Paul Brient, the president and CEO of PatientKeeper Inc., has spent 20 years in the healthcare IT trenches, first with the physician practice management software start-up he founded and ran, BCS Inc. After stints at McKesson Corp. (NYSE:MCK), HPR Inc. and The Boston Consulting Group, he joined PatientKeeper in 2002.
MassDevice caught up with Brient shortly after PatientKeeper raised $13 million aimed at accelerating its application for a “meaningful use” designation as part of the American Recovery and Reinvestment Act. In a wide-ranging discussion, Brient told us why he disputes the notion that healthcare IT will save the healthcare system and why it’s nevertheless a crucial element of true healthcare reform. He also told us why he might be a “glass-all-the-way-empty” pessimist about the prospects for true healthcare reform.
MassDevice: You’ve been working in healthcare information technology for the better part of two decades. What keeps you interested and involved in the industry?
Paul Brient: Healthcare IT is a great combination. I’m a technologist by vocation and interest, as an electrical engineer, but I’m very passionate both about healthcare, because it’s something that makes a pretty major impact on all of our lives, and also because of the fact that my father is a general surgeon. I spent my childhood rounding with him, because if your father is a general surgeon it turns out that the only way you get to spend time with him is by going to the hospital where he is. So I spent a lot of time following in the footsteps of a classic traditional independent physician, and frankly seeing the hardships and the challenges that have been foisted on the medical profession over the past 20 or 30 years. I’m trying to do my part to improve that, improve the day in the life of a doctor, because healthcare at the end of the day really revolves around the patient and the doctor working together to try and take care of them. The more we can make that easier and more efficient the more we’re going to make healthcare better in the U.S.
MassDevice: Give us a little detail about the services PatientKeeper provides. What are the main differentiators between your offerings and the rest of the crowded EHR field?
PB: The one thing to point out is that we are pretty explicitly not a traditional EHR, by definition. One of the things that we always remind people is that we are not a system of record, in a medical/legal context. What we did, which no one else really has tried to do, is set out to automate the day in the life of a physician. So rather than starting with a place like a physician’s practice or a process, like the pharmacy or lab in a hospital or radiology or ordering or signing out or whatever the process you pick is, we said, "Let’s look at a doctor and say, ‘How can we put out a piece of technology for a doctor that’s going to make his or her life better and more efficient and more effective as a physician?’" And we worked backwards into all the complex, myriad systems and places that doctors go and over the past 12 years have built a technological solution that literally is the only piece of technology a physician needs to fully automate their day. That’s kind of a unique statement that I don’t think any other organization would be so bold as to claim.
We’re known for the fact that we kind of invented the concept of helping physicians automate their day by using personal digital assistants, at that time Palm Pilot Professional. We’ve grown up as an organization; most of our users now are primarily based on computers, but they still use their handheld devices — now they’re smart phones — pretty extensively, much like we use them for BlackBerry email or iPhone email. The latest generation of devices, the BlackBerry, the iPhone and now the Droid, have really created a new renaissance of physician adoption of new technology. Anyone who says physicians don’t adopt new technology, I think 60 percent or 70 percent of physicians in the country now have a smart phone. Physicians are good adopters of technology that makes a difference to them, and so we’re seeing really big growth in our mobility business and the excitement around that. It’s been there for the last couple of years, but now it’s just a real new wave of coolness as doctors update their Palm Trio to an iPhone. It’s a significant improvement to their lives and in their use of PatientKeeper.
MassDevice: PatientKeeper recently raised $13 million to help fund its application for a meaningful use designation. That seems like an awful lot of money for that purpose; can you explain why you needed to raise so much for the application?
PB: The meaningful use criteria, and we focus primarily on meaningful use as it applies to hospitals, involves the rollout and deployment of CPOE, computerized physician order entry. And although it’s not yet finalized, we believe it will also involve physician documentation. These are kind of the third rail apps of healthcare. They’ve been on the roadmap and in the future since computers and healthcare first got together 30 years ago, and for the most part have been very poorly adopted in the community space. Only 5 percent or 10 percent of hospitals out there have CPOE and those are mostly academic centers. Very few of them are community hospitals where there aren’t residents.
