THCB

Categories

Tag: Epic

How to Buy and Sell AI in health care? Not Easy.

By MATTHEW HOLT

It was not so  long ago that you could create one of those maps of health care IT or digital health and be roughly right. I did it myself back in the Health 2.0 days, including the old sub categories of the “Rebel Alliance of New Provider Technologies” and the “Frontier of Patient Empowerment Technologies”

But those easy days of matching a SaaS product to the intended user, and differentiating it from others are gone. The map has been upended by the hurricane that is generative AI, and it has thrown the industry into a state of confusion.

For the past several months I have been trying to figure out who is going to do what in AI health tech. I’ve had lots of formal and informal conversations, read a ton and been to three conferences in the past few months all focused dead on this topic. And it’s clear no one has a good answer.

Of course this hasn’t stopped people trying to draw maps like this one from Protege. As you can tell there are hundreds of companies building AI first products for every aspect of the health care value (or lack of it!) chain.

But this time it’s different. It’s not at all clear that AI will stop at the border of a user or even have a clearly defined function. It’s not even clear that there will be an “AI for Health Tech” sector.

This is a multi-dimensional issue.

The main AI LLMs–ChatGPT (OpenAI/Microsoft), Gemini (Google/Alphabet) Claude (Anthropic/Amazon), Grok (X/Twitter), Lama (Meta/Facebook)–are all capable of incredible work inside of health care and of course outside it. They can now write in any language you like, code, create movies, music, images and are all getting better and better. 

And they are fantastic at interpretation and summarization. I literally dumped a pretty incomprehensible 26 page dense CMS RFI document into ChatGPT the other day and in a few seconds it told me what they asked for and what they were actually looking for (that unwritten subtext). The CMS official who authored it was very impressed and was a little upset they weren’t allowed to use it. If I had wanted to help CMS, it would have written the response for me too.

The big LLMs are also developing “agentic” capabilities. In other words, they are able to conduct multistep business and human processes.

Right now they are being used directly by health care professionals and patients for both summaries, communication and companionship. Increasingly they are being used for diagnostics, coaching and therapy. And of course many health care organizations are using them directly for process redesign.

Meanwhile, the core workhorses of health care are the EMRs used by providers, and the biggest kahuna of them all is Epic. Epic has a relationship with Microsoft which has its own AI play and also has its own strong relationship with OpenAI – or at least as strong as investing $13bn in a non-profit will make your relationship. Epic is now using Microsoft’s AI both in note summaries, patient communications et al, and also using DAX, the ambient AI scribe from Microsoft’s subsidiary Nuance. Epic also has a relationship with DAX rival Abridge

But that’s not necessarily enough and Epic is clearly building its own AI capabilities. In an excellent review over at Health IT Today John Lee breaks down Epic’s non-trivial use of Ai in its clincal workflow:

  • The platform now offers tools to reorganize text for readability, generate succinct, patient-friendly summaries, hospital course summaries, discharge instructions, and even translating discrete clinical data into narrative instructions.
  • We will be able to automatically destigmatize language in notes (e.g., changing “narcotic abuser” to “patient has opiate use disorder”),
  • Even as a physician, I sometimes have a hard time deciphering the shorthand that my colleagues so frequently use. Epic showed how AI can translate obtuse medical shorthand-like “POD 1 sp CABG. HD stable. Amb w asst.”-into plain language: “Post op day 1 status post coronary bypass graft surgery. Hemodynamically stable. Patient is able to ambulate with assist.”
  • For nurses, ambient documentation and AI-generated shift notes will be available, reducing manual entry and freeing up time for patient care.

And of course Epic isn’t the only EHR (honestly!). Its competitors aren’t standing still. Meditech’s COO Helen Waters gave a wide-ranging interview to HISTalk. I paid particular attention to her discussion of their work with Google in AI and I am quoting almost all of it:

This initial product was built off of the BERT language model. It wasn’t necessarily generative AI, but it was one of their first large language models. The feature in that was called Conditions Explorer, and that functionality was really a leap forward. It was intelligently organizing the patient information directly from within the chart, and as the physician was working in the chart workflow, offering both a longitudinal view of the patient’s health by specific conditions and categorizing that information in a manner that clinicians could quickly access relevant information to particular health issues, correlated information, making it more efficient in informed decision making.  <snip>

Beyond that, with the Vertex AI platform and certainly multiple iterations of Gemini, we’ve walked forward to offer additional AI offerings in the category of gen AI, and that includes both a physician hospital course-of-stay narrative at the end of a patient’s time in the hospital to be discharged. We actually generate the course-of-stay, which has been usually beneficial for docs to not have to start to build that on their own.

