CHIME Interview Series

Health IT CIO Interview Series: David Muntz, Principal, StarBridge Advisors, LLC

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StarBridge Advisors provides interim management, advisory services, IT consulting, and executive coaching. Their approach is described as “practical unbiased, open, and plain speaking with frank and honest opinions offered based on real-world experience.” We had the opportunity to speak with Sue Schade, Principal, a year after StarBridge had formed, and while at the 2019 CHIME Fall Forum, David Muntz, Principal, graciously sat down to speak with us about how the firm has grown and evolved.

Key Insights

Our philosophy is that the best way to get future business is to do a great job and produce high quality work for the engagement and tasks that are in front of you.

Experience has taught me the importance of two concepts – patience and serendipity.

The role of healthcare CIO has evolved from a traditional one responsible for setting up network infrastructure and providing back-end support to a data-centric role more focused on information science

Campbell: Leading a firm of C-suite consultants likely comes with its fair share of challenges. Managing any consultancy must address utilization of staff, management of a bench and tending to the specialties, strengths, and fit of staff to engagements. How does StarBridge manage these potential challenges? How are you different from healthcare CIO placement firms?

Muntz: The company structure consists of three principals – Sue Schade, Russ Rudish, and me – and 30 interim CIOs operating as independent LLCs. In this model, we don’t have to worry about a bench as each advisor serves as its own subsidiary. Our philosophy is that the best way to get future business is to do a great job and produce high quality work for the engagement and tasks that are in front of you. If our staff had to also worry about their next engagement, and prospecting for new opportunities, they wouldn’t be able to devote their all to the task at hand. We encourage our folks not to look up, but look down, and focus on doing an outstanding job for the work that they are currently contracted to do. As they say, god bless the crooked road – best to live it more and plan less.

Campbell: Isn’t that a saying to live by! That is a great approach and we can appreciate the methods you’ve used to mitigate bench risk, but also to ensure your advisors are focused on providing a superior experience to the clients you partner with. Tell me more about how you leverage that experience to coach and mentor the next generation of CIOs and provide advice to your peers.

Muntz:  Experience has taught me the importance of two concepts – patience and serendipity. I’ll share a story from my time as CIO at Presbyterian Healthcare System in Dallas. We hung a banner with “Patients First! Patience Always!” in the data center. The intent was to inform or remind everyone who entered where to focus and how to conduct themselves. We needed this anchor to help steady us in the turbulence that defines our workplace. Technology is a contributing factor and when we are stressed, we are not as cool as we want to be or should be. Along those same lines, I used to teach the CHIME boot camp and would impress upon candidates that serendipity, luck to some, opportunity to others exists in great quantity – most people are surrounded by it but can’t see it. The point is that nobody can read minds and unexpressed opinions are awful. When providing staff with career planning, it’s important to encourage expression of interest where it will be met, being direct, but respectful as well. Folks in IT tend to be introverted and shy. As a leader, we must pull it out of them to let them express themselves, but not be too judgmental in response. A question often serves better than a quick response, such as, why did you make that statement? A lot of strong leaders will ask why an employee came to a particular conclusion. This helps to protect the integrity of the individual and encourages everyone to be more open. Moreover, it’s important to know your audience and when it is appropriate to open decision making up to a group. The wisdom of the group often coincides with my thoughts and sometimes convinces me to seek a different path.

Campbell: This speaks to the culture you foster at StarBridge. Can you elaborate on how you ensure your staff has a sense of fulfillment with their work and how you go about assigning advisors to particular engagements?

Muntz: Honestly, I see our organization as a lifestyle company. There must be a good life-work balance. As such, the other principals and I play the role of matchmaker. We have to manage the profile of the organization when placing interims and advisors and identify where there would be good chemistry. Organizations should be very careful in picking their clients to make sure they are the right fit. We’ve been fortunate in getting the clients we work with. Not everyone you dance with is going to be the one you marry.

Campbell: As you manage a team of CIOs, how do you see the role changing going forward? How are you preparing your team to adapt to ensure they are best suited to meet the needs of the organizations you partner with?

Muntz: The role of healthcare CIO has evolved from a traditional one responsible for setting up network infrastructure and providing back-end support to a data-centric role more focused on information science and digital health. In addition, new titles are appearing in the C-suite: CAO (analytics), CDO (digital), CHIO (health). CIOs who evolve and collaborate will succeed. Those who cannot will be replaced or find themselves reporting to someone else in the C-Suite or to one of the titles that traditionally reported to them. As such, we underscore the importance of collaboration, coordination and communication to our advisors.

David Muntz is a Principal at StarBridge Advisors, LLC. David began his career as a biostatistician, then became CIO, and ultimately rose to the position of CEO at Wadley Research Institute and Blood Bank in Dallas, TX. He returned to health information technology at Texas Health Resources, where he functioned as SVP & CIO for 15 years. He then worked for 5 years as the SVP & CIO at Baylor Health Care System. In 2012, David accepted a White House appointment to serve as the first Principal Deputy National Coordinator at ONC (Health and Human Services’ Office of the National Coordinator) and was also Chief of Staff and CIO through 2013. David returned to the private sector as CIO of GetWellNetwork through 2015 where he served as a member of the Board of Directors until its sale in 2018. During his career, David has served on 22 other Boards.

In his career, David has led talented teams as large as 770 with budgets of more than $500M to author, acquire, and implement many forms of health information technologies including EHRs from all the major vendors. Under his leadership, his teams managed more than 180 project go-lives annually. Due to his teams’ efforts, he was honored as CHIME’s Innovator of the Year for his achievements with two different employers. His organizations were recognized nationally for innovation in information technology for more than 25 years in a row including his time in the federal government. In 2014, the CHIME Board presented him its CIO Legacy Award.

David has served on the SMU, TCU, UTD, Most Wired, and many other Advisory Councils and Boards. He is currently an Adjunct Professor in the Baylor University EMBA program. He has Fellow and Life status at CHIME where he served on the Board and led Advocacy efforts. He holds the CHCIO (Certified Healthcare CIO) credential from CHIME. He has also been active with HIMSS at all levels and enjoys Fellow status.

David received an MBA from Southern Methodist University in Dallas, Texas and an AB from Columbia College in New York City. David attributes his accomplishments to collaboration with incredibly talented people and strong support from his family.

Health IT CIO Interview Series: Jorge Grillo, AVP/CTO, HonorHealth

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The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company.

Jorge Grillo is perhaps best known in healthcare information technology circles for his MEDITECH 6.0 diary series on healthsystemCIO. After many years as CIO of Canton-Potsdam Hospital, a 99-bed hospital located in northern New York state, just south of the Canadian border, Grillo now serves as AVP/CTO at Honor Health, a $2B non-profit and community focused health care system in metropolitan Phoenix. In this interview, Grillo discusses the transition from CIO to CTO, his perspectives on prioritization of applications as part of decommissioning, and his broad view of the healthcare marketplace in light of increased consolidation.

Key Insights

In a non-healthcare environment, the CIO is responsible for daily ops while the CTO is responsible for deciding what tech to invest in. However, in healthcare, the CIO is the strategist and the CTO is the operationalist.

Aged technology is one of the factors that impact the high cost of healthcare. From my perspective, every organization has legacy hardware, applications, and data.

If there is in fact a broad move to a form of socialized medicine, payers will be under pressure to diversify into the provider and care delivery arena. 

Campbell: After a decorated run as a CIO and MEDITECH 6.0 evangelist at Canton-Potsdam Hospital, you are now with HonorHealth in a slightly different role, as CTO. Can you explain the difference in the two roles, specific to healthcare information technology? How has the transition gone? look at the exipure review for a healthier body.

Grillo: The hardest transition is from a CIO to a CTO. I certainly benefited from experience from a former CISO role. In a non-healthcare environment, the CIO is responsible for daily ops while the CTO is responsible for deciding what tech to invest in. However, in healthcare, the CIO is the strategist and the CTO is the operationalist. For healthcare specifically, in terms of a military analogy, the CTO is the general in charge of defining strategy and the CTO is the tactician for that delivery. Thereby, the CTO is responsible for legacy debt remediation and technically enabling transformation in the interest of transparency and enhanced patient experience.

Campbell: Speaking of the technical debt that legacy systems present, can you elaborate on your experience with enterprise portfolio management? Are you currently going through this exercise in your new role as CTO?

