Health Business Blog

This is the transcript of part 1 of my podcast interview with Christus Health SVP/CIO George Conklin.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with George Conklin.  He is Senior Vice President and Chief Information Officer of Christus Health.  George, thanks for you time today.

George Conklin: You’re very welcome David.

Williams: What is the size and scope of Christus Health?

Conklin: Christus Health is a 44-hospital Catholic health care system based in Dallas, Texas.  We have hospitals in Texas, Louisiana, Arkansas, Oklahoma and New Mexico and seven facilities in northern Mexico.

Williams: What are your information technology capabilities?

Conklin: We have a large data center that we opened in November of 2008 in San Antonio, Texas and a backup for disaster recovery about 25 miles away.  We operate our main and mission critical systems out of that data center, but have a growing number of applications that we operate in the cloud, Humedica being one of those.  We have a smaller but growing data center in Monterey, Mexico for operation of our Mexican hospitals and as we extend further into Central and South America for those organizations as well.

Taking it up a layer, we connect over 380 different locations where Christus does business. They run the gamut from our 44 hospitals to doctors offices, clinics, home care agencies and a wide variety of other kinds of health care services that we operate.  Also –as a reflection of our three-part business strategy—we operate a large array of non-acute services and retail services.  These retail services are found in our hospitals right now but are beginning to move into shopping malls and other locations. We now also have a web presence; you can go to www.christushealth.org and branch off to commercial products that you could buy.  You could buy vitamins and lotions and things like that on our website as well.

The three-part strategy includes:  (1) drastically revamped acute care through a network of hospitals focused on delivering low cost high quality service, (2)  non acute and retail and (3) international.

Our IT strategy is to aggregate information across all of those different entities. We want to be able to bring just the right information back to the point of need.  So a physician treating you would be able to get just the right information to help me in my treatment of you.  If I were an administrator looking at the class of all the David Williams’ or class of all people with congestive heart failure, I would be able to look at the best ways of treating people. The objective is to move us toward our goal of being a low cost, high quality provider.

Williams: That sounds like a very well thought out strategy.  How close is it to being realized?  Is it in place today or is that more of a long term strategic vision?

Conklin: That’s a longer-term strategic vision.  Today, through our portals, a clinician could gain  access to George Conklin’s information from anywhere, but would have multiple log in’s and multiple systems to look at.  We are actively seeking a health information exchange engine to sit on top of all our systems.

We want it to do three things for us.

One is to present the information in a uniform fashion so you won’t have a Meditech system in one location that you’d have to learn how to deal with and a server system in another location that you’d have to deal with.  Instead, you would just have one way that you interact with the systems. So the first thing would be the presentation piece.

The second piece is the decision support piece. There really are no HIE products today that provide that decision support component. We’re working with vendors now to glean just the right information for the episode.  If you think about it, as health information exchanges begin to grow around the country, one of the big concerns among clinicians is being buried in information about David Williams and having to paw their way through all this extraneous information. They need to get to specific pieces of information. It’s important to have all that other information available, but there is also an awful lot of it that’s not going to be relevant to a particular care event that somehow or another we need to figure out how to pull apart.  So decision support in part would help to parse the information so just the right information is being brought to the clinical event.  But the second part of it is to really help a clinician make better clinical decisions based upon science, based upon the costs of different kinds of treatment, based upon the organizational protocols that have been set up for particular organizations like Christus Health.  So that’s the second component of that HIE architecture.

The third component of it is data aggregation for large analytical studies that let you determine the best ways of treating people with diabetes, COPD and so forth.  As a former clinician and psychologist myself, when I used to see patients in the emergency rooms, one of the questions I would ask is, “David, why are we here today versus yesterday?” One of the things that was driven home to me very early on in working in the community mental health movement is that there is a difference –and it’s not always obvious– between people who are sick and people who are ill.  Most of our treatment decisions are based upon bodies of data aggregated in hospitals. This is not necessarily the best body of data for me to keep you well in the community.  So part of our plan is to be able to integrate data across a very large delivery spectrum to be able to look at how we keep diabetics productive and happy in the community longer, not base our treatment protocols on patients who are in our hospitals.

