HIStalk Practice Interviews Albert Santalo, CEO, CareCloud

Albert Santalo is chairman, president, and CEO of CareCloud of Miami, FL.

Give me some idea about the size of the company, number of employees, revenue, and the number of practices live.

The company is about 120 employees now. We’re managing around $700 million in accounts receivable for clients. We don’t disclose specific revenue numbers, but we’ll be in the $10 million or so range for 2012, anywhere from $8 million to $12 million.

How many practices do you have live?

The number of practices is probably 250 or so. They range in size from solo practitioner to larger, multi-specialty groups. It’s well over 1,000 providers.

Countless companies offer PM and EMR systems and several of those have cloud-based solutions. What’s your competitive differentiator and what companies do you see as your primary competition?

We see lots and lots of companies, and we group them into different categories. Almost every company that’s out there that has had any type of success has started in practice management or medical records and bought another company with the other discipline. Very, very few have built what I would call an industrial strength solution for both sides from the ground up on a common architecture.

When you think about the way a medical practice works, the clinical side is not really separate from the financial and administrative side. The whole thing starts with an appointment. At some point, there’s a handoff to a clinician who uses a medical record system. Then it goes back into the billing process to get the doctor paid for what they do. There’s too many clunky handoffs between these old, fragmented systems.

Most companies just haven’t gone to the trouble to build this all on a common architecture. I would say it’s a subtle differentiator for us because most people don’t really get it. But the reality is that when you look at our system and you see what kind of elegant, beautiful experience it is from cradle to grave, it becomes obvious that this all should be built on a common platform.

Yes, there are a few cloud-based players, but most of them built their systems in the late ‘90s or early 2000s. The Internet-based tools to build these systems have evolved two or three generations later, and that is what we’re using.

For instance, some of our competition only works on Internet Explorer on a Windows PC, while the world has changed in the last few years. A lot of physicians are using Macs — if not at work, in their personal lives. There are mobile devices, and physicians need to be able to access information anywhere. A lot of people don’t like Internet Explorer — they want to use Google Chrome or Firefox or Safari. We built this the way you would build it in the last few years, which is so that it works ubiquitously on any browser.

What companies would you say are your primary competition?

We come across all sorts of existing solutions. We compete with traditional players such as Allscripts, Greenway, NextGen, etc. But at the end of the day, the only company that we really feel sees the world the way we do and has built something like what we are hoping to achieve is athenahealth.

You allude to CareCloud’s slick user interface. Does the user interface offer a sustainable advantage given that these entrenched companies theoretically could freshen up their user interface to resemble yours?

That is an issue, but what I would ask is has anyone really been able to duplicate Apple’s user experience? It’s not like it’s not there and everyone can’t use it. Yet all of the stodgy, old companies struggle to create a user experience like what Apple has created.

One of the things you have to understand about CareCloud is that design is ingrained in our DNA. The first person that I hired when I founded the company was Mike Cuesta, who comes from a graphic design background. In other words, Employee #1 was a designer.

It’s really hard, especially when you’re a bigger company, to get design woven into your culture if it wasn’t already there. Design isn’t something that’s done by consensus. Bigger companies tend to be a little more democratic, for lack of a better word, and committees don’t design well. Design is done by really, really talented designers.

On top of that, some of the technologies that the competition uses are not easily employed in a design type of a way.For instance, if you look at somebody who’s developed in straight-up HTML, you know they have to make the leap to HTML5 to really do rich Internet applications, and the HTML5 development tool kits are not there yet. It’s easier said than done, but the reality is as people are imitating our current designs, we’re already working on the next generation of something even better.

Do you have a sales force?

We do. We’re selling the product through a combination of a traditional sales force and through online marketing. As of late, we’ve been ramping up the sales force pretty significantly. I’m amazed at the amount of people defecting from the old world to come here and deal with something new. I’ve been shocked at the talent that’s been showing up, and we’re hiring them.

We’ve got eight new sales people showing up here Monday for training. That will be the next wave, and there’s a wave after that.

Geographically, they’re located all over?

Throughout the US, everywhere from the northeast to the West Coast.

Any plans to distribute the product through resellers?

