Here’s the transcript from interview with John Capobianco from Medecision talking mostly about the “payer-based health records” they’re developing with several big health plan customers, and distributing to providers. The audio podcast is here.

Matthew Holt:  Matthew Holt with The Health Care Blog, still at HIMSS. Now I’m meeting with John Capobianco, who is the President of MEDecision, and also with Tracey Costello, who is the VP of marketing. So welcome to you both, hi John.

John Capobianco:  Hi.

Matthew:  Hi, Tracey.

Tracey Costello:  Hello.

Matthew:  John, tell us a bit about MEDecision. As some of the readers of the blog know, I’ve had folks from ActiveHealth Management and Click4Care do podcasts. I was thinking about the whole space around payers and data, and analyzing what’s going on in that world is something that probably most of our readers don’t know that much about. So give me a brief overview of what you guys do, where you fit in the space generally, and how you compare yourself to those guys, or other competitors.

John:  Hi, Matt. I’d be happy to do that, Matt. MEDecision started about 18 years ago creating a solution to a mission statement that was put forth. That was:  how to improve the relationship amongst payers, patients, and providers. We started out going after the payer community because it was not only where the money is, but where the data is, to create clinical records for patients. If you want to improve the outcome, you want to improve the health of patients, what you have to do is to get health information exchange to actually work.By spending the first 18 years going after providing the right information for care managers, for utilization in case and disease management, we figured out how to analyze and gather the data together that was inherent within the only currently available digital systems in the industry that have a lot of data. That’s from the payer’s claims data. We also then created the workflow applications for the case disease utilization mangers. We’ve now recently added the clinical overlays for both utilization as well as case and disease conditions, and what the best practices and processes are around that. Then just a few years ago we started to create the communication vehicles from those inside the walls of the payer to the outside, to the provider communities.About a year ago now, we entered into what we think is probably the most important phase of that. That is, above and beyond the great work we’ve now been able to do with authorizations and referrals and extensions as communication vehicles, we’re actually now starting to take what we call the patient clinical summary. That summarized view of this patient and all their conditions and move it out to the point of care.With several of our clients now, we are not only populating the personal health records, or personal health management systems that they choose, but we’re also providing that data out to either their provider portals or through the standard vehicles we put in place to do authorizations and referrals. Delivering that patient clinical summary right to the provider at the point of care.

That’s
where you came across that economic benefit study where we showed that
the health information that we were able to gather together, not only
had value inside the plans, where we have 56 plans today with some 42
million members running through the applications, but we also found out
that that piece of information, that patient clinical summary had value
to the provider at the point of care. What the provider said to us was:
"You’ve made the unknown known." They have a pretty good idea of what’s
happened in their office but they don’t know much about what’s happened
outside their office.

Matthew:  Right.

John:
So accumulating all that data within the payer has been valuable. We
also started to expand the sources of data. Originally it was primarily
the claims data that you went through to find stuff. But because now
we’re connecting to the patient portals, the member portals, we can
start to gather some data from there. We can get HRA data; we can pick
up personal lifestyle data. The payers themselves are beginning to
accumulate more data. They’re going out and getting lab results and all
kinds of data that we can incorporate.In addition to that, of
course, most of the payers out there are actually in the business of
care management. They have lots of care management nurses that are out
there communicating with the physicians and the patients on a fairly
frequent basis. We’re able to take that data now, that care management
data, and incorporate with all the other data we’ve been working on.So
were beginning to expand the facility with which we can gather this
data and present it. We’re also expanding the facility with which we
can deliver the data. We’ve noted that the issue around health
information exchange, which is what I think we all believe to be the
next big step in health care, what we’ve shown is that health
information is provide‑able, it has economic value, and by corollary,
it has medical value. Because they didn’t perform tests that they would
have performed and therefore it affected their medical decision‑making,
which is great.We’ve also proven though, because we’ve had a
lot of records available for some period of time now, although it
hasn’t been rolled out as much as we’d like, is that the exchange piece
of that health information exchange has not yet been addressed. So we
have just launched two departments within our organization, one of them
called the  Interoperability Competency Center,
the ICC. Their job, and they’re demonstrating it downstairs on the
HIMSS floor, has been to go out and to break down the technology
barriers between taking our data, the data we provide for our client,
the payer, and how do we make that available to providers and to
patients at the point of care, point of decision‑making. And make sure
there is no technological barrier between us putting it out there.We
don’t have our own member portals, we don’t have our own claims
systems, and we don’t have lots of sources of data. What we have is
great workflow applications and clinical value that we can add to the
data that we can go and collect. Because of that, for instance, as an
example of what the Interoperability Competency Center
has been able to do, in the past three weeks we’ve been able to
integrate our applications to Medem, a provider and patient portal out
in the marketplace that we think is a great value to getting this
adoption level up.One of the barriers to entry might be that
people are suspicious of the data that’s coming and where it might be
going. So being able to take that data and pass it through the
physician to the patient might increase the value of the
patient‑provider relationship, the physician‑patient relationship and
therefore show the value of the data that’s currently available.