We also do the same for nurses as they switch shifts. We give a nurse shift summary, which basically categorizes the relevant information from the previous shift and saves them quite a bit of time. We are using the Vertex AI platform to do that. And in addition to everyone else under the sun, we have obviously delivered and brought live ambient scribe capabilities with AI platforms from a multitude of vendors, which has been successful for the company as well.

The concept of Google and the partnership remains strong. The results are clear with the vision that we had for Expanse Navigator. The progress continues around the LLMs, and what we’re seeing is great promise for the future of these technologies helping with administrative burdens and tasks, but also continued informed capacities to have clinicians feel strong and confident in the decisions they’re making. 

The voice capabilities in the concept of agentic AI will clearly go far beyond ambient scribing, which is both exciting and ironic when you think about how the industry started with a pen way back when, we took them to keyboards, and then we took them to mobile devices, where they could tap and swipe with tablets and phones. Now we’re right back to voice, which I think will be pleasing provided it works efficiently and effectively for clinicians.

So if you read–not even between the lines but just what they are saying–Epic, which dominates AMCs and big non-profit health systems, and Meditech, the EMR for most big for-profit systems like HCA, are both building AI into their platforms for almost all of the workflow that most clinicians and administrators use.

I raised this issue a number of different ways at a meeting hosted by Commure, the General Catalyst-backed provider-focused AI company. Commure has been through a number of iterations in its 8 year life but it is now an AI platform on which it is building several products or capabilities. (For more here’s my interview with CEO Tannay Tandon). These include (so far!) administration, revenue cycle, inventory and staff tracking, ambient listening/scribing, clinical workflow, and clinical summarization. You can bet there’s more to come via development or acquisition. In addition Commure is doing this not only with the deep pocketed backing of General Catalyst but also with partial ownership from HCA–incidentally Meditech’s biggest client. That means HCA has to figure out what Commure is doing compared to Meditech.

Finally there’s also a ton of AI activity using the big LLMs internally within AMCs and in providers, plans and payers generally. Don’t forget that all these players have heavily customized many of the tools (like Epic) which external vendors have sold them. They are also making their AI vendors “forward deploy” engineers to customize their AI tools to the clients’ workflow. But they are also building stuff themselves. For instance Stanford just released a homegrown product that uses AI to communicate lab results to patients. Not bought from a vendor, but developed internally using Anthropic’s Claude LLM. There are dozens and dozens of these homegrown projects happening in every major health care enterprise. All those data scientists have to keep busy somehow!

So what does that say about the role of AI?

First it’s clear that the current platforms of record in health care–the EHRs–are viewing themselves as massive data stores and are expecting that the AI tools that they and their partners develop will take over much of the workflow currently done by their human users.

Second, the law of tech has usually been that water flows downhill. More and more companies and products end up becoming features on other products and platforms. You may recall that there used to be a separate set of software for writing (Wordperfect), presentation (Persuasion), spreadsheets (Lotus123) and now there is MS Office and Google Suite. Last month a company called Brellium raised $16m from presumably very clever VCs to summarize clinical notes and analyze them for compliance. Now watch them prove me wrong, but doesn’t it seem that everyone and their dog has already built AI to summarize and analyze clinical notes? Can’t one more analysis for compliance be added on easily? It’s a pretty good bet that this functionality will be part of some bigger product very soon.

(By the way, one area that might be distinct is voice conversation, which right now does seem to have a separate set of skills and companies working in it because interpreting human speech and conversing with humans is tricky. Of course that might be a temporary “moat” that these companies have which may end up back in the main LLM soon enough). 