Grillo: Aged technology is one of the factors that impact the high cost of healthcare. Sophisticated technology such as advanced virtual health care software is also coming in to play. From my perspective, every organization has legacy hardware, applications, and data. We do in fact have an EPMO initiative in progress to retire legacy systems but retain legacy data. We have a cross-disciplined team that focuses on three main factors – retention, access, and compliance. There are many different categories of applications, and the retirement strategy pursued must make sense for the data associated with an application. As such, we have a three-fold strategy we use: First, use VMware to virtualize the application and make it hardware agnostic. Second, use a data archiving platform. Third, put it off network or inoculate it.

Campbell: You mention many categories of applications. How do you go about prioritizing which applications to decommission?

Grillo: First and foremost, it comes down to how long the data must be retained, which for the patient legal medical record, of course, varies from state to state. An analysis of which data needs to be kept must be performed, and it really boils down to a risk analysis. What are the odds that the data will be needed, and in what timeframe will it need to be furnished, balanced against the regulatory requirements associated with that? As part of the analysis, you must determine where you invest cycles and storage. An application is much more likely to be sunset if it is outside of core applications.

Campbell: Shrewd insight in that risk and compliance play just as much of a role in system retirement as HIM and clinical ops. Looking outside of your organization, what are you seeing in the broader marketplace? From your viewpoint, is the exercise of application portfolio management and legacy system retirement pervasive throughout the industry?

Grillo: In my opinion, we are seeing rural and critical access hospitals – smaller hospitals – that can’t afford integrated electronic medical records. As such, they are prime for getting bought, or seeking a hosting arrangement with a larger entity – especially with the rise of Cerner CommunityWorks and Epic Connect. We are also witnessing attrition of hospitals – if they don’t serve as a community safety net, they are not always going to be bailed out by the state. Moreover, the big have gotten bigger. Five years ago, a $5B system was probably ripe to get bought. The threshold has increased, so now it’s a $12B system that is ripe to get bought. This is an artifact of continued consolidation.

Campbell: Certainly. Consolidation is part of the maturation of any market to deliver efficiencies. What is your broader view of the healthcare marketplace in light of consolidation?

Grillo: Well, you are starting to see the insurance industry and other industry verticals (like Amazon) get into the healthcare delivery marketplace, buying hospitals to get at the data. Sophisticated, technology advanced virtual health care software is also coming into play. An advantage of an insurer owning the hospital is that they may not have to negotiate rates, its part of the contractual basis. Geographically, insurers have the footprint to make an impact, and with more data, actuaries can improve wellness across the board. Of course, also affecting the insurers’ approach, this being an election year, it could very well be that we see some form of socialized medicine, and, as a result, a change in reimbursement models. Because of this possibility, insurers are investing in the provider space more and more because they are sitting on cash. If there is in fact a broad move to a form of socialized medicine, payers will be under pressure to diversify into the provider and care delivery arena. Payers will also look for ways to stay solvent by reducing rates and increasing transparency. We are already starting to see early movers, but it’s still predicated on the result of the election and policy that may emerge.

Jorge Grillo is AVP/CTO for HonorHealth, a $2B non-profit and community focused health care system in metropolitan Phoenix with 5 (soon to be 6 hospitals), encompassing more than 3,400 expert physicians, 11,600 dedicated employees, and more than 3,000 caring volunteers working in partnership with a commitment to wellness management. Prior to joining HonorHealth, Jorge was CIO at Canton-Potsdam Hospital, cited by Hospitals & Health Networks for being among Healthcare’s Most Wired hospitals in 2017. Prior to joining Canton-Potsdam in 2010 he served as CIO of the Bermuda Hospitals Board for four years. Grillo has written about the Canton-Potsdam’s Meditech journey, his experience working overseas, and the evolving role of the CIO, among other topics.

HealthIT CIO Interview Series – Tom Andriola, VP & CIO, University of California

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The University of California (UC) is the premier public research institution with 10 campuses, 6 health systems and 3 national laboratories. Each year it serves more than 270,000 students, conducts billions of dollars of sponsored research, and cares for more than 5 million patients across the state of California. Tom Andriola, University of California VP & CIO, based at the University of California Office of the President (UCOP), oversees the IT function across the UC system, which includes 9,000 IT staff. To foster innovation within an organization of that size and scale, he believes it is key to engage and collaborate across locations, applying lessons learned and leveraging strengths and focal areas. While Andriola’s perspective is shaped by his experience as a global business and technology executive, he is pragmatic in his approach to the pursuit of innovation and collaboration at the university. In this interview, he discusses UC’s continued pursuit of cloud technology, exit from the data center business, and utilization of commonalities across campuses to drive efficiency and scale. He also shares his approach to consistent communication using social media and a blog, and his view on how best to tackle the broad area of population health management.

Key Insights

One of the things that my global experiences gave me was a great understanding of diversity and that environments aren’t better or worse, they’re just different. In all the situations I’ve been presented with, I’ve taken the approach of identifying the best pieces available and putting them together in ways that create unique competitive advantage.

The fact that we have six semi-autonomous health enterprises that are also collective on some level, allows us to collaborate on initiatives while pursuing them in a timeframe appropriate for each institution. We collaborate on vendor selection criteria, but it may be at different points in the road map for each entity. One institution then can pave the road for another, so the others can follow with less friction.

There is also the element of getting that story to the rest of the system and outside world to inform and educate our executives, customers, students, and patients. It reinforces our message that IT is not just a cost center, but in fact is a strategic enabler for the university and its mission.

Population health is not just a way for us to manage care and dollars, it’s also a means for us to find where we need to energize the level of innovation.

Campbell: You come from a background at Philips and joined the University of California as vice president in 2013. You’re very active on social media and very active in the community, especially with the upcoming conference. With that, can you provide background about yourself, what brought you into health information technology and some of the initiatives you are working on?

Andriola: As you mentioned, I worked for Philips globally, where I built an IT services group running a global transformation program and running IT operations across three continents. The program was essential, after a series of acquisitions, to bring the business back in-line with profit expectations for their $6B medical device business. From there I moved into a General Manager role leading the company’s largest healthcare informatics business at the time. It was at the point that healthcare finally decided that it was an information-centric industry and started to move away from its focus on better and faster medical devices (in our case scanners) and concentrate instead on the value they were creating for clinicians and patients with the data coming out of the scanner.  Then I focused on new business development and built a portfolio of IT software and services businesses in growth markets such as Brazil, China and India. Philips is a very global company, and these roles gave me the opportunity to not just travel the world but live in other places and build teams in completely different cultures.

In 2013, I transitioned to the University of California, the world’s most prestigious public research university. UC is a $33B organization that contributes in the areas of teaching, research, healthcare and public service. It consists of many entities – 10 campuses and 6 health systems, with more than 220,000 employees and 270,000 students, and $11B in patient revenues. It also co-manages 3 national laboratories. My experiences with Phillips provided me with the opportunity to step right in and help the academic medical centers figure out how the digital healthcare world was going to affect them. It also allowed me to show UC how to take advantage of the unique capabilities that academic medical centers have in terms of tertiary and quaternary care for the most complex patient populations and leverage not just technology but also, more importantly, the data to improve the quality of medicine, improve patient access, and drive down the cost of care.

Campbell: I appreciate that background. In terms of your global experience, and coming from the vendor side, how did that shape you as a healthcare leader. You’ve previously shared your philosophy on the importance of communication and collaboration. If you could, elaborate on that and speak to how that’s leveraged in your role with UC.

Andriola: One of the things that my global experiences gave me was a great understanding of diversity and that environments aren’t better or worse, they’re just different. In all the situations I’ve been presented with, I’ve taken the approach of identifying the best pieces available and putting them together in ways that create unique competitive advantage.

In joining the University of California, I have encountered great people and assets in the healthcare enterprise. We have deep domain expertise in the system, and it allows us to leverage that expertise to address our most challenging situations. In response to the challenges in the healthcare industry, we’ve created a coalition allowing six health systems and the Office of the President to come together, and look at things both at local and enterprise-wide levels. For instance, one of our locations has deep expertise in digital health, while another’s focus is on gene therapy. It’s a complementary rather than competitive arrangement, and allows us to approach 3rd party partners by putting forward our best-of-the-best along with the UC brand.

Campbell: It sounds like a unique situation for collaboration, and thus offering a competitive advantage. In fact, a recent article featured how six CIOs connected to the University of California, of which you are the group facilitator, have been producing strong results through broad strategic collaboration. That collaboration resulted in the first time ever that two US academic medical centers have linked up to be on one instance of Epic. Can you provide some background on that project in which UC Irvine Health and UC San Diego Health share the same Epic instance?

