your business?

What I like about what’s happening in the market, and this spotlight on the importance of home-based care in the continuum in an increasing way, is that it is inviting a lot of capital and innovation to the challenges we face.

When we talk about challenges related to health system integration and extension of their capabilities into the home, one of the most fundamental challenges that health systems face — and it has an impact on Bayada as a home-based provider — is how a transition works. How do you coordinate someone’s transition from a hospital bed to their living room and all of the steps and coordination that happens along the way? They may have a stop at a skilled nursing facility. They may need new medications, but they have no transportation to get them. They may need coordination and conversations between multiple specialists.

All these things happen in silos. You are constantly repeating lots of different information to different people in the system. Platforms like Dina’s care-at-home platform and network are trying to create seamless transitional care, and that provides benefits to the patient and their family. They get empowered with an understanding of what’s happening. It has benefits to the health system that is trying to ensure that this person has a path home in a timely way. It has benefits to us as a home-based provider, because we then are empowered with historical information context before we enter the house, which helps us create a better service and keep them safe at home, which then ultimately creates a virtuous cycle because we’re avoiding unnecessary readmission and other types of further risk.

Dina is a great example of solving a complex but straightforward problem. When someone arrives at a hospital, how do you make sure that the transition out of the hospital back to home with any steps in between happens in a way that’s actually productive versus super frustrating?

What impact are you seeing from private equity’s increasing investment in healthcare, especially in home care, long-term care, and hospice care?

Our industry was, for a long time, a textbook definition for a cottage industry — highly fragmented, mostly local and small proprietor-owned or not-for-profit organizations. When sophisticated investment and capital comes into an industry, it usually increases the level of competition, which hopefully means that the services and the quality of services goes up for the patient, for the end user. It’s probably too early to tell about how that impact will play out, but in general it is drawing a lot of attention.

Also, third-party investors, financial sponsors like private equity firms, have a lot of relationships and a lot of credibility. The ability for them to put money to work to innovate, but then also put relationships to work to help ensure that those that control the funding and that control the future of healthcare delivery and regulation have adequate visibility and exposure to the power of home-based care. That’s a benefit. A rising tide raises all boats. This is a huge industry with a lot of people that are vulnerable and need a lot of help, and the more sophisticated, competitive innovation, the better.

What changes do you expect in home care over the next three to five years?

The percentage of healthcare services that can be and will be reimbursed and supported from a regulatory perspective to be delivered in the home will continue to increase meaningfully. That will be empowered by better capabilities from organizations like ours. Better technology that makes this delegation of services more palatable, which would include things like virtual care delivery and telemedicine, et cetera. Then ultimately it will be made possible by regulatory evolution and adequate reimbursement. Home care has been an underfunded segment of the system, and to empower scalability of some of this innovation that will enable increases in home-based care for the appropriate types of services, regulatory and reimbursement structures have to evolve, too.

Ultimately, the outcome is that a higher percentage of services will be delivered in the home than they are today, which ultimately is what’s right for the patients as their preferred setting with better outcomes and lower costs.

HIStalk Interviews Micky Tripathi, National Coordinator for Health IT (Part 2)

Micky Tripathi, PhD, MPP is National Coordinator for Health Information Technology.

FTC recently warned companies and developers about using AI algorithms that are biased, intentionally or not. What government involvement do you expect, if any?

We actually just had a discussion about this yesterday within ONC, starting to talk about that, among a set of issues that are related to health equity. That is certainly a part of it.

I don’t have a great answer right now. We are just at the beginning of it. We are just starting to start to think about what the issues are and what federal agencies have involvement in this. You named a couple in FDA and FTC. I’m sure there are others who aren’t necessarily involved from a regulatory perspective, but could be involved from a use perspective. If you think about CMS using algorithms, VA, DoD, IHS, I mean it certainly could be all over the place with different federal agencies that are involved in healthcare in one way, shape, or form.