Matthew:
Let me ask you a bit about that. One of my earlier broadcasts today
was quite an argument, it possibly wasn’t as much of an argument as it
could have been, but there’s this huge issue. It’s that you start where
the data is, because the health plans have got the data. We know that
basically all claims are electronic well by the time they get at the
end of the electronic format, whereas most other data is 80% paper or
whatever the number happens to be. So, the question is, how is that
data getting to places in useable format?You just mentioned
your venture with Medem there which is a way of pre‑populating some of
that information. I want to just touch again on the work you were doing
presenting that format with, I think it’s ChristianaCare, is that
right? Describe that a little bit as to how that actually works in a
nuts and bolts fashion, so a patient shows up in the emergency room,
what happens next?

John:
OK, typically what happens is that the administrative staff finds out
because they are looking for insurance information that this is, in the
particular case for Christiana Care that they are a Blue Cross Blue
Shield member….

Matthew:  You can use another example if you want to use one.

John:
…That one’s fine, that they belong to this particular health plan
and because of that they’re going to do an eligibility check. What
comes back to them is an indication that there is a patient clinical
summary available for that patient, in ChristianaCare’s case, and this
can happen lots of different ways, they press a particular key that
downloads a PDF of that patient clinical summary because their choice
right now is to print that set of data.Now, we supply that data
in xml format or in PDF format so it can be incorporated but one of the
things we’re trying to do is to say "use the data now", so they print
off that PDF, they attach that to the chart for that patient and then
that goes into the triage area where the patient is actually being seen
and taken care of. So they have this patient clinical summary along
with whatever other EMR data they might have because they actually have
quite a good hospital information system at Christiana Care that
incorporates all of their other system data but it doesn’t tell them
anything about what happened outside of their plan.

Matthew:
And that’s the biggest problem in health care, what else happened?
Because you think about the patient that is on about 17 different drugs
and is seeing five different specialists and, you know, who knows?

John:
But that’s the whole point of having the payer contribute the data,
they have a great fundamental application set, they have the great
fundamental set of data, they know which medications there are, they
know which medications have recently been fulfilled, they know what
conditions are present, they know when the last time someone presented
to an emergency room, they know every other doctor you saw and what
their phone numbers are, they know where every lab test, and by the way
we identify not just the lab test but who conducted the test and what
their phone number is, so if you have a question and you’re trying to
make a decision about this patient what you have is a great
longitudinal view of the patient by doing this.Now, we expect
long term that we’re going to get data back from all these places we’re
delivering data, we’ll get EMR data just like we’re going to get this
year the personal health record data out of HCSC’s member portal and
start incorporating more data because it’s important to know what your
lifestyle choices are, it’s important to know what homeopathic
medicines you might be taking or over the counter medications as
opposed to the ones that you were prescribed, so we need more and more
data, but the fact is that there is a great value to the data today and
the physicians at Christiana Care were very complimentary about the
data that was presented to them, and again, I know Henry loves this
line and you’ve talked to Henry our CMO before, we make the unknown
known in that situation and that’s what the emergency room physician
likes so much.