Williams: Speaking of analytics, let’s discuss your work with Humedica. I’ve interviewed the CEO and some of the top staff there and they cite you as a key partner in the development and launch of what they’re doing.  Can you tell me a little bit about you work with Humedica?  What are the objectives? What benefits are you seeing?

Conklin: One of the principals in Humedica is a woman named A.G. Breitenstein. We have worked with A.G. in a number of different positions that she’s held over the years, every one of them having to do with managing large sets of information and deriving usable and actionable clinical or operational information from them. So when A.G. moved to Health Insight, the predecessor of Humedica, we worked with her on new products in development. We have been working with them over the last couple of years on the creation of the database and the analytical framework.

One of the reasons they wanted to work with us is that we did something back in the 2004 to 2006 time frame that many organizations probably wished they had done and are now going to have to move towards themselves. We undertook a massive information and clinical protocol standardization effort across Christus.  We had remarkable acceptance from management, clinical leadership and clinicians across the organization around the concept of moving toward significant standardization.  We undertook standardization of lots of clinical and business processes, ending up with literally tens of thousands of items of both clinical and operational information standardized across the organization.  When we came to Humedica our ability to be able to pull essentially normalized data out of our systems and provide it to them so that we could create very large data bases gave them an awful lot of information that they could very easily work with as they were developing and testing their methodologies.  We were peculiarly positioned because of those decisions that we made back in 2004 to 2006 and we continue to move forward with that model today.

We were able to establish a very rich clinical and operational database that let us easily marry a lot of information about patients with cardiovascular disease or diabetes, etc. across the millions of visits and hospitalizations that we see on an annual basis.  That gave Humedica a very large database to work with without having to go through a lot of normalization effort on the front end. It allowed them then to focus on producing analytics that were very useful to us.

As you are aware from your prior discussions with Humedica, there are effectively two products that they’ve got.  One of those is for retrospective analysis of information and the other is for near real-time or prospective analysis.  The retrospective analysis has been utilized by us over the last several months in pilots to provide clinical leadership with detailed information on an aggregate basis as well as at a physician level about the performance of physicians in different clinical areas. It allows us to go back in those regions where the system is being piloted to look at the low cost, high quality providers, learn what those providers are doing and then talk to the other providers in that area about what we’re seeing from those other low cost, high quality providers.

That is beginning to slowly move performance from timeworn ways that people have been doing things toward newer, better practices. It confirms what we’ve believed for a long time, which is that if we provide physicians with data about how they’re performing then their behavior will change in positive directions.

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Remember the 1980s and early 90s? That’s when HMOs successfully slowed or even reversed health care spending increases with tools such as prior authorization, gatekeepers, restrictive drug formularies, narrow networks and capitation. Employers were happy to save money and also didn’t mind that the HMOs took the blame when patients were unhappy. Then in the mid-90s a backlash against managed care began, leading to the dumbing down of managed care’s cost saving practices and the re-emergence of indemnity insurance by other names (e.g., POS plans). Not surprisingly, costs started rising fast again, a trend that has continued to the present day.

And yet the backlash against managed care continues. Health insurers are being beaten over the head by politicians and others. No doubt some of the criticism is justified, because there are plenty of abuses to be found. But the popular view that cracking down on insurers is going to solve the health care cost crisis is dangerously misguided. Bashing health plans gives others –especially hospitals, clinics, doctors, patients, employers, politicians and regulators– a free pass. The big drivers of health care premiums are volume of health care consumed and rising prices, which are not caused by health plans.

Even the debate about pre-existing conditions is not so straightforward. It’s considered a given at this point that health plans shouldn’t discriminate against people with pre-existing conditions. Yet the fact remains that pre-existing conditions drive up the cost of insuring an individual.

Contrast this situation with other areas of insurance. I am in the process of upgrading my disability insurance, and you can be certain the insurance company is taking steps to make sure I’m a good risk. That means asking medical and lifestyle questions and subjecting me to a physical examination that includes blood and urine tests. It’s the same thing with life insurance. Although it’s unfortunate for people in poor health, this system at least keeps premiums affordable for those at low risk.