Andriola: You hear about moving to the new world of healthcare, moving to the cloud, and getting out of the data center business. We are living it. We have one instance hosted by Epic for UC Irvine, UC San Diego, and UC Riverside. The other health centers – UCLA, UC Davis, and UC San Francisco – are looking at their strategic roadmaps and determining when would be the right time for them to decide about going in a similar direction.

The fact that we have six semi-autonomous institutions, that are also collective on some level, allows us to collaborate on initiatives while pursuing them in a timeframe appropriate for each institution. We collaborate on vendor selection criteria, but it may be at different points in the road map for each entity. One institution then can pave the road for another, so the others can follow with less friction.

Campbell: That’s remarkable – the fact that you are leveraging each other’s strengths and using each other’s experiences to buoy the collective whole. That is what makes CHIME so great, that is, the ability for CIOs to collaborate amongst peers and share best practices. You are doing this on a micro level across the health systems, which is compelling.

Andriola: We do have somewhat of an advantage because there is a single governing body. Linkages, like shared financial incentives, also help align those activities.

Campbell: Absolutely. Shifting gears for a moment, The Huffington Post featured you as one of the most social CIOs on Twitter. You are also an avid blogger, bringing awareness to events, awards and news within UC. Tell me about the importance of having a social media and blog presence, and how it helps you to communicate key initiatives, both raising awareness and also potentially soliciting feedback from the IT staff.

Andriola: Our social media strategy serves both an internal and an external purpose. I’ll start with the internal. We are blessed to have 9,000 IT people across the university who come to work every day and try to make this the best darn research university and healthcare enterprise in the world. That’s part of the reason we use social media – to ensure people know that. We highlight the great work that people do, especially the most innovative practices that are going on. The blog and other communications strategies offer a mechanism for our people to learn from each other. Anecdotally, this could be someone hearing about an initiative at UC San Diego, when they’ve been talking about something similar at their own institution, and so being inspired to engage some UC San Diego folks to help solve the issue they are tackling. It facilitates peer-to-peer learning and reduces the time-to-value of technology efforts.

There is also the element of getting that story to the rest of the system and outside world to inform and educate our executives, customers, students, and patients. It reinforces our message that IT is not just a cost center, but in fact is a strategic enabler for the university and its mission. My job is to make sure that the outside world knows about what we’re doing – whether its healthcare, education, or research funding. I see my role as raising awareness about how UC is one of the most innovative places to work and how technology is a huge part of how we are innovating. The fundamental research we conduct changes the way in which domains are perceived and the way that we take care of patients. I use social media and communications as a means of telling the story of IT and sharing the great work that our people are doing. Everyone likes to have their story told, and that also supports engagement and retention.

Campbell: While on the topic of innovation and knowledge share, can you provide an overview of the University of California Computing Services Conference (UCCSC) that recently took place?

Andriola: When I came here almost five years ago and learned that UCCSC existed, I thought it was a great vehicle to drive collaboration. One of the things I was trying to figure out was a good strategy to connect the 9,000 folks we have in IT. At that time, UCCSC involved roughly 200 to 250 people, and was very grassroots oriented. The CIOs didn’t attend. I thought we needed to invest more into the grassroots conversation, but also bolster the impact of the event through executive presence. And so, we really shifted over the last 5 years as we’ve tripled the size of the event, with close to 700 people attending this year, including 11 CIOs. We took it from being a small event for the same people each year to a true communitywide activity, complete with swag.

It speaks to this collaborative fabric we have now across the organization – the realization people have that, “If I’m struggling today, there is likely someone else in the university who is probably struggling with the same thing. How do I connect to them quickly, and how do I extend my network to solve the problem more efficiently and effectively?” While we have tools in place like Slack, which 4,600 of our IT professionals use daily, the conference provides an in-person experience for sharing insights, best practices, and innovation outside of day-to-day tactical issues. This year I challenged the team to use the network to find colleagues and save 30 minutes out of their week.  It seems like a doable thing for most people. And at 9,000 people, recovering 30 minutes is equivalent to hiring more than 100 new people.  That’s the power of networking.

Campbell: Speaking to this collaborative fabric, an article was recently published on the UC IT Blog providing an overview of the results from a survey UCSB CIO Matthew Hall conducted of the UC location CIOs, asking them to prioritize issues for IT leadership and the university. Can you elaborate on some of those priorities for healthcare, specifically around population health?

Andriola: Population health is one of those initiatives where there is no silver bullet, and it’s not one size fits all. We are moving away from a stance on population health that’s been very individualistic across our UC health enterprise. That doesn’t mean one-for-all population health deployments for all UC institutions. Some of them are multi-billion-dollar enterprises and may have three or four different population health plays. Some extend Epic; others use third-party tools to connect into Epic. We’re trying to take a step back and look at the population health needs in the changing landscape of reimbursement and patient distribution. We are tailoring our population health strategies to allow us to use the data we have, now that we’re fully digital, to make more timely and intelligent decisions.  It’s a challenging space. Epic is certainly a large part of it, but it’s not the only part. There are a lot of other systems that have relevant information about patient conditions and experience that we want to pull into repositories so we can generate insights into how to better reach patients.

Campbell: You share the sentiment of a lot of healthcare CIOs, in that they want to steer away from the boil the ocean approach, and instead address specific use cases. There are components that go into making use of the data, access being one of those, but also transforming the data into the format that’s needed and governance as well.

Andriola: One of the other things that is of benefit to us is that, as academic medical centers, we have a teaching and research component to our enterprise. Some of the insights provided help inform us about where we should be innovating more quickly, and where we should be doing pilots. Those pilots are leading us to work with different types of partners who support home centric care models, for instance. As such, population health is not just a way for us to manage care and dollars, it’s also a means for us to find where we need to energize the level of innovation.

About Tom Andriola

Tom Andriola joined the University of California in 2013 as vice president and chief information officer (CIO) for the system. He provides leadership across the university working closely with campus and healthcare leaders to explore opportunities for technology and innovation to enhance the UC mission of teaching, research, patient care, and public service.

Andriola brings over 25 years of experience as a global business and technology executive, having served as a business transformation leader for a multi-billion-dollar enterprise, a global CIO with staff around the world, and the first employee of a brand-new business.

Throughout his career Andriola has been a champion of change inside organizations, as well as a leader for innovation in the marketplace, having brought first-of-kind solutions to market and led the creation of several new businesses.

Andriola is active in higher education and healthcare associations and serves on several boards, including the Corporation for Education Network Initiatives in California (CENIC), OCHIN, the Pacific Research Platform, and the Risk Services Software Company.

With his background in technology and innovation, Mr. Andriola maintains relationships with UCSD’s California Institute for Telecommunications and Information Technology, UCSF’s Bakar Institute for Computational Health Sciences, UCSF’s Center for Digital Health Innovation, the UC Berkeley Haas School of Business. He is a sought-after speaker on a variety of technology topics in healthcare, higher education, and the changing CIO role.

Andriola holds a bachelor’s degree from The George Washington University, a master’s degree from the University of South Florida, and completed the Stanford Executive program.

HealthIT CIO Interview Series – Ahmad Sharif, MD, MPH, CMIO, Fresenius Medical Care

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Ahmad-Sharif, CMIO

Ahmad Sharif, MD, MPH, CMIO Fresenius Medical Care

According to Wp Health Care News more than 660,000 people in the U.S. have a diagnosis of End Stage Renal Disease (ESRD). Routine treatment with dialysis therapies, kidney disease treatment or kidney transplantation are the key options for ESRD patients and are required to sustain life. The majority of patients receive dialysis treatments three times a week for about four hours at a time, for the rest of their lives or until they receive a transplant. Fresenius Medical Care North America (FMCNA) is the leading provider of dialysis in the U.S. and have one of the largest collections of clinical data on Chronic Kidney Diseases (CKD) & the largest dataset on dialysis patients, treatments, and outcomes, in the world. In this interview, Dr. Ahmad Sharif, CMIO, shares how FMCNA has found ways to leverage data to predict and prevent negative outcomes. At FMCNA, multiple efforts are underway to identify patients who need extra attention, and Dr. Sharif is focused on making these efforts provide useful and insightful information for clinicians. In his words, “success is iterative”, as they learn and improve analytics over time.

Key Insights

I think of my role as a translator; I’m a bridge between the clinical world and our information technology world.  I help the clinical side understand how the technology works and at the same time help the technologists build products that more efficiently and effectively help our staff further the mission of our organization to deliver superior quality care. Another goal of mine is to leverage technology and data to enable next-generation clinical and operational decision making.

Leveraging data from more than 1 million patients and 250 million dialysis treatments, we successfully develop, test, and implement statistical models to predict which patients are most and least likely to be hospitalized, miss scheduled treatments, or have a decline in their functional status, and thus improve patient outcomes by timely intervention.