So with meaningful use, there’s a requirement now that all hospitals eventually get to CPOE. Our objective is to help community hospitals in particular be successful with that. We’re using that money to ramp up our R&D staff, so that we can build the apps necessary to make that successful, and enhance the ones that we have to meet the meaningful use criteria. And more importantly we are ramping significantly up in terms of our service organization, because of the pretty rapid increase in size, scope and number of implementations that we’re doing. Going in and putting a CPOE system in place, and ultimately a physician documentation system in place, is a much bigger task in terms of people required and investment required than deploying our other apps, by a factor of two or three. So we need more bodies and those bodies have to be hired and trained before they can be billable, so its a lot of growth capital, if you will, to make sure that we’re positioned for success in a market that is rapidly growing and expanding.
MassDevice: We’ve heard criticism of the $19 billion ARRA earmark for EHRs as a giant boondoggle. How do you respond to naysayers who doubt that EHRs will have the impact on healthcare costs they’re touted to hold?
PB: Spending on technology alone will not impact costs in a significant way. It is, however, a prerequisite for impacting healthcare costs in a meaningful way. When I used to go to cocktail parties a few years ago and people asked me what I did, two or three sentences into the conversation I’d start talking about the Red Sox because no one cared about healthcare IT. But now people care about it and they say, "Oh my god, you guys are going to save healthcare for the U.S."
No, we’re not. We’re going provide some tools that, if people really want to make some difficult decisions about how healthcare should be delivered in the U.S., will make that process easier to implement. But healthcare IT alone, especially things like CPOE, is not going to move the cost needle at all. And that’s why its not implemented. At the end of the day, you can say what you want about doctors and healthcare organizations, but they put in technology that makes them money.
Every single physician in the country, probably 99-point-something percent, have a practice management system in their office. All voluntarily, without any stimulus dollars involved, went out and bought a practice management system. Why? Because it makes them money. Not very many doctors went out and bought an EMR system for their office. Why? Because it doesn’t really make them any more money or really help them that much and it requires a big, up-front investment and a lot of change. Activation energy high, return low and esoteric. It used to be that EMR cos would come in and tell you that they could save you more money on those silly little labels and charts — that was the ROI, "You don’t have to buy all those paper charts anymore," and that somehow is going to pay for your computer system, which obviously is pushing it. The ARRA money is a very necessary part of moving the healthcare automation curve forward, but it is the beginning of a process of reforming healthcare and obviously as it was defined is a little bit challenged given what happened here in Massachusetts. But it wasn’t going to move the cost needle either, which is part of the reason I think people weren’t so excited about it.
Moving the cost needle is going to require a set of really difficult decisions that are going to be hard to make in a democracy. Unfortunately it was kind of sold as the solution, or people wanted to see IT as the solution, because it’s politically easy: "Spend money on IT. That’s not going to require anyone to change their behavior or change their doctor or feel threatened that their Medicare was going to go away." That sounds good politically, we can all get behind that, but the problem is that it’s a prerequisite. It’s worth spending money on, but then it’s just like any tool. If I hand you a hammer, it doesn’t build a house. But if you don’t have a hammer, you’re going to have a hard time building a house. Now that we’ve got the hammers, we have to say, "OK, I can see the ordering patterns, now I can see what people are doing, now I could begin to standardize medicine and maybe make some decisions about what treatments make sense or not."
But those things start to get real scary. You hear that, you hear "rationing," you hear "the government taking control of my healthcare" — and correctly so, because that’s what those things are — but if you don’t look at cost-effective treatments… Take mammograms. Twenty years ago someone made the arbitrary decision that at 40 years old a woman should get a mammogram every year. And I’m sure they carefully considered the data available, which was not much, and we’ve been doing that for 20 years. Recently someone said, "Hey, let’s take a look at that. Let’s do some analysis and let’s see what the cost benefits are, the population mix, et cetera, and they decided to make a recommendation that mammograms should be given every two years at 50 years of age. And people freak out. I’m not qualified to say whether the conclusions of the study are correct, but those are the kinds of decisions that we, as a society, have to make around healthcare.
That one, assuming the science is correct, doesn’t seem to be hugely controversial, yet it was a political land mine. It’s going to be a real challenge for our country to make the decisions we’re going to have to make to get healthcare costs even to just track inflation. They continue to grow at a rate faster than the GDP, and all I can say for sure is they can’t do that forever. We’re getting to the point where, if you’ve got to spend 20 percent of your output to take care of your workers, that’s a huge drag over countries like China or in Europe, where they’re spending 5 percent or 10 percent. Healthcare IT has been misinterpreted. Everyone would like it to be a panacea and it’s just not.
MassDevice: Adoption of EHRs and EMRs is famously low both for physician practices and hospitals. How should the government and the HIT industry go about making these technologies more attractive to healthcare providers?