Next is the question of, how do we think about bias? There is certainly a piece that is related to help disparities for minoritized, marginalized, underserved communities. That’s a huge piece, one of the things that I was addressing. There are also more general questions of bias. If you think about bias from a statistician’s perspective, it is anything that would bias an inference that one is making using a set of tools. You can imagine, for example, general questions about algorithms that are trained within certain environments. What applicability do they have to other environments, and  what inherent biases are involved in that? How do we measure those or parametrize the learning foundation that a set of algorithms was developed on, and how applicable are they in other circumstances? How do you set some parameters around that to give some assurance that you are addressing as many of those sources of bias that are possible, recognizing that there could be a whole bunch of other ones that are harder to detect?

For example, if we all wanted to move to a world of quality measurement that relies less on structured data elements – which impose a certain burden on providers and provider organizations to standardize that data and to supply that data – and move to a world where that can be complimented by, and perhaps eventually substituted by, a more algorithmic-based approach with more computable types of approaches applied to with natural language processing and other kinds of things, that raises the question of, if the algorithm has been trained to do certain types of detections — let’s say for safety, or is trained to do performance measurement in certain ways – in an environment like the Mayo Clinic or a large set of academic medical centers, is that applicable in other hospital settings? How would one know that it is applicable in some ways? If you are going to start paying people based on the results of that, we are going to have to develop a set of answers to those kinds of questions.

What is ONC’s role in reducing clinician EHR burden?

We have a clinical team that is working closely with CMS on clinician burden. We co-wrote a report that was released at the end of last year. We spend a good amount of time thinking about that with respect to everything that we do, especially as we hear about all of the concerns that people have about health information technology and burdens that have been imposed.

Part of the adoption trajectory is that no technologies are perfect, and the only way to make technologies better is for users to use them. Anything that is designed purely by a set of software engineers without having a good base of users banging away at it and providing that ongoing feedback is not really a reality when you think about the systems that we think of as being the most highly usable. All of those are improved, sometimes dramatically, with the input and the feedback they get from thousands and millions of users. That is true in health IT as well.

So part of that is growing pains, and part of that is things that are imposed on the technologies from the outside. The EHR gets blamed for things that it’s really just the vehicle for, like prior authorization requirements and more documentation requirements. There’s a sense that it’s easy because it’s in the system and is automated, so I have more of it required now than I did in a paper-based world. Users sometimes blame those things on the EHR, when in fact they are being imposed through that vehicle and then pushed through that vehicle separate from the question of the burden imposed by the technology itself.

At the end of the day, it doesn’t matter what the source is. That’s why we spend a fair amount of time worrying about both the technology and usability as well. What is it that we are asking to be forced through that system and are asking users to be able to do?

What will ONC’s priorities be over the next two or three years?

One is certainly coming out of the pandemic and helping the CDC and other federal partner organizations. Working a lot with the CDC on establishing the public health infrastructure of the future and how we think about that as more of a public health ecosystem. Thinking about EHR systems as being sources of information, with a variety of other sources of information, that can be brought together on demand in a more dynamic internet sort of way to be able to respond to crises as part of an ecosystem rather than being siloed systems. That’s a lot of work.

There’s a lot of investment into these systems going on right now because of the pandemic, working hard to say, how can those address the current need as well as the investments toward what the future needs are going to be? We have under-invested in public health infrastructure for too long, which is partly why we are where we are, so that will certainly be a focus area.

Now that the applicability date for information blocking has passed, working with industry to iron out the wrinkles. Compliance is obviously hugely important and there are penalties and real rules, but I really want and hope and expect that we are going to be able to move beyond that to say, I’m not doing it because I have to do it — which means that people will meet the letter of it and perhaps not go further — but I’m doing it because there’s an opportunity here, a new paradigm for the way we think about healthcare. There’s a new paradigm for the way we think about engaging patients. There’s a new paradigm for the opportunities that sharing information presents back to me. Yes, I have to make more information available, but that also means that other organizations have to make more information available to me. I have the opportunity to be able to demand that more of that information be made available to me than I did in the past, and I should be thinking about that.