The estimated average cost to Medicare for  End-Stage Renal Disease (ESRD) care is more than $85,000 per year and nearly 20 percent of dialysis patients are under some form of risk-based care.

UX (user experience), and UI (user interface) to an extent are my top priorities. For several reasons, including meaningful use, I’m of the opinion that in healthcare we have not given enough attention to the UI piece.  In my role, I make sure that we center innovation, optimization, new design, and new projects around users.

 One of the primary things I want to do is create a better and simple interface for our physicians to be able to round in dialysis facilities.  To do this, we are creating a mobile application in conjunction with our product management using advanced usability approaches and leveraging FHIR resources. Our goal is to ensure that the interface is reliable, fast, and nimble so physicians can view historical and current data, in a very user-friendly format and document their notes and care delivery.

Campbell:  Tell me about your organization, your role, and your background.

Sharif:  I work for Fresenius Medical Care North America. We are a vertically integrated company providing chronic disease management and renal services.  We have over 2,400 Fresenius Kidney Care dialysis centers and 80 Azura vascular access centers across the country. Beyond that, we have a risk product through which we manage a subset of our patients under a total risk or total cost of care accountability. We also have a renal specialty lab and pharmacy. We are also providers of largest nephrology based EMR system called Acumen. And finally, we have companies called Med Spring and Choice One providing urgent care services in various states.

FMCNA includes the Renal Therapies Group, RTG, which is a products company manufacturing dialysis machines, dialysis peripherals, dialyzers, and other dialysis supplies.

We’re an international company with our world headquarters in Bad Homburg, Germany, and our domestic headquarters in Waltham, Massachusetts.  Internationally we do of lot other things as well, but I’ll just focus our conversation to the North American region where I work.

My role is that of Chief Medical Information Officer. I think of my role as a translator and enabler; I’m a bridge between the clinical world and our information technology world.  I help the clinical side understand how the technology works and at the same time help the technologists build products that more efficiently and effectively help our staff further the mission of our organization to deliver superior quality care. Moreover, I ensure that IT is collaborative with the business.

I have been in health IT for over a decade. I am a general surgeon by training and have degrees in public health and advanced project management. My background is diverse from different disciplines. I was a technology geek since childhood, but as soon as I got in the practice of medicine and after doing my master’s program, I had the opportunity to interact with some of the EMR systems and view some of the content on a granular basis. I realized that there was a lack of physician engagement and input.  That was pre-Meaningful Use era where applications were primarily designed for billing purposes or to check some of the boxes. I saw that opportunity early on to close a large gap between the physician role and health IT.  Ever since I’ve had a focus on user-centered design for clinical IT systems.

Campbell:  It sounds like you were one of the early pioneers of physician engagement. What is your perspective on the usability of clinical systems?

Sharif: Doing seemingly trivial things such as changing a font, a color, adding a checkbox, altering the design to support clinicians can go a long way to bettering engagement and efficiency. These types of very granular adjustments can facilitate more intuitive and efficient use of clinical decision support tools. Creating better data flow, visibility and data connections can significantly impact the lives of hundreds of thousands of patients at one time. That’s what keeps me motivated and driven to delivering on the promise of health IT improving outcomes.  My goal is to provide the tools to our clinicians so that they can deliver quality health care effectively and efficiently.

Campbell:  That is a powerful sentiment in that what may seem inconsequential can lead to true impact. Can you share insight into Fresenius’ enterprise clinical system portfolio? How are clinical decision support, advanced analytics, and data warehousing enabled in the enterprise?

Sharif:  There are a few layers to it. We have a base EMR solution, eCube, and point of care system, Chairside, along with an ancillary application ecosystem deployed in over 2400 clinics in seven different time zones. The data we generate on our patients goes into our single data warehouse and we’ve put together an HIE in the middle, where we perform enterprise patient matching and normalization of the data from internal and external sources.

Leveraging data from more than 1 million patients and 250 million dialysis treatments, we successfully develop, test, and implement statistical models to predict which patients are most and least likely to be hospitalized, miss scheduled treatments, or have a decline in their functional status, and thus improve patient outcomes by timely intervention. When one of our patients misses a treatment, that has a ripple effect that can cause significant degradation in patient care, lead to hospitalization, and certainly adds additional cost as well. For example, we can predict with very good accuracy, which patients will be potentially missing a treatment and then design interventions to meet immediate patient needs that might help avoid hospitalizations and readmissions.

Campbell: It sounds like you have an elaborate infrastructure in place to facilitate care coordination and interventions. What other type of surveillance occurs in your patient population?

Sharif: In certain markets, we are expanding services so that as soon as patients land in any of the ERs, we get a real-time alert, which allows the nephrologist to be immediately informed and engaged. The nephrologist can communicate with the ER physician or hospitalist and decide whether outpatient dialysis treatment is an alternative to an inpatient or ICU admission.  By doing that we can navigate more effectively and help our patients avoid treatment in a higher acuity setting that could potentially complicate their care further. That leads to better outcomes for patients, and generally for the health system as well.

Another initiative in place is with fluids management, which is key to good patient outcomes. Through our point-of-care system, we run underlying analytics and provide different suggestions to our staff members to support helping every patient achieve an optimal weight. We do some retrospective modeling as well, looking at the variations of the patient’s weight to provide prescriptive suggestions for the clinicians to manage that patient at the point of care.

Campbell:  That’s extremely fascinating and compelling. It sounds like you can intervene at a granular level fueled by the predictive analytics infrastructure you’ve put into place. As we move to value-based care, how is this transition being managed for patients that require a constant regimen of dialysis that generally occurs daily to three times per week? Are you leveraging social determinants of health (SDoH) as part of this transition?

Sharif:  The estimated average cost of caring for End-Stage Renal Disease (ESRD) patients is more than $85,000 per year and nearly 20 percent of our dialysis patients are under some form of risk-based care. That said, when you are responsible for total cost of care for a patient, you have more leverage in terms of gathering the data that fuels out of the box thinking and innovative interventions. One thing that we are doing outside of our ESRD bundle payment framework is to begin to incorporate social determinants of health. We’ve found that one of the impediments for patients to receive treatment was transportation. As such, a large opportunity exists to provide transportation when it is not available through traditional means. It’s amazing how much we have missed in healthcare in terms of the importance of social determinants of health.

Campbell: Absolutely, you mentioned earlier the most trivial things, in this case patient transportation can have such a huge impact.  It is often overlooked for the glitz and glam type of initiatives. Switching gears, as a CMIO, you need to act as a broker between IT, clinicians, and administration. Talk a little bit about usability and how you represent the physician community that you’re responsible for. Can you share the process that you use to deploy new features or new initiatives?

Sharif: Sure. UX (user experience), and UI (user interface) to an extent are my top priorities. Due to several reasons, including meaningful use, I’m of the opinion that we in healthcare have not given enough attention to the UI piece.  One of the things I have been doing in my role is to make sure that we center innovation, optimization, new design, and new projects around users. One way I accomplished that was working with our UX and UI teams within our IT department which our CIO had the foresight to create, which from my experience wasn’t really a norm. We have one UX or UI resource to support any major initiative we are working on.

I lead several councils in different areas of our organization, where we have a group of physicians, nurses, dietitians, social workers, and nurse practitioners or the Physician Assistants. We engage them in the design and development of any technology initiative very early on.

To deploy new capabilities, we’ve experimented with different types of change management. Historically, we were typically like anybody else, in that we leveraged a waterfall methodology.  We are moving away from that using an iterative approach based on sprints framework.  We engage our end users for feedback with every iteration. Even so, sometimes end users will tell you “this is what we want”, and if you don’t holistically study that and determine how it fits in the overall architecture, you just produce a tool for them that also lacks the adoption because it does not fit with the rest of their workflow.

Using this approach and soliciting end-user feedback, we deliver a solution which is user-centered, meets the user’s needs, and we enhance the user’s experience as well.  It may be cliché, but I like to think that any IT solution, tool or utility should be a joy for the clinicians to use.  We are committed to identifying and creating the tools, pathways, and structures so that we can break the mold or traditional archaic healthcare UI design.

Campbell:  It’s so true. You see some of the user interfaces that clinicians are presented with and it’s not elegant. It emphasizes the need to get back to simplicity to help alleviate the burden on clinicians. Thank you for sharing that perspective. One more question to ask: With the plethora of initiatives that are taking place in 2018, what is it that you’re focused on for the next quarter in delivery for the organization?