Yes. There’s a lot of traditional VARs and such that are out there, and especially with larger installs, we can use help with implementations. In fact, we’re already working with some VARs that are partnering with us to put our solution into their client base.

You recently launched CareCloud Charts. What are the advantages and disadvantages of entering the EMR market late in the game, especially late in the ARRA game?

We could have entered a lot earlier, but we’re big believers that we just have to build things correctly and not rush them too much. You have to always build on a strong foundation.

I would say that the disadvantages are that there have been a lot of people that have purchased the EMR already, but there are also a lot of people that have gotten burned in that process. They’ve been chasing the Meaningful Use dollars and they realize that they made a poor choice in what their EMRs are.

The good news is that they already have bought into the EMR as something they have to do, but a lot of them are looking to swap it out. We’re seeing a lot of that. With our type of solution, which is really pay-as-you-go, it’s a pretty easy transition from a financial perspective, because they don’t have to buy eight servers and do all sorts of creative stuff like with other solutions.

The other about coming late in the game, something that isn’t quite apparent to everybody yet, is most of the EMRs — if not all of the EMRs that have been written and developed up until now — have been developed with the idea that what we’re trying to do is capture the information as it relates to a doctor and a patient seeing each other in a brick-and-mortar type of setting.

The reality is that the world is moving towards much more of a real-time, instrument type of model. We envision that in the not too distant future, people will be wearing sensors. They’ll be stepping on their scale in their home, and that scale will be connected to the Internet, taking their blood pressure, etc.

The way we’ve designed our clinical system is such that it lends itself to this real-time world, where there’s lots and lots of data being captured in real time on specific patients. The system has to provide strong analytics and alerting to the providers so that they’re not inundated with all these data.

It’s a very, very different architecture than what’s out there, especially if you compare it to systems that are written in MUMPS, which is technology from the ‘70s. As you know, this is what you see in healthcare IT. It’s ridiculous. We wouldn’t buy any piece of technology in our personal lives that had anything in it from 1967, yet people are spending tens, hundreds of millions of dollars on systems like Epic, which is crazy.

You’ve said that CareCloud offers a social infrastructure. Explain that.

Think of the social infrastructure like this. When you really look at healthcare, it is a social business. Today, especially with the kind of the fragmented world that we live in on the provider side, a patient bounces around from practice to practice as they’re getting care. A primary care doctor may refer a patient to a cardiologist or urologist, but there isn’t any good infrastructure to push data between these providers.

People talk about HIEs and things like that, but the reality is penetration of HIEs is very low. We’ve built a secure, social framework within our system so that that data is usually pushed from person to person, business to business so that it’s not captured again. It doesn’t infringe on the patient experience, so that errors aren’t introduced. It really speeds up the delivery of care and can help eliminate some of the redundant care that exists.

We think of an HIE as, “Why can’t an HIE be a secure Facebook as opposed to this thing where I have to get my CIO to talk to your CIO?” Guess what? Most doctors don’t even have a CIO. This whole integration between practices and systems is not realistic in ambulatory healthcare. We built it as a friendly place where everyone can interact.

If I use eClinicalWorks or athenahealth, I can access the social infrastructure?

Yes. We’re not there yet in terms of those capabilities, but yes, you will be able to access that infrastructure. Absolutely. And our hope is that you’ll stop using eClinicalWorks. [laughs].

In your various company announcements, you talked a lot about investors, innovation, and awards. You don’t say a lot about customer successes. Who are your notable customers and what have they accomplished using your product?

There are many, many flavors of customers that we have. Some are larger, some are smaller. The successes mostly relate to financial successes. That’s the biggest way that we measure the success around here, that these practices are able to derive more revenue from what they do. Because, as you know, a lot of practices do a lot of work and don’t get paid properly for it.

That’s the first piece, and at the same time, they are able to save on a lot of costs because we convert what’s typically a fixed cost to a variable cost. There are so many bills and this is thrown into our offering that they just do it a lot more effectively and more cheaply.

Your EHR product has been ONC-certified, correct?

Yes.

Have any of your early users been able to attest?

They need to use it meaningfully for 90 days. We’re not there yet, but that’s coming.

