"A lot of point solutions are emerging, but if they’re not integrated into the EMRs, they’re likely to fail."

Q: Can you talk about Whitman-Walker, your role there, and about your prior experiences?

Harry: Whitman-Walker is a federally qualified health center. It was started back in 1979 to serve the needs of the gay and lesbian community of Washington. Since then, it has evolved with all kinds of services for the growing demand in Washington. About 10 years ago, it became a federally qualified health center. Today, it offers medical, dental, mental health, specialty care, specific youth service, and pharmacy services in multiple locations. Whitman Walker has a division that does clinical research in HIV and hepatitis. It’s got a policy and advocacy arm, and an education arm.

I joined the board back in 2014 when I was still the CIO of CareFirst. Today, I sit on two boards – Whitman Walker Health, which is the federally qualified health center where all the clinical services are, and also chair the board of Whitman Walker Health System, which houses the Whitman Walker Foundation and the Whitman Walker Institute for Research Policy and Education. It has been a fascinating ride. I’ve been in healthcare forever but began around 1999 in what was then called e-commerce, which we now call digital health. I started in the space with PricewaterhouseCoopers, then through Coventry Health Care as their vice president of eCommerce, and then at Kaiser Permanente as the regional CIO. Lastly, at CareFirst, and then, in more recent years, as an independent consultant. All of my work has its anchor in core digital health. I had the opportunity at the beginning at Kaiser Permanente to implement the mid-Atlantic region’s first telemedicine for primary care in certain specialties like dermatology, and then at CareFirst, worked extensively with third party telemedicine vendors to implement that service for our members.

Q: How has the pandemic impacted care for Whitman Walker’s patient population?

Harry: It’s been dramatic. When Washington DC issued their stay-at-home order, we shut down for two days. Over those two days plus a weekend, we pivoted completely to virtual services.

Whitman Walker uses eClinicalWorks as their EMR. In a three-day period, they had to bring up the module, test it, develop patient education documents, and develop staff training documents. They implemented DocuSign, because all the forms that you would fill out in the office, now had to be done virtually. Luckily, CMS around that same time made some changes in both repayments. So, if we couldn’t do telemedicine, we could do an audio encounter with a patient who might not have been able to do video services and we can still get reimbursed for it. CMS also lifted some of their licensure restrictions. Earlier, patients came to us in one of our locations in Washington, DC. Now that we serve the tri state area, we have patients in Maryland and Virginia and then a small population of patients from across the country, who come for our specialty LGBT care. Before the pandemic, if you weren’t licensed in a state, you couldn’t virtually see someone in the state. That’s been lifted now, at least temporarily. So, we pivoted over a very short time and opened on Monday morning. Everything went virtual, except for a small number of patients who were still coming in for more serious issues – COVID related and breathing kind of issues.

All the rest went virtual and it’s continuing to evolve. We had started out with everything on the eClinicalWorks. We found that for patients with behavioral health, some in individual and some in group sessions, eClinicalWorks couldn’t handle groups. It handled patient to doctor. So, we pivoted to zoom for behavioral health. Also, the bandwidth demand was better in Zoom with lower bandwidth could still get high quality video. ECW had a little bit higher requirement for that. So, we now operate with eClinicalWorks for all of our medical and dental patients and then we use zoom for behavioral health and substance abuse treatment for individuals and groups.

Q. Were there any unique needs for the LGBTQ populations that you had to take care of while standing up these capabilities?