Don’t get me wrong. I’d also like to see a ban on discrimination based on pre-existing conditions. But this does have to be coupled with mandated coverage in order to bring the whole population into the risk pool.

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Chatswood Consulting hosts the 100th edition of the Cavalcade of Risk blog carnival. Enjoy!

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In part 1 of our podcast interview, Christus Health SVP/CIO George Conklin described describes how his 44-hospital system leverages IT to support its business. In part 2, he explains how organizational culture, psychology, technology and leadership interacted to enable the organization to achieve massive standardization of data and protocols.  That effort has allowed Christus to generate value from the scale of its information resources, for example through its partnership with Humedica.

When Christus Health came together several years ago, Conklin and his colleagues realized the time was not ripe for standardization. Regional leadership was protective of their individual approaches, and senior management chose not to resist. Instead, Christus initiated its 4 Directions to Excellence program emphasizing:

1. Clinical quality
2. Service quality (with measures of patient, physician, and employee satisfaction)
3. Business literacy
4. Community value

These four elements were tracked in a balanced scorecard, which led to subtle competition among the different parts of Christus and adoption of best practices, setting the ground work for standardization.

By the time the regional CEOs approached senior leadership with the request for a single IT system in 2004, they were ready to accept the idea of large-scale standardization, rather than being so protective of local autonomy.

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 David Williams interviews George Conklin: Play Now | Play in Popup | Download

Welcome to Grand Rounds 6:24. Regular readers know I provide a mix of health care wonkery, cheerleading of entrepreneurs, and light-hearted, humorous Grand Rounds. But this week’s batch of submissions is mostly in the pain and suffering category.

If you think I’m joking, read on.

Pain and suffering

Other Things Amanzi is profoundly affected by the death of a kidney transplant patient. The fellow walked into the hospital with the realistic hope of life without dialysis and departed on a cold morgue slate. Can’t win ‘em all, but that’s not much comfort in this case.

Dr. J’s HouseCalls was tempted to “employ extreme physical violence” when a minister said at a memorial service that her cousin was going to hell after his suicide. Twenty years later she’s not completely over it.

We don’t really know why the SeaWorld whale killed its dedicated trainer last month or why it wasn’t euthanized after that. ICSI Health Care Blog ties that observation to the public’s feelings about health reform.

Infertility is tragic. Using a branding iron to imprint pictures of sperm on someone’s skin don’t generally make things better, reports Dr. J’s Surgical Adventures.

If serious illness weren’t trouble enough, how about the guilt it brings to a marriage? The sick spouse feels guilty for ruining things by being sick while the healthy person feels guilty for being healthy and able to live a normal life. In Sickness and In Health explains.

Pain and its (possible) relief

The Game of Life (especially the Rite Aid version) is tedious. After collecting lots of tiny tokens, somehow there’s always just one missing for a fabulous prize. At least for Fibro World, that’s what fibromyalgia is like. Yet hope remains.

College rejection letters are coming, and Teen Health 411 has suggestions for coping. Hint: the magic word is empathy.

Got back pain? Exercise is the only thing that seems to work. From the Fitness Fixer.

How to Cope with Pain has a basic relaxation exercise for you.

Is that just a twisted ankle or does your kid need a trip to the ER for an x-ray? Ottawa Ankle rules were the most sensitive test in a recent study, according to Ankle Rules for Children.

Psychiatric problems

Psychiatry is floundering, reports the Cockroach Catcher. Diagnoses are becoming foggier, drugs less effective.

Perhaps one of these pills or pecans from the Examining Room of Dr. Charles will do the job.

Lockup Doc discusses the conditions under which a psychiatrist might discuss his private life. Example fitting our theme: when a psychiatrist and patient are both mourning the loss of a child.

Ready for the Freeze Phase change model? If so, Will Meek PhD is your man.

Is lack of time really the problem in doctor/patient communications? Mind The Gap has an opinion on that one.

Happy 5th birthday

It’s not all doom and gloom, folks.

Diabetes Mine reminisces about a Dr. Seuss “Fun With Diabetes” book she wrote back in March 2005.