Sharif:  One of the primary things I want to do is to create a better and simple interface for physicians to be able to round in dialysis facilities.  To do this, we are creating a mobile application in conjunction with our product management team using advanced usability approaches and leveraging FHIR resources and APIs. Our goal is to ensure that the interface is reliable, fast and nimble so the physicians can view current and historical data, in a very user-friendly format and document their notes and care delivery. We have gathered end-user requirements, determined what physicians need in rounding at dialysis facilities and created an application tailored to those needs with consistent user input.

Another initiative I am working on is our partnership with Epic. Fresenius is also an EMR vendor, as we have a subsidiary, Acumen Physician Solutions, which provides an EMR solution to nephrology practices we don’t own. We have the largest market share in the country in the nephrology EMR space and are now collaborating with Epic to leverage the power of their tools to improve usability and enhance data sharing capabilities for our physicians and clinicians.

About a year and a half ago, we were at a crossroads where we had to make the decision as to whether we continued evolving our in-house built application, which was a fully meaningfully use certified EMR. We had to decide if we should continue to put in a lot of effort, money, and resources into the back-end plumbing of the application and making it a more sophisticated and elegant EMR system. The alternative was to partner with somebody who does this for a living in the interest of patient care coordination, population health management and so forth.

As such, Acumen 2.0, which is powered by Epic, provides our nephrology practice customers with improved access to a longitudinal and comprehensive view of patient data to help make more informed and timely decisions. Our Acumen team with its deep nephrology practice experience continues to “nephrologize” the content and workflows and provide best in class service to our customers. As we roll-out this partnership solution, our customers will be provided with the ability to connect through Epic’s feature-rich tools, tailored for their practice and patient needs by Acumen team and their nephrology peers.

Campbell: That sounds very promising and I look forward to following the progress of the partnership in the coming months.

About Dr. Ahmad Sharif

Ahmad Sharif, MD, MPH, is Senior Vice President and Chief Medical Information Officer at Fresenius Medical Care North America. Dr. Sharif has extensive experience in health information technology, consulting with over 25 health systems across the country and abroad, implementing and optimizing electronic health records, clinical practice management and technology solutions for multi-facility large academic institutions and smaller community and critical access hospitals.

For more on the topic of patient data, read Dr. Ahmad Sharif’s whitepaper “Connecting Patients with Their Health Information.”

HealthIT CIO Interview Series – Mathew Gaug, Lima Memorial Hospital

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Mathew Gaug, CIO

Mathew Gaug, MSIS, ITMLE, Executive Director, Information Technology, Lima Memorial Hospital

Lima Memorial Health System was founded in 1899 as Lima City Hospital by the citizens of the Lima, Ohio community. The hospital is a not-for-profit health care organization with more than 1,500 employees, and 25 facilities in their 10-county service area in the region. Lima’s CIO, Mathew Gaug, works hard to ensure that technology enables a convenient, efficient and high-quality experience to that same patient community that was originally responsible for the founding of the organization. Like many other healthcare delivery organizations, Lima Memorial is challenged with a non-integrated ambulatory EHR and EMR. As such, driven by its physician community, it is pursuing adoption of Meditech’s web-based ambulatory product to replace eCW. Ultimately, this will offer a streamlined solution to improve provider efficiency and consequently, patient experience, while providing a foundation for additional patient engagement and telehealth services to be offered.

Key Insights

From a historical context, our organization took a best of breed approach where we went MEDITECH for the acute side, but eClinicalWorks for ambulatory practices. We recently embarked on a new strategic direction, where we are looking to consolidate applications and making a patient-centric decision to have only one record across care settings.

An integrated system enhances the historical context, as the ambulatory side wouldn’t necessarily always have access to the acute side. It greatly simplifies things, as there is only one medication, allergy or problem list to maintain. From a provider perspective, harmonization of different nomenclatures isn’t as burdensome.

We rolled out the ideas at Healthcarebusinesstoday.com of a consolidated ambulatory practice, had demos, and evaluated products. We were vigilant in ensuring it was a physician-based decision rather than being driven by IT. Our physicians drove the evaluation as to keep the status quo or to adopt a new workflow and mentality with the technology used to practice medicine.

 A lot of the communities we serve are rural and telehealth will allow for our patients to have better and quicker access to care. Our goal is to have it integrate to our new patient portal, which will make visits for our patients that much more convenient.

Campbell: Tell me a little bit about Lima Memorial, your role within the organization and your background.

 Gaug: Lima Memorial is a community hospital in Northwest Ohio. We have roughly 1500 employees and 25 facilities in 10 county service areas. We are an affiliate of ProMedica, but at the same time we are the furthest south, so we kind of stand on our own when it comes to medical and clinical decisions, and decision-making processes. In terms of my role here, I’ve only been at the organization for about 1 year now. I came to Lima via the Cleveland Clinic as a promotional opportunity. I was looking to spread my wings a little bit, as I’d spent 20 years at the clinic. My formal title is Executive director / CIO, and I have a team of 56+ with everything IT-related rolling up through our group, which includes technology, development, biomed, communications and informatics.

Campbell: Coming from Cleveland Clinic, obviously you come with the perspective of an organization that’s typically on the forefront of healthcare information technology adoption and it’s probably doing some innovative things that may be ahead of what the broader marketplace is doing. In terms of the application portfolio that you manage tell at Lima, can you tell me a bit more about that mix. Namely, the mission-critical applications, the history of those applications within the organization, adoption rates and any optimization you may be pursuing today?

Gaug: Our main application within the hospital today is MEDITECH. We upgraded to 6.15 a month after I started in the organization, and as such, the project was well underway when I got involved. The team did a fantastic job of getting that implemented. From a historical context, our organization took a best of breed approach where we went MEDITECH for the acute side, but eClinicalWorks for ambulatory practices. We recently embarked on a new strategic direction, where we are looking to consolidate applications and making a patient-centric decision to have only one record across care settings. As such, we are looking to adopt a new ambulatory platform with MEDITECH’s web-based ambulatory product. We’re looking to adopt that same mentality and go that way with our platforms.

Campbell: The sentiment of having an integrated, single record is one that has certainly been echoed amongst the CIOs who have participated in this series and given how the MEDITECH web-based ambulatory product has evolved from a UI perspective. It seemingly limits complexity as providers have a familiarity on the acute side and more capabilities can be offer on the ambulatory side based on some of the innovation the web-based ambulatory product has offered with syndromic surveillance, population health management, and facilitation of coordination of care. I’m sure that approach is supported even more so due to MEDITECH’s acute product being well embedded at Lima?

Gaug: The hospital has been on MEDITECH in one for form or another since the first install in 1994. An integrated system enhances the historical context, as the ambulatory side wouldn’t necessarily always have access to the acute side. It greatly simplifies things, as there is only one medication, allergy or problem list to maintain. From a provider perspective, harmonization of different nomenclatures isn’t as burdensome. In addition, the providers no longer have to familiarize with two different user interfaces, workflows, etc. Most importantly, from the patient’s perspective, via the portal, they are provided a comprehensive view of ambulatory and acute visits.

Campbell: Tying into managing multiple applications across care settings, can you touch on provider satisfaction within the organization. Recently KLAS introduced the Arch Collaborative to benchmark provider satisfaction, and the new clinical informatics track at the CHIME Fall Forum was well received as it highlighted provider engagement methodologies. How do you approach provider satisfaction within the organization today?

Gaug: We have a subset of the team from my informatics group that round, visit with and train providers as one of their sole or main responsibilities. We have a 24 hour a day, 7 day a week physician hotline where providers can call and get in touch with one of my team members directly. That goes a long way in terms of provider satisfaction because the last thing we want is a provider being stuck and have it potentially impacting patient care. We are focused on providing exceptional services and response so we avoid problems with technology or issues with the electronic medical record preventing our providers from being able to make clinical decisions. Another thing that we have most recently done is separated the role of Vice President of Medical Affairs and CMIO. It was previously a single role with dual responsibilities, and it has enabled increased energy and focus for the two areas.

When we rolled out the ideas of a consolidated ambulatory practice, had demos, and evaluated products. We were vigilant in ensuring it was a physician-based decision rather than being driven by IT. Our physicians drove the evaluation as to keep the status quo or to adopt a new workflow and mentality with the technology used to practice medicine. I think that’s key with driving the success of any type of implementation of a new application. Ultimately, we want to make sure that as a result of our decision, patient care is more convenient and it’s more efficient for the providers.

Campbell: Great. Thank you for providing some color around that. Let’s talk about population health initiatives within your organization. I imagine rollout of capabilities will be eased in having an integrated platform. That said, what initiatives are taking place today? Do you maintain any chronic disease or wellness registries? Have you evaluated or adopted technology perhaps within Meditech or externally to address the potential need?