As you know, there’s a lot of noise in the system around this whole thing. Although you spoke of the timing earlier, we’re still early in the game in terms of the attestations. You can even see the people that are making a lot of noise, like Practice Fusion. They say they have 100,000-something providers. They only have like 100-and-something providers that have gotten Meaningful Use dollars, which is abysmal, in my opinion.

Any additional thoughts that you’d like to share?

We’re very excited about what’s coming this year. There’s a lot of innovation we’re going to be releasing. We worked very hard in making sure that the EMR was ready for the marketplace, but now, a lot of what happens now that the product is completely rounded out, is a lot of building on top of what we already have. It will be a tremendous amount of refinement. There will be a movement into the mobile space and so forth this year, so it should be pretty exciting.

News 1/31/12

Two weeks after the AMA sent a letter to House Speaker John Boehner urging him to stop the implementation of the ICD-10 coding system, the American Health Information Management Association (AHIMA) tells the healthcare community to keep moving forward on their ICD-10 transition plans. Dan Rode, AHIMA’s VP for advocacy and policy, warns that Congress may not act on the requests of the AMA and others and that stopping implementation would result in “significant financial loss to the healthcare providers, health plans, clearinghouses, technology vendors and the federal government, all who have invested in the transition and have been preparing for the last several years.”

Allscripts announces plans to incorporate speech and language understanding technology from M*Modal into its ambulatory and acute-care EHR platforms.

Mendelson/Kornblum Orthopedic and Spine Surgeons (MI) selects SRS EHR for its 37 providers.

A Navicure VP outlines some of the more common problems causing rejections or denials of HIPAA 5010 claims, including:

• Listing a tax ID or SSN rather than the required NPI
• Using a PO box instead of a street address (although a PO box can be used as the billing address to receive payment)
• Not including a nine-digit ZIP code
• Submitting more than four diagnosis codes for a specific service
• Not providing a code description when using an unlisted CPT or HCPCS code.

An AMA News article highlights key provisions that providers should consider when contracting for an EMR, including a clear understanding of who owns the clinical data, who can use the data and how, and how data can be accessed, especially in the event a practice and vendor part ways.

GE Healthcare announces plans to sunset its Centricity Advance product, saying that its flagship EHR/PM solution Centricity Practice Solution addresses similar needs for small and medium practices. GE is giving Centricity Advance clients an option to migrate to a hosted version of Centricity Practice Solution (including data migration, training, and implementation) or to retrieve their data in a read-only format through the end of the year. GE purchased the Advance product (formerly MedPlexus) in March 2010.

Aprima Medical Software partners with DiagnosisOne to provide the latter’s clinical decision support for the former’s HER.

The Bipartisan Policy Center reports on the state of EMRs and other HIT tools, noting that the lack of health information exchange is a major obstacle, as is the lack of PHR adoption by consumers. The Center’s recommendations include the development of a viable business model that gives providers a financial incentive to share information. To engage consumers, the government is advised to address gaps in privacy, security, and accuracy of records and to take steps to raise awareness of technology; consumer engagement also requires PHRs to become more usable and include easier data import and export tools.

E-mail Inga.

DOCtalk by Dr. Gregg 1/27/12

Have Fun, Make Money, Change the World

Last year at about this same time, I was introduced to Health Care DataWorks (HCD). Located in Columbus, OH, they were a start-up with about 11 employees working in an almost archetypically Spartan start-up office space with programmers all sitting around one large conference table, pounding away on laptops, coding and debugging and trying to build a future.

They invited me back last week to see their new digs – and probably to show off just a bit as they had been having a pretty good go of it since last we met. I had truly enjoyed our first meeting so, as they are geographically near, it wasn’t that hard to decide to drive over.

Economic downturn be damned. HCD apparently hadn’t gotten the news of the economy’s slowdown. They had expanded to some 40 employees. They had moved into a gorgeous new space with real offices, real furniture, lots of lovely lake view windows, plus a company ping pong table. They were even getting ready to knock down some walls to expand yet again.

Of course, that’s all bows and ribbons and wrapping paper. The package inside is what I was interested in.

I’m very happy to say that the folks there had not let the transition from start-up to emerging growth company and their successes against some giants like IBM and Oracle go to their heads. They remained focused, clear, and personable.