That also happens to be when I launched the Health Business Blog, which I celebrated with a 5th anniversary edition last week.

This that and the other

A word of advice: don’t mess with EMS success. From Everyday EMS Tips.

InsureBlog pokes fun at a New York Times article that claims 22,000 people died in 2006 due to lack of health insurance. Clever satire –but honestly I would have preferred a critique of the IOM, Urban Institute and Families USA research the Times cited.

ACP Internist advises that the quality chasm is being crossed -albeit slowly.

Sniff test: device sniffs employees’ hands for soap residue to make sure they’re washing up in the hospital. Bedside monitor will light up if employee is good to go. From ACP Hospitalist.

The Office of Disease Prevention and Health Promotion (part of HHS) has launched the National Health Observances Toolkit, to be used to help engage the public in health promotion activities. Learn more at Highlight Health.

And now for something somewhat different

Hospitals and doctors are using social media such as Facebook and Twitter. Medicine and Technology reports on the topic from HIMSS. He’s hosting next week, so do him a favor and send submissions that are a little more chipper!

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In this podcast interview, Christus Health’s SVP/CIO George Conklin describes how his 44-hospital system leverages IT to support its business. The overall organization has a three-part strategy:

1. Revamp acute care to lower costs and boost quality
2. Shift toward non-acute settings including mall-based retail clinics
3. Expand internationally, starting with Northern Mexico

The IT group seeks to provide just the right information at the time and place it’s needed, across the continuum of care. A health information exchange (HIE) architecture is rolling out, and will include  clinical decision support and data aggregation capabilities along with the ability to present information.

Christus has a head start in generating useful information from large data sets, thanks to a “massive” data and protocol standardization effort it undertook about five years ago. As a result of the effort, the organization can extract normalized data from its systems relatively painlessly. This capability has made Christus an attractive development partner for Humedica, a clinical informatics company I profiled late last year.

Christus has worked with Humedica on the development of large-scale databases and analytical frameworks that enable Christus to make better clinical decisions.

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 David Williams interviews George Conklin: Play Now | Play in Popup | Download

Princeton economist Uwe Reinhardt has a thought-provoking piece in the New York Times (How Much Fraud and Abuse Is There in U.S. Health Care?) in which he argues that there is inordinate attention paid to ferreting out fraud and abuse in US hospitals. The column is a response to one of the ideas Republicans raised at last week’s health care summit: the use of undercover agents posing as patients to find fraud and abuse.

Reinhardt makes a few interesting observations:

• Hospital try extremely hard to avoid defrauding the US government. The penalties are just too great
• The effort that hospitals put in is onerous and costly
• We could learn from foreign governments, who practice scrutiny by exception –only focusing on outliers rather than everyone
• Wide variations in costs and practice patterns are driven by affiliated physicians –not the hospitals’ own employees– and hospitals have little control over them
• I especially like his suggestion of evidence–based administration (EBA): “just as the use of clinical procedures should be based on solid empirical evidence that they work and are worth their cost, the ever-new administrative burdens that government imposes on health-care providers should meet the same evidence-based test.”

Maybe because it’s the Times, the reader comments are pretty good, and they add some important dimensions to the argument:

• Much of the fraud in health care lies outside major hospitals in small operations such as home health care and ambulatory clinics
• A lot of high spending and unneeded testing is wasteful –but isn’t fraud. The public tends to get these things confused

I’m generally with Reinhardt. There’s so much focus on compliance with billing rules –not to mention other regs like HIPAA– that costs go up and service levels fall. It really is smoother in some socialized systems, a fact it’s hard for Americans (including me) to accept.

And I really don’t like the idea of fake patients. It reminds me a bit of the health care “mystery shoppers,” which I also don’t care for. I don’t want my doctor wondering if I’m a real patient. It will introduce a whole new form of defensive medicine if it happens and may also cause physicians to  be wary of new patients in general.

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Check out the Health Wonk Review: Kabuki Theater Edition at Wright on Health.

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This is a transcript of my recent podcast interview with Steve Goelman, CEO of Unique Wellness.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speak today with Steve Goelman.  He is CEO of Unique Wellness, which makes super-absorbent adult briefs.