Harry: As a federally qualified health center, we serve the entire community, and a portion of our patients are in the LGBT community. Because it’s a federally qualified health center, it’s often lower income. So, we have issues of technology disparity where people may have a cell phone but may not have an email. We find our younger clients usually have a phone but often don’t have a PC or a tablet. Our older patients may or may not have a phone, or another device, but often struggle with the technology. I have a 92-year-old mother that I do tech support all the time and I know how hard it can be when you’re trying to get someone to hold the camera a certain way and point the camera here. A lot of people have these challenges. About half of our patient population is below one 100 percent of the federal poverty level and thirty nine percent are below 50 percent of the federal poverty level. We have folks at the other end of the spectrum, too. When you have this tremendous diversity of background, it makes rolling out telehealth ubiquitously difficult. We have patients, living at the lower end of the poverty level, who may not want us to see where they live. They may have access to technology, but they’re uncomfortable having their homes seen. There are these very interesting, unique situations that are not LGBT specific, but are more issues of equity and what people have in terms of education and access to high-speed internet and technology.

Q. What are you seeing in terms of efforts by the technology community to address these technology disparities and making healthcare more inclusive for everyone?

Harry: It’s an interesting question. We got two small grants and we’ve been able to purchase three Wi-Fi only phones. That’s helpful up to a point because the individuals in the community may or may not even have access to Wi-Fi. There is no Wi-Fi in some areas of Washington, D.C. So, it’s useful if someone doesn’t have a phone, but they still have to access Wi-Fi for a virtual visit. There is a lot of point solutions I see emerging, but if they’re not integrated into the electronic medical record, they’re likely to fail. Every time you’ve got a standalone point solution, it is more work. When we’re using Zoom, we have to schedule the patient in the EMR and then schedule zoom separately. We’re using the eClinicalWorks for a virtual visit only and then we’re using them for the digital part as well. It’s all set up within the system. We create the scheduled event, we say that it’s digital. Automatically, the patient gets an email with the link and then later a text with a link. So, there’s some really fast emerging useful technologies in this space. The issue all along has been interoperability and integration.

Q. If you just expand the Zoom versus the eClinicalWorks situation you went through, how you kind of roll it out across a broader ecosystem?

Harry: The larger, well-funded delivery systems have the luxury of having enough cash and can choose best-in-class solutions and integrate themselves or work with the vendor to integrate them. If you’re a CIO of a small clinic, you don’t have that luxury. In Washington, in Whitman Walker’s case, eClinicalWorks is funded by the DC Primary Care Association for all seven FQHC’s in the District of Columbia. So, it’s not a technology choice Whitman Walker made. They wouldn’t have been able to afford that kind of platform without the DC Primary Care Association. So, your ability to pick best-in-class really depends on who you are and what kind of assets you have to invest in technology. The bigger systems just have the luxury of doing a lot better job of picking best-in-class solutions. Although I will say that there’s a thorn there too, because if you let best in class run wild, you have a situation soon enough where vendors get acquired. What was best-in-class this year is not best-in-class next year. And so, you’re pulling things in and out of connectivity around your electronic medical record, which is kind of the heartbeat of it all. So, you’ve got to choose very carefully when you think about going best-in-class. Make sure it’s not going to get acquired by a bigger player because they’re so small right now, because that can also cause a lot of rework and a lot of spending down the road.

Q. Tell us a little bit about how your experience with CareFirst as a CIO of a health plan. How is that different from your similar role at a leading provider was is Kaiser. What are the big points of difference between payers and providers at a broader level when it comes to approaching digital patient engagement today?

Harry: Kaiser has two arms of its company. It has the insurance company, and it has the whole care delivery operations. And because of their scale, Kaiser has the luxury of truly picking best-in-class. And they have been an early investor in EHRs. They really put the Epic chart on the map, and they’ve been a big investor in digital solutions for their patients. When you get to the payer side, it’s a very different world because there’s a lot of intent to help on the clinical side. But it’s really around the edges as far as I see it, because at the heart, you’re an insurance company. So, when you look at the member portals of an insurance company, they are your claims, your explanation of benefits, your annual deductibles, and co-pays. They may have other services like telemedicine, but they are really rolling out telemedicine in support of the clinical community outside their four walls. It’s a different perspective. My observation is that the payers often have more money to invest in technology. The very large clinical delivery systems have money, but the smaller hospitals can really struggle to stay abreast of the technology. Implementing a hospital EMR, like Epic or Cerner, is millions and millions of dollars and a multi-year process. They often make or break projects for the organization. So, it takes a lot to bring up these massive EMR solutions.