Providing “business intelligence solutions that enable healthcare organizations to improve quality and reduce costs”, HCD delivers enterprise data warehouse and research solutions along with hospital and health system analytic dashboards to help improve quality and control costs. Sort of the “Intel inside” for hospitals. Their tools are pretty slick and very comprehensive. As they were recently featured on HIStalk’s Innovator Showcase, you can read more about “the what” there.

Here, I’d like to give just a little more of “the who,” because, if you’re like me, you also want to know about the people behind the scenes of cool tool creation and which way their personal bents bend.

Herb Smaltz is in his first role as a CEO, having lived his prior life in CIO shoes. He is well trained to see the problems he’s trying to help solve. He’s also enjoyable and enthusiastic with an almost child-like awe and joie de vivre. One very enjoyable trait: while he fills his role as the company’s head cheerleader well, he is not so mired in his own world as to miss the view of what might expand it from beyond.

COO Jason Buskirk is their business intelligence (BI) engineer. He’s just as pleasant as Herb, but quiet. He listens intently and seems to gobble up information, speaking rarely. But when he does, it’s with keen and concise insight.

Co-chair and CFO Jeff Wilkins provides a sense of comfortable confidence to the team. His self-assured nature completely avoids any sense of pomposity despite his long track record of corporate success. (Among other things, he founded CompuServe back in the ‘60s and helped open the World Wide Web to us all.) He easily mixes great stories about wild swans and “Henry and Dick” Block with insights into corporate culture and strategies.

They seem to swim in a pool of “I get it.” Not only can they expound upon the values and challenges and solutions within their current laser focus market of BI for large to mid-size hospital systems, but they easily perceive potentials that may be tangential to their foci. I have found this rare. To me, C-suiters seem to more often have an air of “we know best” rather than having a willingness to listen or examine other perspectives (especially when speaking with any lowly non-C-suiters.)

Maybe they’ll gain some proper C-suite arrogance once they move beyond emergence into maturity. But for now, they are the type of people you want to see behind any technology, product, or service you’re considering. (Shhhh… Yes, that’s right. Don’t say anything, and nothing’s firm, but they did hint at some potential tools that would more directly serve the trench grunt world.) Maybe when HCD grows up, they’ll abandon their Pollyanna-esque corporate approach, but I hope not. Personally, it’s one of my favorites, summed up by their Jobs-ian company credo, “Have fun, make money, change the world.”

Makes a geeky American capitalist smile.

From the trenches…

“I would trade all of my technology for an afternoon with Socrates.” – Steve Jobs

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 1/26/12

eClinicalWorks releases a letter from CEO Girish Navani, who recaps 2011 accomplishments and outlines plans for 2011. Some highlights:

• The company now serves 60,000 physicians across 22,000 ambulatory practices, including 33% of the country’s community health centers.
• Revenues grew by 35% in 2011 to more than $200 million. The company remains private and profitable.
• Employee count grew to 2,000, including 600 new hires in 2011.
• 2012 initiatives include the introduction of an iPad solution, 500 new enhancements, an ACO portal, and a commercial version of its Hub Population Health System platform.
• Live chat capabilities will be introduced in the customer service area and at least 250 more support engineers will be added.

If you are on of the 355 Eligible Providers who unsuccessfully attested to MU last year, CMS now offers an appeals process for both the Medicare and Medicaid programs. Beginning in February, appeal decisions will be posted on CMS’s Website under the Office of Clinical Standards and Quality.

Mississippi Coast Physicians negotiates special member pricing for MediStreams’ remittance automation services.

An Internet-based survey  of 1,000 practices finds that 45% of doctors in small to medium-sized offices report their practices are doing better this year compared to last. The top negative pressures facing practices were insurance, reimbursement, and patient compliance issues.

SOAPware partners with Ambir Technology to offer Ambir’s document scanning technology to SOAPware’s EMR clients.

The executive director of the American Academy of Private Physicians (AAPP) says the surge in government-backed to physicians offices indicates the financial struggles of today’s independent physicians. SBA loans to doctors have grown from $60 million in 2000 to $675 million in 2010 as physicians in solo and small offices struggle to make payroll and pay monthly expenses. Decreasing reimbursements, rising costs, and technology investments are contributing to the financial woes of doctors.