Gaug: Thus far, the adoption has been within eClinicalWorks. As such, we are really focused on the future with the Meditech ambulatory application and what capabilities we can introduce with the integration of the two platforms. There are some exciting things that we’re anticipating coming forward, but for the time being we use care navigators and our offices to make sure that our patient scorecards are being maintained and they identify opportunities for intervention.  We also have a physician group that’s within our organization which oversees all population health and care navigators that are going on in the practice today.

Campbell: It sounds like there are some innovative initiatives on the horizon regarding population health management and it should enhance what may be a manual or patchwork process today. I recently read that you achieved EMRAM Stage 6, a recognition that’s bestowed upon hospitals for achieving higher patient safety through improved documentation. Tell me a bit about that clinical documentation improvement initiative.

Gaug: That opportunity manifested itself when we upgraded to Meditech 6.1.5. We made sure that not only were we going through an EMR upgrade, but we also analyze and pursued clinical workflow optimizations. With the testing that was taking place to upgrade MEDITECH, in parallel, we went into all the clinical and ancillary departments, evaluated workflows and implemented improvements. That went a long way to eliminate non-electronic workflows and improve existing workflows as we pursue stage 7 recognition.

Campbell: Related to PHM, are there any initiatives you might be introducing to better engage patients? I recently read an article published on the Lima Memorial website that was more marketing focused, addressing how patients should plan a well visit. What other types of things are you dabbling in regarding telemedicine and telehealth?

Gaug: It’s interesting you bring this up as I recently authored an article on telemedicine’s role in advancing patient care.  One of our primary strategic initiatives in 2018 is to have telehealth and telemedicine capabilities implemented and offered if not in all the practices, at least all the types of specialties we have. Telehealth may not be achieved in every family medicine practice, but we want to have at least one of those practices using telehealth. A lot of the communities we serve are rural and telehealth will allow for our patients to have better and quicker access to care. It will also enable us to offer different services we may not have today. Our goal is to have it integrate to our new patient portal, which will make visits for our patients that much more convenient.

Campbell: Absolutely. It closes the loops they have a comprehensive view of the interactions with their provider to complement the clinical record. That’s the bevy of questions that I had for you. Thank you for sharing your perspective and insights and best of luck to you with the transition.

About Mathew Gaug

Mathew is a highly accomplished IT business professional with more than twenty years of executive experience guiding the strategy and execution of mission-critical technology infrastructure and support for large-scale health service providers. Mathew is experienced and has expertise in integrating newly acquired facilities and establishing system-wide compliant technologies as well as migrating data centers. Serving as Executive Director,  Information Technology at Lima Memorial Hospital, he successfully orchestrated the implementation of multiple technology initiatives, touching every aspect of health care operations, significantly reducing costs and increasing efficiencies within an aggressive time frame. Mathew holds a MS in Information Systems and a BS in Computer Science from Baker College. 

CHIME Fall Forum Interview Series: Doug Dietzman, Executive Director, Great Lakes Health Connect – Part 2

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This is the 2nd part in a two-part interview. Read part 1 here.

Brian Sterud, CHCIO, FACHE

Doug Dietzman, Executive Director, Great Lakes Health Connect

There are two parts to the health information exchange value equation: how do you add to it, and how do you demonstrate that value? Doug Dietzman, Executive Director at Great Lakes Health Connect, knows this all too well. Leading Michigan’s largest HIE means listening to what providers and organizations need, and creating solutions they can easily integrate to create more connected communities. In this interview, Dietzman discusses how being a nonprofit has made GLHC more in tune with their consumers; why he welcomes the scrutiny that’s put on HIEs; and the unique approach GLHC takes to demonstrate the value of their services. Dietzman also touches on top of mind topics such as the recent hurricane disasters and how HIEs are a vital part of our emergency preparedness.

The establishment of patient identity needs to originate at registration within the provider organization, where care is being delivered.  It will always be more difficult and messy to fix it on the backend.

We need industry consensus around a single security certification process that will satisfy all healthcare participants. 

As a neutral community-focused organization, HIEs sit in the middle of the health plans, hospitals, primary care offices, public health, and all the other physical, behavioral and social service organizations involved in healthcare.  There are compelling reasons why and simple ways how these industry stakeholders can all work together to do the right thing for the people we all serve.

Campbell: I’m going to shift gears, to a topic that’s of interest to a large audience, and certainly has a lot of differing opinions and confusion around it: Patient Identification. What I’d like to get at is how that’s managed within the HIE today, what tools you might leverage, what ideas you have. Mike Gagnon, from Nevada HIE, spoke about some of the vendors he’s talked to about facial recognition, as that’s become more ubiquitous, and whether it’s on private industry to solve, or the responsibility of government. Keeping politics aside, I’m more interested in how it’s technically facilitated at Great Lakes Health Connect and some of the advanced things you’re doing in that regard. Could you touch on any patient matching issues that you may have, and how those are automatically or manually resolved?

Dietzman: I don’t know that we’re doing much that’s different from everyone else.  Medicity remains our virtual health record platform; the MPI that we’re using is through them as well. We don’t have resources dedicated to maintaining or fixing patient identity issues, as we don’t encounter a great deal of those issues on a daily basis. As such, from an administrative and use standpoint, what we’re hearing from our customers is it’s not a huge problem that’s getting in the way of what they need to do. There’s a lot of work we can do in the HIE that doesn’t even require an MPI to be involved in the first place. We do have an analytics environment where we’re doing some patient matching for those purposes, but overall, not a huge issue for us.

It’s interesting that some are trying to solve the problem on the backend. It seems to me that when we talk about patient identity, it needs to originate and start at the registration within the provider organization because that’s where the care is being delivered. If we’re trying to fix it on the backend, it’s always going to be more difficult and messy. In my mind, we’re giving the wrong people the wrong care, potentially, if the patient is misidentified. Palm scanners, facial recognition, and other biometric devices would be the easiest way to solve this. From a social standpoint, there may be some problems with that. We need to make sure we’re treating the right person at the point of care. If we’ve accurately captured it at that point, the backend reconciliation should be much more straightforward. As such, I don’t see this necessarily as an HIE problem.

Campbell: That’s a great perspective. Thank you for sharing. Switching topics again, SHIEC held an annual conference at the end of August, and I was curious of insights gleaned and takeaways from the event.

Dietzman: I’m on the board of SHIEC (Strategic Health Information Exchange Collaborative), and was recently re-elected to a second term, so I’ve been involved with the organization for a while. The conference itself was great. The conference was bigger than the year before. I was encouraged by the energy and the sharing of ideas. It wasn’t just about us getting together and drinking our own Kool-Aid. The ONC was there for all three days, and a number of vendors came to show their support, and have meaningful conversations with the group, which was great. I heard a lot of positive feedback on the quality of the content and conversations. I thought it was another good step forward for the organization. We’ll have some big expectations to fill next year down in Atlanta.

Campbell: That’s fantastic. What were the themes that dominated the event and what problems were tackled at this year’s conference?

Dietzman: Patient Centered Data Home (PCDH) was a big topic; specifically how PCDH can serve as a mechanism for how we can connect SHIEC Member HIE networks on a national level. This was important conversation for helping people understand how SHIEC Member organizations are demonstrating success within our regions. Another was a series of updates on how various organizations are doing things. For instance, Dan Chavez of San Diego Health Connect led a session on how his group is supporting emergency medical services, and how other HIEs can replicate their program. In the breakouts, there were a lot of topical presentations that gave provided ideas and helped us understand behavioral health use cases. Some of the folks from the Nebraska Health Information Initiative (NeHII) shared what they’re doing around prescription drug monitoring programs (PDMPs) with controlled substances and medication databases. Exchanging ideas, collaborating, and being able to have meaningful conversations with industry peers is always helpful.

Campbell: Thank you for elaborating on that. Sounds like it was an invaluable event. I look forward to next year’s conference. That said, I always like to weave in practical stories of use cases where they’ve been impactful. I know you probably share those among staff to develop an understanding of the true impact of the HIE. If there’s one that comes to mind that you could share with us about how Great Lakes has made a difference in the lives of patients that would be great.

Dietzman: Let me give you two quick ones. We’ve been working with a community mental health organization here in Michigan, over towards Ann Arbor, and their use of our Virtual Integrated Patient Record (VIPR). We’ve been challenged with the consent laws and other legal frameworks to accept behavioral health data into our virtual health record. What we did in this case was to make sure their behavioral health care workers were provided with physical health information on their patients. There is no regulatory restriction there, and having access to that information informed their ability to care for the folks they were seeing in the CMH. The Director, Mike Harding, talked about one particular lab test that they would order on a regular basis for their patients. Once they gained access to the community health record, they could see the results of past testing, eliminating the need to run an additional panel. He estimated that their organization was able to eliminate about 200 tests a month because the necessary results were already in the record. This translated to a savings of $72,000 a year for them!