Q. How does all the regulatory environments affect the pace of acceleration or pace of adoption of digital health and telehealth?

Harry: United States unlike a lot of countries has healthcare at the local level, rules at the state and often county level. With the pandemic, public health has been in a mess of a rollout because everything is at the local level. In Maryland, for example, we have state rules following CMS rules. Then we have county versions that are different. So, by county in Maryland, when you get your inoculation, it will vary because the rules are different. I say that as a backdrop because reimbursement and regulatory landscape is a little bit like this. When you think of the fact that providers during COVID almost universally are getting reimbursed for telemedicine, whether it’s a private payer or Medicare or Medicaid. Before COVID, they didn’t get reimbursed for a phone call. They are temporarily getting reimbursed for a phone call. If that goes away, it will hurt the lower income portion of the patient population. Same thing with provider credentialing. Whitman Walker Health, for example, wants to serve their communities in Maryland and Virginia with telemedicine services. If the rule switches back to what it was before COVID, that’s going to be a barrier for us. So, the more that CMS, HHS and the states can break down these healthcare islands and barriers through rule making or credentialing. I think it’s going to be critical. When CareFirst was looking to do telemedicine, we were looking to hire a third-party company to be our telemedicine provider. One of the big challenges was finding a company that had providers credentialed in every state and not all the companies did. So being able to learn the lessons of what worked and what didn’t work during this pandemic and be able to carry some of those temporary regulations and make them permanent, I think would be really valuable as we go forward.

Q. Can you talk a little bit about the startup ecosystem in the context of Whitman Walker? What are they getting right today and what are they missing?

Harry: Whitman Walker for the most part is using more established vendors. First, looking at emerging technology in the digital space, the biggest challenge I see is multiple vendors telling how incredible their new thing is. Most don’t understand the complexity of medicine. They don’t understand the complexity of health insurance. So, when you look at the life cycle of a claim insurance you look at the workflow in the clinical delivery side. These are incredibly complex today. Any vendor that wants to make it, must bring in enough clinical expertise that they understand and they’re not naive about how complex the health care world is.

Secondly, I would say going back to what I said earlier, they must be integrated with the major players. So, for example, Whitman Walker is implementing a texting solution called Well. And if you look on the Well website, they integrate with all the major EMR. So, we’re looking to do bidirectional text messaging with our patients. We’ve got to be wary of HIPAA rules, about privacy as we do that. And so, going with a major player, is important, but also going with a major player that fully integrates that into EMR is absolutely critical of the box. So, we’re not creating an island somewhere of information separate from the EMR. So those are two key areas I think are critical success factors.

Q. Big tech companies like Amazon, Microsoft, Google all have their sights set on healthcare. Companies like Microsoft have been in the enterprise workplace collaboration software space for a long. What can we expect from them going forward?

Harry: It’s a great question. On the truly clinical side, I personally don’t think a lot. Microsoft touted its own health record years ago, which is now shut down heavily. I think they’ve all struggled with solutions that rely on deep domain knowledge of healthcare. But if you take a broader view, AWS has done well. It’s not HIPAA certified, but it’s something like that. It’s an area that’s more secure to meet HIPAA regulations. Microsoft and Google have similar parts of their domain. That’s a big area because there’s a lot of fear in the clinical space of what do you put in the cloud. If I put it in the cloud, what happens if it’s breached and what are my liabilities from the perspective? I would say to payers and hospitals and clinics, delivery systems, to look closely at what these three companies call their HIPAA space in the cloud because they take no liability. They offer you increased protection, maybe from their regular everyday part of the AWS or cloud environment, but they’ll indemnify you for very little. But nonetheless, it’s where the world’s going. We are going to see more and more movement to the cloud, but I would also tell the healthcare domain spaces to move very carefully and thoughtfully because there is significant risk at the same time.