PB: That’s a very astute and, to some extent, an even controversial question, believe it or not. If you think about adoption of technology, people who are faced with voluntarily adopting technology do so for the most part for one reason, which is it somehow makes their lives easier and more effective, makes them more money, does good things for them as individuals. One of the problems with healthcare IT historically has been that we go out with technologies, e-prescription is a classic example of this: It’s a no-brainer. It’s a win for the entire healthcare system, reduces costs, improves patient safety, lets you find people that are abusing the system, all this great stuff. Except for one small detail: The person who has to use it, the doctor, it slows them down. And if you’re a doctor, time is literally money. If I slow you down, you see fewer patients and you make less money. And the capacity of the healthcare system goes down, which is a big problem because that means it gets more expensive. So you need more doctors to take care of the same amount of people.
So the way you get adoption is you put technology in place, in particular if you’re looking at physician adoption, that speeds physicians up and benefits them personally. This is a little bit of a challenge, in that a lot of the temptation, when you go out to look at the things you’d like to do with technology, involves slowing doctors down. Traditional CPOE systems are a poster child for this. "Let’s do all this rule-checking, let’s file all these alerts, let’s give all these doctors all this information so that they make better decisions." It’s hard to argue with that, except that it slows doctors down. If every time I put in an order I get two alerts that I’ve got to read, well, now instead of writing an order on a piece of paper that takes me 30 seconds, I have to deal with these two alerts and maybe I have to put in a reason why I read them and chose to ignore them. It sounds really good and it’s very noble, but in reality if you slow the doctors down even by 20 percent, you cut their net income by 40 percent because they have a 50 percent fixed overhead. If I said to you, "Hey, here’s some technology that’s good for the rest of the world but it’s going to cut your income by 40 percent," I doubt you’d be very excited about it.
The real challenge here is we want to effect change, we want healthcare to improve, which means that doctors, by definition, have to change. Yet we have to put technology in front of them that they’re going to adopt, and by that we mean will have a positive impact on them. So much of that has been left out of the discussion. The meaningful use legislation isn’t very specific and they were very clever, in that they focused on adoption. It’s going to be a real challenge to the industry, because most CPOE systems out there today aren’t focused on helping doctors. They work in academic centers, where there are residents. As the residents are trying to learn medicine, the alerts are pretty helpful for them because they don’t always know how to practice medicine. And they have to do what they’re told and the productivity of resident isn’t bad, because they have to work 80 hours a week and they’re paid a low salary. But when you get to the community hospital setting, where you have a visiting surgeon who has maxed out his practice and has seen his income go down year over year because of reimbursement cuts and all that good stuff, and barely has any free time at all, and now you say, "We’re going to slow you down," they just say, "No." And that’s why the adoption rate is so low.
Every one of our customers who deploys our technology does so on a voluntary basis. In other words, no one says, "Hey, we’ve got PatientKeeper, Doctor, you must use it or you can’t work here." So every one of the now 17,000-plus physicians that use our system on a daily basis to take care of their patients does so because he or she has made the decision that this benefits them personally. It saves them time, in some cases it makes them money, it helps them be more effective at practicing medicine. Doctors still care about that, they’re just not willing to invest 40 percent of their income to that task. Especially since most doctors think they do a pretty darn good job already, thank you very much. That’s our value proposition and all of our software is designed with that as the number-one goal. We will sacrifice functionality, we’ll sacrifice extra-cool bells and whistles if they get in the way of doctors.
MassDevice: Where do you see the next advance in HIT and EHR technology coming from?
PB: The cool thing about this is once we get stuff electronic, we have the opportunity, whether we have the will or not, to begin understanding the efficacy and the impact of treatment decisions at a level that’s never been possible in the past. We can start looking at even simple things like drug-drug interactions and side effects. Medco has done a couple of really cool things, where they looked in the drug databases and picked pairs of medications and look at proxies for outcomes — re-admissions or interactions or other drugs that were prescribed — and they’ve learned that there are some drugs that interact in ways that we never understood before. We can start testing things empirically. Lots of healthcare gets delivered in this country, we can see what works and what doesn’t if it’s electronic and standardized, just by looking at the data. There’s so much practice information out there.
We all talk about not wanting variation, but I’m actually of a different mind. We should encourage variation to a point and study it. So you look at places where cardiac catheterizations are done at a rate of half in one population versus another. Rather than homogenizing that, let’s figure out first which is better. Are we getting better outcomes in one versus the other? It’s comparative effectiveness in the real world, not in some crazy study. Some of this stuff is ethically difficult to study even, let alone practically difficult. Controlled studies are so hard and expensive to do, but if we use our country as a lab and find ways of looking at data, we can learn what’s working out there.