There are a lot of wrinkles that we have to iron out for sure. We are trying to do that with FAQs, and with something as complicated as healthcare, you put out a regulation and a million questions start coming, all of them legitimate. There’s that twist on it, and, oh, here’s a circumstance that we didn’t think thoroughly about and now we have to give an interpretation of that. There’s certainly a whole bunch of that that we need to get past, and that’s all understandable. But I want to be able to help the industry get to that next level as quickly as possible.

We are paying a lot of attention to structured data right now, which is the USCDI, the United States Core Data for Interoperability, and those elements that are required to be made available for the first 18 months through APIs. But we should also not lose sight of where the puck is headed here, and that is toward that more general construct of EHI, which is electronic health information. That is the electronic representation of the designated record set, which is in theory — I’m putting air quotes around this – “all of the patient’s data.”

We know that all is a very slippery term because there’s a lot of information contained in a hospital system, especially for a complex patient. Defining “all” could be very tricky and may not be what someone wants. But going back to the earlier part of our conversation when we were talking about algorithms, when you start to think about all of that information being made available now, it’s the information beyond what is structured. The idea is that we shouldn’t be waiting for data to be standardized and structured before we say that it should be generally available, in part because if that is rate-limiting, it’s going to take us a long time to get there.

The standards work slowly and methodically. That is saying that that information just needs to be made available in whatever form it exists, then let the users figure out what they’re going to do with it. But the obligation to make it available is preeminent. That speaks to algorithms and what we’re going to be able to do with that data. Who is going to be ahead in making sense of that data once it’s available and being able to do high-value things with that information?

I’ve been trying to talk to as many people as I can about  remembering that is coming. How are you going to position yourself for that? What are the tools that you are going to bring to bear? How do we start to develop those tools and those capabilities to be able to take advantage of that?

Equity is a huge priority. Thinking about that from a design perspective, meaning all the way down at the core, so that disparities are not an afterthought or a hope for output of the system, but something that is baked more into the fundamentals of the way data is collected and the way data is aggregated and analyzed. Some of that relates to the bias questions that we were talking about before, and ultimately, what actions we want that information to be able to inform. Because there’s no data collection for the sake of data collection — data collection has got to be geared toward a specific set of decisions that you’re going to make and a specific set of actions that you want to take one way or the other. We haven’t had enough of that. We need to think about health equity and the data that we want to be able to get to help inform health equity.

The last thing is interoperability as it relates to networks. TEFCA — the Trusted Exchange Framework and Common Agreement — is a really important part of thinking about that as we enable these networks to finally be able to rationalize interoperability across the network, so that as a user, that is all deprecated into the background. When I’m on my AT&T phone, I don’t think for one second about how it magically connects me to a Verizon user or an Orange user in Europe. But right now, unfortunately, providers do have to think about that. I’m hoping that we can get TEFCA to a place where it pushes all of that to the background so that we no longer need to think about that, and we have interoperability for users that just happens in the background and no one needs to worry about the engineering piece on the front end.

HIStalk Interviews Micky Tripathi, National Coordinator for Health IT (Part 1)

Micky Tripathi, PhD, MPP is National Coordinator for Health Information Technology.

What has surprised you most about working for the federal government?

The extraordinary amount of work that it takes to align the federal partners, working within the federal government. I don’t think I appreciated that as much when I was on the outside, where all my interactions with ONC were with things that were externally facing. I always knew that there was a role that ONC plays in coordination of the federal partner activities, but now that I’m on the inside, I appreciate how much there is, how hard it is, and how much opportunity there is. 

More and more of them are discovering that they can do things with electronic health records. As we start to move to an ecosystem that has FHIR-based APIs, they’re starting to see the value in that, which is both a blessing and a curse. The good news is that they are seeing it, and the bad news is that they are seeing it, because keeping all of that aligned is a growing challenge.