Meanwhile, Vine Kuraitis, Girish Muralidharan & the late Jody Ranck just wrote a 3 part series on how the EMR is moving anyway towards becoming a bigger unified digital health platform which suggests that the clinical part of the EMR will be integrated with all the other process stuff going on in health systems. Think staffing, supplies, finance, marketing, etc. And of course there’s still the ongoing integration between EMRs and medical devices and sensors across the hospital and eventually the wider health ecosystem.

So this integration of data sets could quickly lead to an AI dominated super system in which lots of decisions are made automatically (e.g. AI tracking care protocols as Robbie Pearl suggested on THCB a while back), while some decisions are operationally made by humans (ordering labs or meds, or setting staffing schedules) and finally a few decisions are more strategic. The progress towards deep research and agentic AI being made by the big LLMs has caused many (possibly including Satya Nadella) to suggest that SaaS is dead. It’s not hard to imagine a new future where everything is scraped by the AI and agents run everything globally in a health system.

This leads to a real problem for every player in the health care ecosystem.

If you are buying an AI system, you don’t know if the application or solution you are buying is going to be cannibalized by your own EHR, or by something that is already being built inside your organization.

If you are selling an AI system, you don’t know if your product is a feature of someone else’s AI, or if the skill is in the prompts your customers want to develop rather than in your tool. And worse, there’s little penalty in your potential clients waiting to see if something better and cheaper comes along.

And this is happening in a world in which there are new and better LLM and other AI models every few months.

I think for now the issue is that, until we get a clearer understanding of how all this plays out, there will be lots of false starts, funding rounds that don’t go anywhere, and AI implementations that don’t achieve much. Reports like the one from Sofia Guerra and Steve Kraus at Bessmer may help, giving 59 “jobs to be done”. I’m just concerned that no one will be too sure what the right tool for the job is.

Of course I await my robot overlords telling me the correct answer.

Matthew Holt is the Publisher of THCB

Bevey Miner, Consensus Cloud Solutions

Consensus is taking fax data, received by rural clinics, post acute, substance abuse clinics, home health et al, and helping them put it into their systems of records–which are in general not FHIR-enabled. They allow those facilities & services to receive referrals from acute care hospitals. By 2027 many of these standards are going to need to be FHIR enabled. Bevey Miner, EVP at Consensus, is a health care veteran who is working on both a policy and technology level to improve access to care, and thinks a lot about what unstructured data means in a world where we are trying to use data for AI and more. Super interesting chat about the murky backwaters of health care data and services. As Bevey says, “Not everyone is going to be Epic to Epic to Epic”–Matthew Holt

Jonathan Bush, Zus Health

It’s always fun to chat with Jonathan Bush. You kids today may not remember that he was the first CEO to take a cloud-based (Health 2.0!) company public back in 2007! Athenahealth didn’t end up challenging Epic because a cosmically evil hedge fund took it (and him) down as it was on its way to try to do that, but Jonathan has moved on and is now building a clinical data integration company called Zus Health. We talked Zus, digital health, whether there will ever be value-based care and more. 20 mins of digital health gold right here–Matthew Holt

Aneesh Chopra talks Cancer Navigation Challenge & more

Aneesh Chopra is the former CTO of the US under Obama. He’s now head of strategy at Arcadia, but this week is one of the driving forces behind the new challenge called “Transforming Cancer Navigation with Open Data & APIs” . I caught up with Aneesh about why the need for this type of data exchange and why caner, and also more generally about interoperability, data analysis (his day job) and the impact of AI. Aneesh is an optimist but also about the most articulate person in health care explaining what is going on the ground and in policy with the regulations and actions of data exchange, and its uses. Pay attention–Matthew Holt

Lyle Berkowitz, Keycare

Lyle Berkowitz is an old friend and these days is CEO of Keycare, which provides a virtual care workforce, primarily for major health systems. It’s based on Epic taking advantage of Telehealth Everywhere, which means that patients can get to them from within their MyChart accounts and it can easily integrate its EMR data with its health system clients. It’s being used primarily for out of hours care, but increasingly primary care expansion for population health and patient outreach. I call Keycare dinosaur preservation, but Lyle tells me it’s expanding the balloon from within!–Matthew Holt

Epic’s Consumer Strategy Is Bold. Its Tactics Push The Boundaries.