Matthew:
What do you find after you roll that out has been the most useful
data? And then we’ll talk a little bit about the economic results from
it.

John:
I think the two most useful data, the ones that everybody goes to
first are the list of other physicians and what their phone numbers
are, if I find out you have a Cardiologist and you’ve come in
unconscious with chest pain, I might think that might be important so I
might call them even if I don’t know what the results of a test are, I
might also see an EKG test there, but the other piece of information
that everybody finds most important is the list of medications and when
their last refill was, because those two things give the treating
physician the most information, most quickly, the rest on it is add‑on,
but those are the first two things they single out.

Matthew:  Are you doing this much outside emergency rooms or is that the primary place it has been used so far?

John:
I think it will wind up being everywhere, but where the greatest risk
is and where the highest cost is, is in the emergency room so it makes
sense to make this information first there, because you have the least
amount of data, you have the highest amount of risk and you have the
highest amount of cost, so it makes sense to deliver the information
first to emergency rooms.We expect that we will deliver this to
emergency rooms and hospitals and other large practice groups, because
the larger the group the easier it’s going to be to deliver the data to
them and we get buy‑in and adoption from them.

Matthew:  Well let’s talk a little bit about what happened at Christiana Care with the economics of this.Tracey:   HCSC is rolling it out to all of their physicians.

Matthew:  Great

John:
HCSC is actually taking an interesting approach to this, HCSC is, as
you know, the fourth largest insurer in the market place, and the
largest of the non-investor owned companies, that’s of great value to
them because one of things they get an opportunity to do is, regardless
of anything else, they get a chance to go and say "we’re going to go do
this because it’s the right thing to do" and their approach has not
been “lets just roll it out in hospitals and emergency rooms,” although
I still believe that’s what going to happen because that’s where your
concentration points are, but their intent is to roll it out to every
physician that treats a member. Because what they want is a better
outcome and what they know they’ll get is a better outcome and a better
cost using the patient clinical summary and delivering it to every
physician in the network.

Matthew:
Now let’s talk a bit about what happened at Christiana Care on the
cost side and the utilization, so you roll this out and Henry had some
numbers last year and you’ve probably got some more detailed numbers, I
think I mentioned in the blog last year, but my recollection was that
you saw the physician charges went up but the hospital charges went
down, so essentially is that roughly right?

John:
That’s correct, actually what happened is, we saw if you looked at all
the patients we had 900 in change patients and a control group of 3600
and in that group of patients that received patient clinical summaries
we saw an average reduction of the ED visit plus the first day of stay
for those that got admitted, it was about 18% if I remember correctly,
and that reduction was $545 per ED visit in reduction. The interesting
part of that is that was a net number and it included a $34 increase to
the treating physician and also, not part of that study, but we have a
webinar we just did and we’d be happy to give you the address for that.In
speaking about that at Christiana Care they also saw higher throughput
of patients, which you would expect, it’s intuitively obvious, but they
saw higher throughput that’s going to allow them to see thousands of
more patients at Christiana Care every year just because they have a
patient clinical summary with the ones that are coming in without
having to increase their overhead, their expense, their capital
structure at all.

Matthew:
So they’re going to make up on the swings what they lose on the
roundabouts, so you’re not going to be thrown out immediately by the
hospital CFO when he sees that reduction in $500 in overall use?

John:
Well yeah, you’ve got to remember that reduction of $500 is not just,
you know, there’s a cost to them associated with that too, so they
don’t get to do cardiac casts for free even though, yes they charge a
lot of money for them, and all those hospital supplies they didn’t use
weren’t free to them either, so yes there’s money that wasn’t made
there but there is actually benefit to the facility, there’s benefit to
the physician, there’s benefit to the patient and the care because $545
came out of the system, some of that accrues in a lot of different
areas.One of the things that HCSC, is talking about doing is
providing incentives for people to go and use these records it’s
beneficial to everybody and, quite frankly, there is a value to it, to
them, that makes sense for them to go out and set up programs so that
the physicians have better data about their members. [creaking/crashing
sounds]

Matthew:  We’re getting some good sound effects from next door as they break apart the building or something.