Within HHS alone, CMS creates and consumes a lot of data, FDA is looking at real-world evidence and post-marketing surveillance, and CDC has data-driven public health activities. Is there a big table where all of HHS’s groups figure out an overall HHS data strategy?

ONC chairs the Federal Health IT Coordinating Council, which brings together all the federal partners who have health IT activities going on. The last time I looked, that was probably 30 to 40 federal agencies across the government participating. I’m trying to energize that so that it has focus on particular topic areas where we can make forward movement. That’s a place we can exercise a little bit more to get more coordination.

Some of it is just reaching out and having bilateral conversations, figuring out where there’s a connection of dots to say, wait a minute, I just heard the same thing from four different agencies. Let’s try to get them together and start to think about how we’re going to think about this together.

ONC’s initial work with Meaningful Use was focused on increasing EHR adoption, and now as a by-product, we have real-time data available to support pandemic-driven clinical, operational, and research needs. Are we just starting to realize how much information we have immediately available?

I think that’s right. We had high level, gauzy ideas about the learning healthcare system. I’m not saying that to deprecate it. You would be able to tap into different types of data in more of an ecosystem kind of approach. We never really operationalized that, or we were never really forced to operationalize that. Part of it was probably because until very recently, like the last couple of years, we were were focused on laying the foundation, with that always being a part of the goal. But now here we are with a pressing and urgent need that has really tested the system.

As we look ahead, and as you pointed out with FDA and others thinking about real-world evidence and other kinds of opportunities, that is starting to come into play. It is now more more specific. That said, we are just at the beginning of thinking about how to do that. If you look at the pandemic, for example, we made very little use of the EHR systems that are in place. We hadn’t built the ecosystem around it to tap into that information in ways that are more functional than one-way reporting for what public health needs to be able to do in a pandemic. That’s the next chapter.

We’ve seen pandemic-related technology failures, such as rarely-used contact tracing apps, failed vaccine management and scheduling systems, and reliance on paper cards to prove vaccination status. How does HHS look at the role of consumer technologies as part of public health?

In all of those areas, there is a lot of opportunity for a lot of potential, and potential and opportunity with the maturity of that kind of ecosystem. Part of the challenge, probably with all of the examples that you raised, is that if you are going to think about those from a consumer access perspective — and a couple of them arguably could be thought about that way, like contact tracing and the vaccination credentials, with scheduling being a little bit harder – you would want to leverage the maturity of patient experience. Patients are familiar with the idea that there are use cases where they have, at their fingertips, control of health data. They can interact, both in terms of getting data as well as interaction bi-directionally or in a more synchronous way than they are able to today.

We are at the very beginning of the beginning. Most people don’t realize that they can download records onto their phone, for example. Because of the way that health information technology has rolled out over the years, and because it’s new in terms of EHR penetration, for whatever reason patients don’t naturally think of apps as being the way that they can interact with healthcare, even though they do that in every other walk of life, such as Uber or ordering food or whatever, where they turn to their favorite apps. Until now, that has been an unnatural act for them. I think that will be more of a natural thing in the next few years and we’ll probably get a better reception for these kinds of capabilities.

We will also face a challenge in that we want to make the opportunity available to patients, but we still don’t have the answer of how many patients actually want to have that kind of interaction with healthcare. To me, that’s an open question. I don’t think that that undercuts at all the obligation on us as an industry to make all of that data available in the easiest possible ways possible for individuals so that they can take that opportunity where they want it. But I do think it’s still an open question of how much they patients themselves want to be in the driver’s seat for that.

We haven’t seen much evidence that supposedly empowered healthcare consumers will vote with their feet in leaving providers who don’t practice transparency or interoperability. That means the only available recourse is for a patient to recognize then their provider isn’t following the rules, then take the trouble to report them for possible government action.