By SETH JOSEPH

This is part 3 of Seth’s series about Epic that has generated much interest and a little controversy and we are happy to host it on THCB. Part 1 and Part 2 were published on Forbes earlier this year.

According to people in the room, Judy Faulkner’s vision on stage at Epic’s 2022 User Group Meeting was epic, in the grandest sense of the word. 

The company, which had grown as a unified clinical and billing EHR system, was now laying out a roadmap in which it would be the digital front door for all things consumer facing. A massive panoply of capabilities including, according to Epic’s own subsequent documentation, customer relationship management, provider finders and online scheduling, online check-in, patient financial experience, and many others. 

Core to enabling all of this was shifting how patients interact with MyChart, the patient-facing application that allows individuals to access their health records. 

Historically, each MyChart account was ‘tethered’ between an individual and a hospital system and represented a simple portal for the individual to view her records. If an individual had been seen at multiple different hospital systems, then she would have multiple separate MyChart “instances”, or entirely separate accounts and logins. 

Now, Epic would ‘stitch together’ the health records and data from different hospitals on behalf of the individual in advancing what colloquially has been called Epic’s ‘national MyChart strategy’, and enable robust new functionality, creating compelling network effects between consumers and hospitals.

There were only a few problems with Epic’s strategy: first, many customers weren’t asking Epic to develop these capabilities; second, there were startups and incumbents already providing many of these capabilities; and third, the company was in a race with a federal agency, which was pushing for open standards and access that threatened Epic’s plans. 

But for a company that had slowly and steadily become the dominant health technology player, whose staff meetings for a period ended half-jokingly on a slide with the words “World Domination” on them, these problems were all fixable. 

The Promise Of Consumer Empowerment Tools

As modern history has demonstrated time and again, the ability to own or control the consumer entry point for technology can be a strategic advantage. Apple’s sleek product designs, user experience and tight ecosystem enable it to extract 30% of app developer revenues seeking to reach Apple’s users. Google’s dominance in search has positioned it to be the entryway to the internet for billions of consumers regardless of their ultimate destination, resulting in extraordinary revenue growth and profitability. 

In healthcare, the ability to meaningfully engage consumers through technology has long held promise of solving intractable problems, while also potentially positioning the firm that figures out how to do so as a new locus of power, similarly as Apple and Google above. Triaging care options for consumers, navigating them to lower cost services, facilitating payments, and providing modern convenience options are just a few of the hundreds of use cases that consumer-facing technology holds.

Key questions facing the firms seeking to find healthcare’s holy grail are how best to do this and where to start, as consumer habits and sentiment toward healthcare has proven challenging for tech companies to figure out. 

For instance, tech giants Microsoft and Google had both placed significant bets on ushering a new era of consumer empowerment in the late-2000s, with Microsoft HealthVault and Google Health. Known as patient health records (PHR), the two companies sought to enable consumers to access, aggregate, store and potentially share their health records. 

In retrospect, Microsoft and Google’s efforts were perhaps a bit too early, as both initiatives were shut down in the early 2010s, before an ecosystem of health technology adoption, connectivity and capabilities that could have feasibly supported their vision. And before consumers had a compelling reason to change their own use of technology to engage in their healthcare.

By 2022, however, the ecosystem had arrived. After the EHR Incentive program, more than 90% of doctors and hospitals had EHRs. The Covid-19 pandemic drove rapid adoption of telehealth by both physicians and consumers. Approximately $100 billion in venture capital had flowed into health technology innovation. New price transparency policies were shedding sunlight into formerly opaque and labyrinthine contracting practices. The 21st Century Cures Act put teeth into driving interoperability, introducing information blocking as a civil penalty with million dollar fines. One industry group published a report titled “Unbundling Epic: How The EHR Market Is Being Disrupted.” This author proclaimed The EHR Is Dead.

If the EHR was dead or being disrupted, then every EHR company needed a survival plan.