John:  They do this on Halloween. [laughter]

Matthew:
Great, so, obviously the other big change that’s gone on with
MEDecision since we last spoke was that you guys are public now, so
tell me a bit about how it’s going and what’s different.

John:
Probably the different part that’s most obvious is what we’re allowed
to say and not allowed to say. Things have been going very well, we’re
very pleased, it gave us a visibility to the company that I think is
important for our clients, it gives us some transparency that everybody
wanted, it allows us as we become more and more the trusted third party
between patients and providers the ability for them to trust in our
future and not put too much faith in somebody that might wind up being
bought someplace else, so I think it helps us a great deal to be in the
public markets aside from the fact that it gives us a currency to chase
some of our dreams.

Matthew:  And personally how has it been different being president of a public company as apposed to being a private company?

John:
Actually, to tell you the truth, it really doesn’t change very much,
we have the same ambitions, the same goals, the same ability to go out
after them, we have to be a little bit more cautious about our quarter
to quarter performance and those are always of concern, but the fact is
I don’t watch the stock price every day, what I do is I make sure that
MEDecision is on the right path for the future and we go get the things
done we have to get done so the people are engaged, we’re engaged, it
really doesn’t change it as much as you might suspect.

Matthew:
Interesting. Let’s talk a little about other companies in the space
and your competition, I mentioned that I talked to the folks at active
health management and Click4Care and, to the uninitiated in this area,
I mean although I’m sure you see a big difference between those kinds
of companies and Trizetto when you’re talking about providing software
that takes in data and does stuff to it within a health plan and spits
back out either information or the next steps for you or nurses or
whoever, obviously you’re all kind of in that space, who do you think
you can better this, and how do you differentiate yourself from them?

John:
Truthfully, the competitors that have been around for a long time are
McKesson and more recently Trizetto as they contemplate building care
management systems, McKesson has been around a long time doing exactly
those same things, we think we have certain advantages, each one of us
does good things, all the systems I think are, quite frankly, pretty
good.We feel like we have a much broader array of applications
between our analytics and data gathering, our workflow applications for
advanced medical management, our clinical overlays for not just
utilization management but also for case and disease management and
best processes and procedures. We have, I believe, an advantage in our
communication vehicles because we have multi‑payer communication
vehicles, so that when one physician comes in and they log into the
application they can make an authorization request to Blue Cross Blue
Shield of Illinois or to Blue Cross Blue Shield of Maryland Carefirst
or to one of our other customers out there in the market place without
having to log on and log off, we think that’s a huge advantage.Also,
very, very important when you talk about being the trusted third party
of delivery of patient critical summaries out to the physician
communities, we have the opportunity to take a whole array of data from
a lot of different payers and make it look somewhat standardized and
deliverable through a single portal.Those are the kinds of
advantages we think we have, but we have great competitors in the
marketplace, there are, again, it’s primarily McKesson and Trizetto I
know you mentioned others but quite frankly we don’t see them all that
often they haven’t been all that successful in the market.

Matthew:
Well, Yeah, They’d argue differently of course! I think it’s an
interesting differentiation between the different ways of doing things,
so we talked a lot about the new different things you’re doing, we
talked about interoperability and the payer based health record but
presumably the core of the business is still utilization and management
analysis piece?