A good buddy of mine is an athlete and he wanted to evaluate whether he should have a laminectomy, which is a procedure on the back. He had really bad back pain. He called me up and said, "Hey, you’re in healthcare IT and you know all this stuff about healthcare. Try to figure out if I should have this or just suck up the pain." We tried to find any sort of meaningful study about what the two-year efficacy was — the surgery helps right away, but the question was, in two years are you better off or not?
There was really nothing out there and at the end of the day, a really good orthopedic surgeon I know said, "You know, it basically comes down to this: The best thing to do is to not have the surgery, but if the pain is so great that he’s on opioids, he needs to have the surgery because otherwise he’s going to become addicted to opioids and ruin his life."
We can do better than that in today’s world and I think there’s a real opportunity to look at that. Laminectomies are done all the time and laminectomies are decided not to be done all the time. It would be really cool if you could pull a study up that says, "Here are 100,000 people who did and 100,000 people who chose not to." What’s it look like after two years? Are they all getting the surgery anyway, or are they all reporting pain? We could do that with a fully electronic system. That’s what gets me excited about this, that we could really learn about healthcare and really learn about what works and what doesn’t and then, if we have the stomach, make the decisions about investing in the things that work and saying no to the things that don’t or have marginal benefits. That’s where I think things will become difficult, but I think that’s ultimately what we have to do.
MassDevice: So are you glass-half-empty or glass-half-full on the prospects for healthcare reform?
PB: I think I’m pretty half-empty — maybe I’m all-the-way-empty. We’ve tried this three or four times in the past 20 years as a country and it is just a minefield of epic proportions. It’s so difficult to make meaningful change. You look at the Senate bill that ended up getting passed and it was so watered down. It wasn’t status quo, because it would have taken care of more people, which is noble, but it didn’t change the cost equation at all. It just moved costs around, and in sensible ways, but it didn’t go after healthcare reform. It was health insurance payment reform.
I’m skeptical that a political process is going to create real, meaningful healthcare reform. I actually think the way it’s going to happen, if it happens, is that the doctors, who were kind of left out of this whole thing, if we can encourage the doctors to get together and really understand and think through the costs and the efficacy of what they’re doing — which they really don’t today — and to make real recommendations. Then, I think people would start listening.
If I were king for a day I would start empowering doctors and individual communities to go solve this problem, and say, "Hey look, let’s first tell you how much all this costs." It’s amazing. If you go to the doctor and say, "How much does it cost when you prescribe Zantac?", no one knows. Can you imagine working in a business where you’re making the buying decisions and you don’t even know how much it costs? That’s healthcare, and patients don’t know either. Most patients think drugs cost five bucks or ten bucks or 30 bucks, whatever their copay tiers are, but they have no idea whether the underlying cost is 200 bucks a month or 100 bucks a month. We’ve just taken the whole cost out of the equation.
And we’re really uncomfortable about it, because we want the best and we assume the most expensive is the best. So someone says, "Hey, these pills cost 10 bucks and these pills cost 40 bucks. They’re close enough, some patients respond better to one versus the other," why would you settle for the cheap one? If you’re buying a car, you’ll take the cheap one. But if it’s healthcare, you’ll feel like you got cheated. It’s a tough, tough, tough problem. I do not envy anybody who sets out to reform the healthcare system. Yet I think it fundamentally must get done, because what’s going to happen if we don’t is that we’re going to have some kind of horrific crisis where we’re going to reform it in some very draconian, brain-dead way, like, "OK, we just cut Medicare by 50 percent because we can’t afford to do anything else."
In Massachusetts a third of our budget goes to Medicaid. In three years the projection is it’s going to be 50 percent. Well, what 17 percent of things are we not going to do as a result of Medicaid? No more paved roads? No more snowplows? It’s a real problem. The default reaction’s going to be, "Oh no, we can’t afford it so we’re just going to randomly cut it across the board." That isn’t reform, it just creates even worse things, because what most often will go are the least acute things. The preventative stuff that actually helps over the long-term is the first to go. Do you need the stuff right now or not if you have a heart attack and show up at the emergency room? Well, you need it and you need it right now, you can’t argue with that. So the carving-out piece becomes the preventative stuff, which is the last thing you want to go if you’re trying to make things cheaper in the long term or trying to make your population healthier. That’s the real rub. It’s a very complex problem.