The other example is a center in Grand Rapids that works with a complex population; folks that have physical, behavioral, substance abuse, or other issues that drive frequent visits to the emergency room. We implemented the community health record with them as well. Their workflow and process was for the entire staff to meet as a team first thing in the morning, before patients started arriving. They could then review the records of everyone scheduled for that day to get a sense for each patient’s status and needs. On one occasion, a woman was scheduled for an appointment, and had requested a referral for a CT scan to help identify the cause of some head and neck pain she was experiencing. When they looked in her record, they realized that the previous week she had presented to all three emergency rooms in town on successive days, and had received CT scans during each visit! On one hand, this is not a great story. It highlights the work we have yet to do to inform different care settings and avoid unnecessary, redundant, and potentially dangerous treatments. But also, in this case it empowered those providers with the information they needed to intervene and quickly identify that there was something more going on with this patient. They were able to bring behavioral and social resources to bear on her behalf, and address the root cause of her complaint, rather than continuing to blindly treat the symptoms of her complaint.

These are just a couple of examples of how tools provided by the Health Information Exchange are being used to help people do things differently.

Campbell: Great, thank you for sharing those. Wrapping things up, I know earlier in the year you received a HITRUST distinction for security and privacy and that’s a topic that you take very seriously as an HIE. Could you touch on that topic, maybe conversations at SHIEC to that regard or any insights or points you want to make, regarding security and how that’s managed, and how you continue to evolve, as cyber threats manifest?

Dietzman: GLHC has a responsibility to be just as diligent about data security [if not more-so] as any of the large health systems that we work with. Gaining the HITRUST designation provided us with the assurance that we’re doing the right things where security is concerned. More importantly, this demonstrates to our participants that we can pass that highest level of scrutiny from an independent third party organization, considered the gold standard in this area. It doesn’t guarantee anything. As you said, the threat changes on a continual basis. But HITRUST shows we’re doing all we can to stay in front of those threats. One of the challenges, and some of the conversation that we’ve had within SHIEC and elsewhere, is the lack of a standard industry-wide security certification. There are some health plans, for example, that require HITRUST while others say HITRUST isn’t sufficient and require a different certification. HIEs are in a position, depending on their participants, to have to “check all the boxes” in order to be compliant. This is very expensive, and frankly not realistically possible. So, from an industry standpoint, I’d love to see some kind of coalescence around a particular security standard that we could all align behind. It’s not the security requirement that’s hard, they’re all essentially the same. Going through the process multiple times is a challenge. Having to do it six to eight times to get through all the different varieties is exhaustive.

Campbell: Certainly, there’s a lot of effort that’s involved in penetration testing, just to ensure you’re whole and don’t have any paths to exploitations. One topic that we didn’t touch on that I’d like to conclude with, is a little bit of bio about yourself, how you came to Great Lakes, your background, and how you got into healthcare IT.

Dietzman: Well, I got into it by happenstance. When I graduated, my dad was in retail and I went to work for a retailer for about a year, then I moved to another part of the country and got linked up with Anderson Consulting. When I showed up, I was a green rookie, and they said, ‘you know what, we need people that can breathe down at Aetna in their employee benefits division,’ and I qualified. I started working on some projects there, doing PowerPoint presentations as a young guy, and at some point the partner came up, after a little bit, and said, ‘you know what Aetna’s buying these things called HMOs down in Texas, we’re not sure what this managed care thing is, so go down, spend 30 days in the library and learn everything you can about managed care and all these terms that they’re throwing around and come educate the rest of the team so we can provide better service.’ And I did, and once I spent 30 days pouring through the details of the industry it kind of became my thing. I was hooked.

I spent most of my career, from that point, in managed care, mostly in health plans. I worked for a couple different health systems serving in different capacities: Project Management; IT; Management Consulting. I then worked with Spectrum Health, in Grand Rapids, MI, helping them develop connections to the providers in the community, delivering results and doing other things that they needed. A conversation started with other hospitals in town who were using the same technology about how we could do things better and collaborate around this clinical data exchange. They asked me to facilitate the conversation and then, once we decided to become a real entity and incorporate in 2010, they asked me to lead the effort and see if there was a business model and how the organization would go forward from there. It was just me, and so from 2010 forward it’s just been growing one person at a time, to try and solve problems, and figure out how we can build a model that will sustain itself. For me it was cool, I’d been in health plans, I’d been in hospitals, I’d been in primary care offices. It seemed to me that there was a way for all three legs of that stool to work together in a way that could advance healthcare outcomes. As an exchange, we get to sit in the middle and work with all the legs of the stool to figure out how we can share data and do the right thing for patients. It’s a great way to bring all of that experience together.

Campbell: That is so profound. Thank you for sharing. It’s always fascinating to learn of the turns and twists in someones career, and how that shapes, not only who they are, but the organizations that they lead.

CHIME Fall Forum Interview Series: Doug Dietzman, Executive Director, Great Lakes Health Connect

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Brian Sterud, CHCIO, FACHE

Doug Dietzman, Executive Director, Great Lakes Health Connect

There are two parts to the health information exchange value equation: how do you add to it, and how do you demonstrate that value? Doug Dietzman, Executive Director at Great Lakes Health Connect, knows this all too well. Leading Michigan’s largest HIE means listening to what providers and organizations need, and creating solutions they can easily integrate to create more connected communities. In this interview, Dietzman discusses how being a nonprofit has made GLHC more in tune with their consumers; why he welcomes the scrutiny that’s put on HIEs; and the unique approach GLHC takes to demonstrate the value of their services. Dietzman also touches on top of mind topics such as the recent hurricane disasters and how HIEs are a vital part of our emergency preparedness.

Key Insights

There’s nothing about HIEs that have a right to exist just because we’re HIEs. We should only exist if we are indeed adding value, like any other business or organization would have to do.

CommonWell, Care Quality, and other networks connect EMRs and there is a strong role there but what’s the plan during a disaster when a good Samaritan clinician from Missouri is now in Houston and they want to look up a person’s record who has walked into a shelter with thousands of other people? Do we have to give them access to all the EMRs in town? As a practical matter, an HIE is really the right solution.

One of the things that makes us unique from many is we have not developed ourselves, or built, our operations, even to this day, and going back to the beginning, from any state or federal dollars. We had the mindset coming into it that if we can’t develop solutions and services that the stakeholder community is willing to pay for, that actually solves a problem, then we’re going to go out of business someday when the grant money dries up.

When we get into the community health record, this is probably true for a lot of my peers as well, nobody argues that a longitudinal record is a bad thing, everyone thinks it’s great, but if a hospital is going to pay increasingly scarce dollars for access to this longitudinal health record, how do we measure the value of that to them?

Campbell: I am flattered and humbled to interview you as part of this HIE series that we’ve been running, there’s no better example of the value of an HIE than Great Lakes Health Connect. Certainly, there’s been some scrutiny put on HIEs, there’s been some sentiment that HIEs don’t show the value for the effort or money put into it. Broadly, what is your perspective on the current state of HIE?

Dietzman: A couple of initial thoughts. To your point on scrutiny, my perspective would be, it’s very appropriate, there’s nothing about HIEs that have a right to exist just because we’re HIEs. We should only exist if we are indeed adding value, like any other business or organization would have to do. I think what we will continue to see is those that haven’t figured out how to do that well will be challenged. There may still be some consolidation, or HIEs that cease to exist, if they haven’t put a sustainability model together. That shouldn’t mean that the whole concept is wrong, just that, like in any business, some work and some don’t.  For example, there are some that know how to run a book store and some that don’t, and the bad book stores go away and the good ones continue to exist. So, I welcome that scrutiny and what it will mean for what we’re doing to enhance care coordination and facilitate cost optimization.

Campbell: That’s a great point. Tell me about some of the initiatives currently taking place within GLHC that contribute to sustainability.

Dietzman: There are a couple things percolating or that are of interest. One would be the recent hurricanes. There’s been press reporting on how HIEs uniquely helped there in the midst of the immediate aftermath. We are focused on how an HIE like Great Lakes Health Connect provides a unique value beyond some of the other national networks or other ways EMR vendors are talking about connecting with each other. You would not be able to deal with 1,000 people in a shelter, all coming from a wide variety of different places and have a uniform record for those nurses or care workers who are coming in from all over the country to help in the disaster, absent having the HIE there to provide that visibility. It’s a perfect use case for me, and when those crises come up, the HIE plays a vital role.