John:
Well that’s true except that’s not the big time benefit that our
customers are going to get from us, while the core applications I think
will always have viability and always cause us to have a nice lock‑in
with all the clients that we have, and they do, the fact is that it’s
the innovation pieces that are really benefiting our clients the most,
it’s the patient clinical summary, it’s those transaction sets that,
you think about auths, referrals and extensions and pieces like that,
those transactions, because we can bring them in through an online
terminal through the web, for instance, or over IVR, and we can do
automatic authorizations for those, up to about 85% of the time we can
dramatically drive out administrative cost for our payers. And for the
providers–remember they’re on the other end of the phone trying to get
an authorization done, so when they can just do a submission over the
web and get that part done, that’s of great benefit to the healthcare
system.But even more important are things like the patient
clinical summary, the new electronic health records and that delivery
out into that marketplace, the ability to cause the collaboration
between the payer, the care manager, the physician and the patient all
around a central point, everybody looking at the same set of data has
really much greater value to our clients than the tradition of the core
applications, they’re always going to be important because they feed a
lot of the data that gets delivered, the treatment opportunities for
the diabetic who hasn’t been to an Ophthalmologist in over a year
showing up in the patient clinical summary has to do with the care
management process so we think about collaborative care management as a
much larger facility than just what our core applications have been of
CMDM, those are always going to be important, but the key issues are
how do you communicate effectively with a common patient view and
deliver that out to the point of care, that’s really going to be the
key to the future of all of the companies.

Matthew:
I think that sounds exactly right, it seems to me, if you develop the
information extraction some of it’s for the patient view, for their own
use and you’re seeing that now, obviously WellPoint has a big push on
to do that currently, and you mentioned HCSC (Health Care Service Corp)
and others who are working with you to do that.And then on the
other hand, there’s a lot of information around, and we’ve got to
figure out how to share it rationally, because, as you said, the key
problem is, and it may or may not be in people’s economic interest to
do this and so on the provider side, but the key problem is that we do
a lot of stuff that we shouldn’t do, probably; or providers are doing
all the stuff that in hindsight shouldn’t be done, but probably at the
time of care they just didn’t know.

John:
That’s really the main problem. While everybody quotes the, you know,
there’s all these errors and huge cost of waste and all that stuff,
that’s not because the physicians don’t want to do the right thing,
it’s because they don’t know! This whole process of making this
electronic record available about the conditions that this patient has,
who his doctors are, what the medications are, allow the physician at
the Point of Care, allow that decision process to be made with data
rather than just with what you could figure out while you were looking
the patient in the eye.The fact is that the physicians, and
what has been so interesting to me as I’ve entered this industry only
four years ago, is that the physicians, whether the physician works for
the payer, the physician works for a hospital, or the individual
physician that’s working with that patient, all have the same goal:
they want a better outcome, they want it to be at a more affordable
cost so that they can provide better outcomes for more people.They
actually have a value there to themselves and their own morals that
say, they want to go and get this done. And I get exactly the same
response to my personal physician as I do when I talk to the Chief
Medical Officer of HCSC, who says: "I want a better outcome for that
patient." I get exactly the same response from their CEO; I get exactly
the same response from them all. And there’s a value that gets brought
there that I think we should not ignore.By providing the
information, by making (as they said to us) the unknown known, we
actually allow them to make a better decision, and that will drive
better outcomes, and that will drive more affordable care, and that
will make it more available for us all.

Matthew:
So, on one piece which I just want to touch on before we go, because
you obviously are going to be getting involved in this if it hasn’t
started already, is the issue of people moving between health plans,
and taking their data with them. I’ve been kind of joking around about
that issue, whether you can do it. I actually had a conversation with
some folks at Kaiser Permanente ‑ well, I say conversation, I was
presenting and then they were ‑ and I asked them the rude question
which was, (I think it was Kate Christensen from HealthConnect,) I said
to them: "Well OK, if I’m a Kaiser patient in Northern California and I
decide that I want to move from my Kaiser facility and want to change
health plans, and get up to Palo Alto Medical Clinic, you guys both
have Epic PHRs (Personal Health Record), you know, can’t I just take my
data with me?" And there was sort of coughing, and shuffling their
feet, and discussions of difference of database, and the committee are
looking into it, and the rest of it!Meanwhile we’ve seen AHIP
(America’s Health Insurance Plans) and the Blues (Blue Cross Blue
Shield) come out with this plan to make interoperable data amongst
their Personal Health Records ‑ no one’s using personal health records
much yet, but they’re growing of course, in our estimate.But
the nitty‑gritty, it sounds like people like you are going to have to
be doing the work of actually moving this data between plans. Do you
have any customers now who are either starting to allow your data to be
moved around, so that if I go from HCSC and I join the United plan or
whatever, I can take my data with me? Where are you in that process?