Steve, how widespread is the problem of urinary incontinence?

Steve Goelman: The numbers that we currently have is up to 25 million Americans experience some form of incontinence from moderate to heavy incontinence. It is a growing problem, especially as baby boomers age. Those affected range from pregnant women to war veterans to the mentally disabled.  (They’re not physically incontinent but unfortunately they’re not able to go to the bathroom properly when they need to.) You also have active people such as lawyers and doctors that have undergone some form of prostate surgery.

Williams: What sort of approaches do people use to manage incontinence?

Goelman: I’m glad you said it that way. The words “managing incontinence” is exactly what our business is about, not treating incontinence.  Obviously the first step is to try to treat incontinence. You go to your local urologist, take medications such as Flomax, try Kegel exercises, and so forth. However treatment doesn’t work for everybody and we’re left with the issue of managing incontinence.

Managing incontinence is a very difficult scenario.  We start with those that are bedridden, such as those that are in nursing homes.  They are left with bedsores and there is discomfort for both the nurses and the patients themselves who have to constantly change or get changed.  There is also a huge financial burden involved with that because in order to just achieve the level that you need in order for the patient to stay dry and not susceptible to any medicine, you would have to change an average of ten times a day.

That is the way incontinence is currently managed.  Every time you change someone you need to use latex gloves, creams, cleansing wipes and so forth.  That’s all associated with incontinence. There is also an environmental impact with all of this waste because of the way incontinence is being managed.

We came up with a new way of managing incontinence because for about 50 years, nothing has changed in the way incontinence is managed.  We said we have to come up with a gold standard to help people who suffer from incontinence. We focus on: A) cost effectiveness, B) a more humane and easier way to handle and manage incontinence, C) the environmental impact.

We emphasize the three C’s: comfort, control and the confidence.  Confidence is a very big issue, especially for those who are active.

We came up with the three-a-day way to manage incontinence. All you have to do is change them three times a day with our product.  How could we even conceive this idea?  We said to ourselves: wait a minute, we do know that NASA astronauts go up in space and they have an eight hour space walk to service the Hubble space telescope or the International Space Station. They wear these absorbent undergarments called MAG’s, maximum absorbency garments.  So we do know that they have to be wearing something to keep them dry and confident with whatever they’re working on, because if they have an issue then they can’t work properly for at least eight hours at a time.  That’s A.

B) We do know that astronauts who go up into space are susceptible to various forms of infection and NASA has to take the appropriate measures to prevent that in every possible way.  So we could apply the exact same concept to the typical person suffering from incontinence.

We created the Unique Wellness brief, which has what we call Incon tek technology.  It’s based on the same principles as the maximum absorbency garments worn by NASA. We’ve developed a system where one who wears these briefs only needs to change them three times a day on schedule.

So they know if they are going out to a movie at lets say 6:00 pm and the regular change would be at 11:00 pm at night, 7:00 am in the morning and then again at noon time.  So they know where they stand exactly.  So that’s where control, confidence and comfort come in.

Then you have the cost effectiveness issue that I mentioned earlier. Your typical Depends cost about $0.90 each.  Ours retail between $1.39 and $1.49 each. However if you do the math you realize you only need three a day of ours as opposed to nine or ten of the Depends.

It’s not just the amount.  One of ours is equivalent to nearly five of Depends.  Using the three a day of ours you’re setting a new standard; it would be like  changing someone about 15 times a day.  The way people manage incontinence today is that they wait until you run out of capacity.  By the time someone has their adult briefs changed they already have gotten wet.  They already have gotten susceptible to a form of infection.  They’ve already gotten to that point of discomfort.  That’s what even prompts people to change.

There’s no official system.  That’ why they get to that point.  Using our system and our product you never get to that point.  You never run out of capacity.  You never get to the point of discomfort of living with incontinence.  You’re never susceptible to any form of infection.  Your cost of managing incontinence is lower by about 50%.

Williams: I have a question for you about NASA.  That’s a very interesting observation that if the astronauts are able to do it, it should be able to be done here on earth.  I guess another difference is space is the issue of gravity and weightlessness. With all that absorbency, won’t the brief get too heavy on earth?