Campbell: That point can’t be underscored enough, and that’s just one of the value propositions for an HIE, but it’s a profound one because what alternatives do you really have? Can you expect someone to bring their record on a device? They probably don’t have it in those circumstances. Depending on the practice, you may not have access to that information, and otherwise, to transfer those records, so, the HIE is critically important in those scenarios.

Dietzman: CommonWell, Care Quality, and other networks connect EMRs and there is a strong role for that but what’s the plan during a disaster when a good Samaritan clinician from Missouri is now in Houston and they want to look up a person’s record who has walked into a shelter with thousands of other people? Do we have to give them access to all the EMRs in town? As a practical matter, an HIE is really the right solution. From an emergency preparedness standpoint, we stock pile beds, we stock pile supplies, we stock pile all sorts of things. Should a facility need to be evacuated or there’s a crisis across the country, what’s rarely thought about is: how do we prepare the clinical data and the records in a way that we can actually care for the people when those things happen? I’m hoping the continued push on this will put more of a spotlight on the need for seamless information sharing as part of how we prepare for these sorts of events, rather than always being caught off guard and then wishing we had.

Campbell: Right, a business continuity and disaster recovery plan is vitally important.

Dietzman: So that’s one, another is the patient centered data home activities we’re heavily involved with in SHIEC (Strategic Health Information Exchange Collaborative) and the Heartland Project, which is connecting seven HIEs here in the Midwest and working with the other regions to connect those together into a national network as well. It’s all activity that’s currently live. We’re actually exchanging ADT (admissions, discharge and transfer, data) with those other states today, and are working on adding the query capabilities. That’s pretty exciting for us and something that people have been requesting for a long time.

The last point I’ll mention is, we have added another non-profit organization under our corporate umbrella. Making Choices Michigan is specifically focused on advance care planning. We have partnered with them regionally for a while as the electronic repository making documents available once the conversation had occurred. But we recognized we could have greater impact if  our organizations were aligned to expand our collective capacity across the state. This would give us a consistent process, consistent tools, and a consistent state-wide delivery mechanism for those documents to really try and make difference in advance care planning and culture conversation. That’s another initiative that’s new for us and that I’m pretty excited about.

Campbell: Great, thank you for sharing that. That’s something that I actually talked to Todd Rogow about at Healthix in New York. He talked about their use of advance directives and defining the different value areas, maybe it’s in disaster prevention preparedness, or in the wake of those disasters, you’re providing access. Advance Directives is another area where HIEs can provide value, beyond just exchange of CCD (continuity of care) documents, results, or other clinical information.

Dietzman: Yeah, I was thinking about the concept of patient data a little bit more broadly. I mean, we’ve been focused, since our inception, on making sure a patient’s data gets where it needs to go to support care, and patient wishes are a portion of that. To that extent, as I see a lot of very small, pocketed, fragmented efforts all trying to create this culture, and through that fragmentation it’s losing some of the gravitas it could have. I’m hoping Great Lakes Health Connect, with our state-wide network, and the capabilities and trust we’ve created to this point, can help elevate that conversation and make it something that folks across Michigan start to tune in to. If most healthcare expenses are incurred late in life, it seems to me that increasing the percentage of the population who have advance care documents in place, and readily accessible can’t do anything but honor their wishes better and care for them according to what they really want. This can significantly lower the cost of healthcare for things people don’t want, and also save families from significant disagreements and heartache when those wishes are unknown.

Campbell: Certainly. So, if I may, I’ll present you with a loaded question, something that I’m interested in. I’ve asked a few of the other folks who I’ve interviewed as part of this series, what’s been the biggest differentiator for Great Lakes Health Connect? I know you folks are very advanced in terms of both the public and private HIEs, but whether it’s strategy, culture, technology, time. We’ve spoken with Maine HealthInfoNet, and for them, they’ve been around for so long, started early, and now they’re really advanced in their use of predicative analytics, where others may still be grappling with onboarding and participants. I know that GLHC is very deeply penetrated in the participant market, with those people who you provide value to, it’s not just hospitals and clinics but also community and mental health, public health, behavioral health, so I know you’ve really expanded that footprint. If you could provide a few points about what’s been the key differences in terms of how you manage your money, how you provide governance, I would be appreciative.

Dietzman: One of the things that makes us unique from other HIEs, is we have not developed ourselves, or built, our operations, even to this day (and going back to the beginning) from any state or federal dollars. We had the mindset coming into it that if we can’t develop solutions and services that the stakeholder community is willing to pay for, that actually solves a problem, then we’re going to go out of business someday when the grant money dries up. While I would’ve loved having $15 million dollars to play with, not having it focused us pretty intensely on the things that we needed to do to  be of value to our stakeholders. The point that I keep bringing up is, there’s a lot of basic blocking and tackling, exchange work, that is still a pain in the neck. Hospitals and other providers need to have those tasks taken care of for them. For all the standards that have been developed, and all the talk about interoperability, nobody is talking about how we make it so that a result message from a lab can automatically go into any EMR without having to do any sort of integration work. We still do a lot of that, and our participants are willing to pay us for it because they don’t want to have to deal with it themselves. That’s one of the key points for us, being very in tune with our customers, what are the tangible problems and needs that they have? How do we position ourselves to meet those needs and scale in a way that allows us to be sustainable?

Campbell: Right, that’s a great point and it’s hard to wean yourself off of grant money too. I’d spoken with Todd Rogow of Healthix, who are supported with a lot of government money. Once you’ve incorporated that into your business model, it’s awfully tough to substitute it, once you’ve gone down that path.

Dietzman: The tricky thing is, once a customer has gotten something for free, it’s hard to get them to pay for it later. So, it’s not so much the problem with the HIE, and one type of fund or another, but once you’ve given something away, to come back after a couple of years and say ‘well now you’re going to have to pay for it,’ when the mindset for those folks probably is ‘hey this stuff should be coming down in cost,’ or, ‘this is something I’ve never had to pay for before,’ that’s a hard conversation to have.

Campbell: That’s a great point, I’m glad you revised that for me, the point I was trying to make, but taking it from the angle of the participants. That’s so true. Speaking of subscriptions or pay-for-service from your participants, how do you report value to them? How do you show them the value that you’re providing for the funds they’re paying? I’m talking about just from a reporting perspective, and maybe saying, ‘hey these are the number of transactions, these are the ways we’ve intervened, this is how we’ve impacted your patient population from a public health perspective, or these things on the roadmap.’

Dietzman: It’s a good point, and on some level, a challenging one for us. The reason that we built our model in a menu set is we wanted those menu items that the providers are paying for to tie more directly to the value that they are receiving so that it would be clearly visible. If there is just one big fee to join an HIE and you get all this stuff associated with it, it’s harder for me to articulate exactly what they’re getting for their investment. If they only want 25% of the solutions, but they have to pay for 75%, then it makes the whole value-dollar dynamic really squishy. We established a core participation fee when you join, just to encourage further participation and active use of the exchange, but then additional solutions are broken out separately. So, results delivery would be an example item, and you pay for that. It’s easy to go to them and say, here are the number of offices for which we have built interfaces, or are getting your results through inbox, that sort of thing.

Translating that into how much that saves the organization from doing it themselves, or the exact value proposition, is where it gets  hard. Most  provider organizations haven’t developed a baseline, or know what it was costing them before. We are performing tasks that are outside of their core business, and that frees up there internal resources. From one perspective, the associated costs our participants are willing to pay is a reflection of the value that we’re delivering to them.

When we get into the community health record, this is probably true for a lot of my peers as well, nobody argues that a longitudinal record is a bad thing, everyone thinks it’s great, but if a hospital is going to pay increasingly scarce dollars for access to this longitudinal health record, how do we measure the value of that to them? The value depends on how much it’s actually used within the workflow and what it means inside the organization. We don’t control the relationship with the patient. That’s where it gets even more squishy with  ROI. That’s why we highlight use case examples  like emergency preparedness, and ask “what would you do in that situation?”. It’s happened in New York, when they had the ransom-ware attack and were able to use the HIE data to continue serving patients; otherwise their clinical data would’ve been locked up inside their EMR. Those are more subjective illustrations that  demonstrate value, rather than through an objective ROI. But it is very clear in a rapidly evolving value-based reimbursement model environment that those at risk MUST know what is happening to their assigned population when outside the 4-walls of their enterprise.  The longitudinal health record is going to be a core success platform in the coming years.