Physician referral rates doubled between 1999 and 2009, likely a result of increased specialization in medical care and the increased responsibilities of primary care providers who lack the time required to treat patients with certain chronic conditions. Researchers suggest a correlation between the increase in referrals and rising healthcare costs.

E-mail Inga.

More news: HIStalk, HIStalk Mobile.

Joel Diamond 1/24/12

ICD-10:  A Brief History

Those who follow my not so regular posts will know that I make an incredible effort to avoid offensive and controversial material. Today, I will keep to the high road and offer an academic discussion of ICD-10. 

But first… a few words about the term douchebag. Not only is it regularly used on TV nowadays, it is a word frequently bandied about in hospitals—often as the quintessential description of certain patients, but more often aptly used to describe particular physicians.

The term d*bag was defined in the Oxford English Dictionary in 1968 as popular epithet for "an unattractive coed." It was later defined as "a general term of disparagement, esp. for an unattractive or boring person." Clearly there exists a need to stratify this description, not only for general insults, but also for standardized documentation and even commerce and billing. 

Many believe that ICD-10, or the 10th revision of the International Classification of D*bags, will resolve this issue. Its deep dictionary of 68,000 terms (compared to 13,000 in the 9th revision i.e. ICD-9) will go well beyond the general term for disparagement, while its 3-7 alphanumeric character codes will allow for greater specificity and detail. For instance, I do not need to delve into the benefits of ICD-10’s detailed description of body parts compared to ICD-9’s generic terms.

I believe that these benefits alone will justify the estimated implementation cost for conversion—thought to run from $5.5 billion to $13.5 billion, with additional productivity losses of $752 million to nearly $1.4 billion.

I thought it would be interesting to gain some historical perspective on this subject. (please note: the names are correct, but the facts are altered to protect the humorless).

Early History

Francois Bossier de Lacroix (1706-1777) is often credited for the first rigorous attempt to classify d*bags in his now famous Nosolgia methodica. He formalized the many ambiguous terms used in his day, such as “Beetle-headed, flap-ear’d knave,” “canker-blossom,” “bolting hutch of beastliness,” and the ever-popular “lump of foul deformity” and organized them according a rough hierarchy.

In 1837, the first medical statistician for the General Register Office in England, William Farr, noted that “the nomenclature of various miscreants in our midst is of much importance in this department of inquiry… and should be settled without delay,” which led to the 1st International Statistical Institute and it’s now famous Classification of Douchacity.

It wasn’t until the Fifth International Conference for the Revision of International Classification of D*bags held in Paris in 1938 that the more familiar insults that are still used today began to be assembled in an organized nomenclature. For instance, under the pejorative “dumb,” one could also classify “imbecile,” “idiot,” and “moron.” Furthermore, for the first time a combination term emerged, which allowed the specification of “a stupid- idiot.” Nonetheless, historians will recall that representatives from Austria and Luxembourg walked out on the sessions, as they felt that these terms did not fully express the gestalt of the true d*bag.  

The Ninth Revision

Meeting in Geneva in 1975, the now common three-digit codes were agreed upon and the currently used International Classification of D*bags-9 (ICD-9) was formalized. Most practitioners agree that ICD-9, while useful for general insults and humor, severely limits the accurate description of people we dislike. Take for instance the term “D*bag Not Elsewhere Classified.” It has serious and negative implications in epidemiological studies and retrospective analysis. Similarly, the combination term “D*bag with or without a stupid grin that one might want to punch” is frustratingly ambiguous. Finally, so much has already been written about the plethora of “worthless” E-codes pertaining to injuries (i.e. motor vehicle accident secondary to d*bag talking on cellphone,) yet the classification misses common conditions such as “d*bag at the gym who constantly looks at himself in the mirror.”

ICD-10

Now seriously, I hope the above parody sheds some light on the absurdity of our ridiculous emphasis on billing at the expense of true descriptive medicine, clinical communication, and interoperability. 

In fact, the closest real-life ICD-9 code that describes a d*bag is 301.81 – Narcissistic Personality Disorder.   

At least ICD-10 allows the more clinically rich picture to emerge:  F602- Dissocial personality disorder, with Z437-Attention to artificial vagina, Y607-During administration of enema. 

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.