John:
Well, there are some interesting twists and turns in what you just
said. One of the issues is, that it’s clear, within HIPAA that we can
provide information from someone who has a current contract with a
Payer, and for their benefit, I can deliver that data to a Point of
Care, or I can use it for medical operations. So we can use it in the
Payer, and I can deliver it to the patient, and I can deliver it to the
physician. If they no longer have a contract with that company, it’s
not clear that I can actually still deliver the data, even if it lives
there, to any place, because there’s no current contract, they’re no
longer a member, and there is no implied consent for them to move the
data.

Matthew:
Even if it’s their data? So I’m a member of Blue Cross of Illinois or
whatever, and I want to go and my company switches me over to United,
you’re telling me that I can’t… I understand practically there may be
difficulty getting it, but let us assume that I have ten years of
claims state and I wanted to move that over, you’re telling me that
because I’m no longer a Blue Cross of Illinois member, I can’t move it?

John:  No, I didn’t say you
couldn’t move it, I said they can’t. It’s not clear based upon the law
that they can still send it. OK? As long as you still have a contract
from them and you want to download that into your Personal Health
Record and you want to take it anywhere you want, nobody sees any
problem with that. The concern is, and it’s really one of legislation
that we have to get taken care of, is that once you’re no longer a
member there, it’s not clear that they can any longer supply the data.So
as long as you take it before you’re no longer a member, I don’t think
there’s any problem with that. What’s unclear in HIPAA is that once
you’re no longer a member, I’m not sure that they can send it anymore,
even if they still have it. So it’s really not an issue of what can YOU
do, it’s a question of, if you have no longer given them implied
consent by being a member, can they still supply your data? It’s a big
question that has to be answered in the legislature. It really doesn’t
have anything to do with United, Blue this or anybody else. It has to
do with a legislative issue that’s there.

Matthew:
Well, that’s interesting. Let’s assume that that gets taken care of,
in terms of practically doing it, are any of your customers discussing
this yet or have they started doing it, or are you at early stages?

John:
They really haven’t. This is all so new that I don’t think that
they’ve addressed that issue. It appears though that maybe the best way
is that the person takes care of their own record and transports it
with them where they might want to go next. Now, because there are all
kinds of other issues that have to do with the data once you’re no
longer a member, what’s the liability for the data?It’s
interesting, it’s quite boggling. And I think that this is all so new,
the fact is that we have good quality data that can be provided from
your current Payer today that can go to your provider that can help you
through the course of your life. I think we ought to take advantage of
that.There are lots of questions yet to be answered when we
think about the next generation of Electronic Health Records.
Electronic Health Records are going to be made up of Personal Health
Records, EMRs (Electronic Medical Record), and what we call the PBHRs
(the Payer‑Based Health Record information). Those three sources are
going to be data, and remember, there’s going to be lots of EMRs and
potentially several PHRs, OK, and one to many Payers. There could very
well be.We’ve got a lot of questions we’re going to have to
answer over the next 10 or 15 years, as we wade through that. The fact
is, we don’t have to wait for those to be answered to get value out of
the data that’s available today.

Matthew:
Fair enough, I’ll let you off with that, [laughs] at the end there!
OK, great. So I’ve been talking with John Capobianco, who’s the
President of MEDecision, and also with Tracey Costello, VP Marketing;
and thank you guys both very much for your time.

Tracey:  Thank you.

John:  Thank you. Thanks for the interview.