Epic’s Fear And Unfair Advantage

According to one hospital executive, it was this backdrop that concerned Epic’s leadership: with a rapid influx of new players and a shifting balance of power, Epic might be relegated to “just being the pipes” while others capitalized on new opportunities. Given the company’s rigid belief – proven correct time and time again – that it alone would deliver the best results for its customers and consumers, Epic thought such an outcome would be a disaster. 

To combat this risk, Epic by mid-2022 had a new strategy with MyChart and network effects at the heart of it. 

Continue reading…

Patty Hayward, Talkdesk

Patty Hayward is GM of Healthcare and Life Sciences at Talkdesk. Talkdesk runs the technology for contact centers that helps companies across health care connect and manage their consumers. You’ve probably unknowingly used their technology when you call (or now text or email) your health plan, your provider system or call into one of those numbers on the drug adverts. Patty told me about the business of technology for contact centers, and how the transition is happening between voice to text and for that matter from on-prem to cloud. They’re also deeply integrated with Epic. Pretty interesting view into a not-often-thought-about part of the puzzle.–Matthew Holt

Can Someone Actually Be Responsible?

By MATTHEW HOLT

I was having a fight on Twitter this week and it hit me. America 2024 is Japan 1989. 

The topic of the fight was right-wing VC Peter Thiel. In 2001 he put a ton of Paypal stock allegedly worth less than $2,000 into a Roth IRA. The Roth IRA was designed so that working stiffs could put post tax cash into an IRA, grow it slowly and take out money tax-free. (For traditional IRAs you put in pre-tax money and get taxed when you take it out). You may have read the story in ProPublica. Magically Thiel earned less that year than the max allowable income limit (around $100K) to contribute to a Roth IRA, and magically that stock was within weeks worth much more and then, later, hundreds of millions more. Since then Thiel has invested those Paypal returns in Facebook, Palantir and much more, and that Roth IRA has billions of dollars in it that can never be taxed.

My twitter adversary was saying that Thiel obeyed the law. I doubt it, but that’s not really the point. When the Roth was introduced it wasn’t meant to be a loophole that Silicon Valley types could use to hide billions from tax. But neither my twitter “friend” nor Peter Thiel want to take responsibility or pay their fair share.

Japan in 1989 was wealthy and successful and heading off a speculative cliff which it’s since taken 3 decades to dig out of. There were numerous academics pointing this out, but the most interesting analysis was The Enigma of Japanese Power written by a Dutch journalist named Karel van Wolferen. Here’s a summary from wikipedia with my emphasis added

Van Wolferen creates an image of a state where a complicated political-corporate relationship retards progress, and where the citizens forgo the social rights enjoyed in other developed countries out of a collective fear of foreign domination….Japanese power is described as being held by a loose group of unaccountable elites who operate behind the scenes. Because this power is loosely held, those who wield it escape responsibility for the consequences when things go wrong as there is no one who can be held accountable.

In Thiel’s case a collective network of tax accountants, junk philosophers, and purchased politicians like JD Vance ensure that no one has to be accountable. Ultimately Thiel doesn’t feel responsible for paying what he owes. Of course the exposure of Trump’s tax cheating shows that he doesn’t either. And many people find this OK.

Meanwhile I got into it a little with Jeff Goldsmith on last week’s THCB Gang about why hospitals are still paid per transaction when it would be much better for them to be paid some kind of global budget for the services they provide and for doctors to be paid a salary to exercise their best judgment rather than be tempted into providing care just because they get paid for it. Both COVID and the recent Change Healthcare outage put health care providers in a terrible situation financially because they depend on being paid fee-for-service via claims for individual transactions. Did the leadership of America’s hospitals and doctors come out asking for a change to the system? No, they just got a government hand out and begged for a return to standard operating procedure. No one can rationally look at how we pay for health care in America and say “give us more of the same” but there’s no leadership to change it at all.

Talking about lack of leadership, Amber Thurman died in Piedmont Henry Hospital because no-one on the medical team was prepared to give her the D&C that she desperately needed. They were scared of going to jail under Georgia’s draconian anti-abortion law. There are many, many guilty parties here.

Continue reading…

If data is the new oil, there’s going to be war over it

By MATTHEW HOLT

I am dipping into two rumbling controversies that probably only data nerds and chronic care management nerds care about, but as ever they reveal quite a bit about who has power and how the truth can get obfuscated in American health care. 