There are real questions about whether healthcare will be a consumer good that conforms more to neoclassical economics and markets than not. That is a testable hypothesis that we will see. But I agree that there could be challenges there in terms of consumers wanting or being able to act in that way, because of the complex economics of healthcare and the complex ways in which people decide on their care. And how willing or able they are to break out of that to do consumer search, and thinking about healthcare as something that you do real search for based on value, cost, and quality in the same way that you do with other kinds of goods and services.

My kids certainly approach healthcare differently. They are much more willing to go out get healthcare on the spot market, as it were. Whereas when I think of my own care, I’m in a system and I’m going to stay in that system because I’m concerned about interoperability not happening. I’m voting with my feet to say, I’m going to go to a place where I know that all of my records will be in the same place. It’s multi-specialty and all the specialists are are tightly connected to a hospital in a very good hospital system. I’ve basically voted with my feet to say that I want to make sure that I’m in a system in which I know that interoperability is going to happen.

Whereas my kids are much more willing to just be in the spot market and say, I’ll just find a doctor based on some kind of scheduling app or whatever it is. I’ll go see them, and then I’ll go somewhere else. Now of course they have few needs and lightweight needs, and maybe their views will change once they get older and they have more acute needs or more ongoing needs. But we should all leave open the possibility that we’ve got a generation of digital natives who may genuinely think about this differently.

The providers in that spot market that you mentioned are likely to be in urgent care or telehealth companies that probably need the patient information that big health systems have, who in turn aren’t as interested in getting data from those spot market providers. How do you address information blocking if it is mostly big health systems that aren’t willing to share?

That’s all a part of information blocking. There is a requirement for them to share that as the first instinct, and to only have good reasons for not sharing. It is precisely designed to address that.

Going back to that expectation of a younger generation, although we don’t want to paint people with too-broad strokes, there is an expectation that interoperability is happening in the background. My kids, even if they are on those spot markets, have an expectation that their information is being shared behind the scenes, and may they have less tolerance for that information not being there. Then, through their own searches, they may discover places where that’s happening versus not happening because of efforts that are going on or not going on behind the scenes to get that information to the right place. There is certainly a regulatory angle to that, which is about information blocking, but there could be a consumer demand angle for that as well.

How do you educate consumers who perhaps have never actually seen interoperability in action that they should have those expectations and that providers who don’t share information are not complying with federal requirements?

Interoperability is happening that is invisible to patients. They expect that more of it is happening, by and large, than is actually happening, which is always eye-opening to some people. Their ability to have apps with features they are used to in other parts of their lives might be a way of being able to expose in a more direct way whether interoperability is happening.

Some of the more innovative payer systems do these kinds of things, with apps and functionality where users can track the progress of prior authorization and referral notes. Those can start to put in front of the consumer the basic kinds of customer service things that they see happen when they go to Home Depot and Amazon, but that they don’t see happen in healthcare. That can make it a more explicit what’s happening behind the scenes and can point out where some of those things aren’t happening behind the scenes. I don’t think that happens overnight and that’s fairly spotty what I just described, but it’s not hard to imagine that if you start opening that up, that starts to give more visibility and more of a window into what’s going on behind the scenes. But right now it’s all been under the covers.

Who do you expect to file information blocking complaints, consumers or other providers?

We are open to all, obviously. I find it hard to believe that a large number of patients would be coming forward with those kinds of complaints about provider-to-provider exchange, simply because they may not be aware of it. You can imagine more coming forward with complaints about their own access to their own records, which is also an important part of information blocking. The more savvy have an expectation of getting access to their own records. I can imagine more of them filing a complaint about information blocking because their records should have been transferred from the ED to their primary care physician and weren’t.

That seems like a less likely scenario to me, but again, that could change. We’ll see what happens. Because of institutional knowledge and the awareness in the industry, more of the complaints are going to come from organizations, whether it’s vendors, providers, networks, or those who are covered by them or who have an expectation of what the opportunities might be with information blocking, and then try to test it and find that it’s not there the way they perceive it should be there. I think that’s going to be more of what we see, but we’re still very early.