Goelman: Well actually our briefs absorb more than those that the NASA astronauts wear and we designed it for that.  We actually had a recent phone call from a urologist who basically was furious and said it’s ridiculous to have someone wear up to 87 ounces.  That means they would have to change them once every day or every two days.

We said this is a very big misconception.  We’re not trying to tell someone to wear our products until they can’t wear them anymore.  We’re trying to tell them that they are so absorbent that by the time you’re changing them it’s still as dry as when you put them on. With the average person, you’re looking at maybe 20 ounces.  So when you asked the question about gravity, you’re right.  The math is a little bit different because of gravity and we address that issue by the amount of absorbency that we could take in.  So regardless, within that scheduled changing time within those eight hours, you’re never going to have a problem with that issue.

Williams: Tell me about how these products are paid for.  Does it tend to be an out of pocket purchase or is there a reimbursement from insurance or other programs?

Goelman: Most insurance don’t cover any form of adult briefs.  Now certain States do cover adult briefs from the Medicaid program. Different Medicaid programs work differently.  Some programs give you a certain budget with which to work;  x amount of money per month to cover adult briefs.  It doesn’t matter what you buy or what kind of briefs to use.

I know for example here in New York State someone using Medicaid would have a very difficult time using our product because Medicaid pays one dollar per brief. Usually it’s supplied by a nursing agency; whether it’s Depends or something cheap out of China. They pay up to $220, which is approximately eight changes a day for a month.

However by using ours it would translate into about $90 a month times $1.39. That’s $134, which is a 40% savings for Medicaid. However this is not the way Medicaid works.  Medicaid pays per brief and not per managing incontinence.  Now for New York State this is something that wouldn’t work well because Medicaid would never pay more than $1.00 for a brief.

However I know that in States like Florida and New Jersey, their system doesn’t work on per brief, it’s per cost of managing incontinence.

Williams: What are you doing in terms of distribution?  Where are these products available or where do you hope to make them available.

Goelman: Right now they’re primarily through the Internet.  We have ourselves and other retailers that are selling them through the Internet for us, because we’ve realized that someone looking for a specialty product will find them through the Internet.  Stores such as your typical Rite Aid, CVS, unfortunately are not interested in carrying our products because it’s not as profitable for them.  They realize that they make more money selling more briefs than using our program.

We are working on a specialty medical supply stores, surgical supply stores for those who have been purchasing them through the Internet.

Williams: Do you expect that your product is going to be evolving over time or will you add other complementary products and services? Is this the product that you expect to be on the market as-is for a number of years?

Goelman: Well that’s a good question.  Actually for the last year our product has consistently been evolving, whether it’s been improving on the absorbency end, whether it’s been some issues with raw materials.  I think that we’ve been consistently improving and we are consistently committed to always making a better product.

Right now one of the things that we do have, which people appreciate, is the fact that we have different colors for different sizes, such as the medium is blue, the large is green and extra large is purple.  This helps people automatically realize which size they are holding in their hands, whether they need to change their patients or their self.  There is not confusion in that.

There is something else in the works that’s rather interesting.  We’ve realized there’s a very big stigma of incontinence, especially for active people. They feel very uncomfortable in what we call today adult briefs, but technically they’re adult diapers.  We are working on coming up with a designer series to make people feel that basically they’re not adult babies.

Williams: I’ve been speaking today with Steve Goelman, CEO of Unique Wellness.  Steve, thanks so much for your time.

Goelman: My pleasure.

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About 25 million adults in the US suffer from urinary incontinence. The standard management technique –wearing adult diapers– isn’t great, as the diapers need to be changed often and can become smelly and uncomfortable. Unique Wellness offers a more absorbent product that only requires three changes per day. The company touts the control, confidence and comfort that can be achieved with its product, which is based on technology used by astronauts during their lengthy space walks.

In this podcast interview, Unique Wellness CEO Steve Goelman describes the concept for his company’s product, and touches on the functional, economic and environmental benefits.

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 David Williams interviews Unique Wellness CEO Steve Goelman: Play Now | Play in Popup | Download