This piece is about the data nerds but hopefully will help non-nerds understand why this matters. (You’ll have to wait for the one about diabetes & chronic care).

Think about data as a precious resource that drives economies, and then you’ll understand why there’s conflict.

A little history. Back in 1996 a law was passed that was supposed to make it easy to move your health insurance from employer to employer. It was called HIPAA (the first 3 letters stand for Health Insurance Portability–you didn’t know that, did you!). And no it didn’t help make insurance portable.

The “Accountability” (the 1st A, the second one stands for “Act”) part was basically a bunch of admin simplification standards for electronic forms insurers had been asking for. A bunch of privacy legislation got jammed in there too. One part of the “privacy” idea was that you, the patient, were supposed to be able to get a copy of your health data when you asked. As Regina Holliday pointed out in her art and story (73 cents), decades later you couldn’t.

Meanwhile, over the last 30 years America’s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a chart of 91 health systems with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don’t need me to remind you that many of those systems are guilty with extreme prejudice of monopolistic price gouging, screwing over their clinicians, suing poor people, managing huge hedge funds, and paying dozens of executives like they’re playing for the soon to be ex-Oakland A’s. A few got LA Dodgers’ style money. More than 15 years since Regina picked up her paintbrush to complain about her husband Fred’s treatment and the lack of access to his records, suffice it to say that many big health systems don’t engender much in the way of trust. 

Meanwhile almost all of those systems, which already get 55-65% of their revenue from the taxpayer, received additional huge public subsidies to install electronic medical records which both pissed off their physicians and made several EMR vendors rich. One vendor, Epic Systems, became so wealthy that it has an office complex modeled after a theme park, including an 11,000 seat underground theater that looks like something from a 70’s sci-fi movie. Epic has also been criticized for monopolistic practices and related behavior, in particular limiting what its ex-employees could do and what its users could publicly complain about. Fortune’s Seth Joseph has been hammering away at them, to little avail as its software now manages 45%+ of all encounters with that number still increasing. (Northwell, Intermountain & UPMC are three huge health systems that recently tossed previous vendors to get on Epic).

Meanwhile some regulations did get passed about what was required from those who got those huge public subsidies and they have actually had some effect. The money from the 2009 HITECH act was spent mostly in the 2011-14 period and by the mid teens most hospitals and doctors had EMRs. There was a lot of talk about data exchange between providers but not much action. However, there were three major national networks set up, one mostly working with Epic and its clients called Carequality. Epic meanwhile had pretty successfully set up a client to client exchange called Care Everywhere (remember that).

Then, mostly driven by Joe Biden when he was VP, in 2016 Congress passed the 21st Century Cures Act which among many other things basically said that providers had to make data available in a modern format (i.e. via API). ONC, the bit of HHS that manages this stuff, eventually came up with some regulations and by the early 2020’s data access became real across a series of national networks. However, the access was restricted to data needed for “treatment” even though the law promised several other reasons to get health data.

As you might guess, a bunch of things then happened. First a series of VC-backed tech companies got created that basically extract data from hospital APIs in part via those national networks. These are commonly called “on-ramp” companies. Second, a bunch of companies started trying to use that data for a number of purposes, most ostensibly to deliver services to patients and play with their data outside those 91 big hospital systems.

Which brings us to the last couple of weeks. It became publicly known among the health data nerd crowd that one of the onramp companies, Particle Health, had been cut off from the Carequality Network and thus couldn’t provide its clients with data.

Continue reading…

Health in 2 Point 00, Episode 107 | SoftBank Money, Judy Faulkner’s Letter, & Practice Fusion Gossip

Today on Health in 2 Point 00, we have SoftBank Money! I managed to beat Chrissy Farr to this piece of gossip by about 3 weeks, but digital pharmacy startup Alto raises $250 million from SoftBank. Medloop raises 6 million euros doing communication with patients, and mental health startup Spring Health raises $22 million as well. Turning to the EMR drama, I also give a rundown on Judy Faulkner’s letter, and explain the cautionary tale that is Practice Fusion & the Purdue opiate promotion. —Matthew Holt