Episode 10 - Special Guest Elaine Dorr discusses the CMS Request for Information (RFI) on building a more effective Health Technology Ecosystem

Please see below for a full transcript of this episode:

 Building a digital health ecosystem. We're here to examine the concept with Elaine Dorr from Wells Stack AI.

Welcome to Redefining Health Law, brought to you by the law firm of Parker Hudson Rainer and Dobbs, LLP a boutique law firm with offices in Atlanta, Chicago, and Tallahassee. Your host for this podcast is Tara Ravi, a healthcare partner with prior work experience in both clinical research and patient care delivery.

She is an adjunct professor at the Emory School of Law where she teaches corporate health law. Tara leverages her past work experience in the healthcare industry to advise healthcare organizations facing growth related challenges, although Tara is a partner in the law firm of Parker Hudson, the views expressed in this podcast are Tara's personal views and not the views of the firm or any of the firm's clients, and are not intended to be legal advice.

We hope you enjoy this podcast.

Tara: Hi there, and welcome to Redefining Help Law. We are here with our special guest, Elaine Dorr from WellStack AI, and a quick little bio about you. Thank you so much for coming by the way, but a quick little bio. Throughout her 25 plus year career, Elaine has followed her passion for bringing innovative solutions to providers, payers, and public health organizations that improve quality, lower cost, and deliver better outcomes across the care continuum.

Elaine's experience includes solution sales for Microsoft Vibrato, Hiro AI, and currently WellStack AI. Thanks again, Elaine, for coming.

Elaine: Thank you so much for having me. I'm really excited about today's discussion. I've had, you know, over 25 years of experience in healthcare technology and I have worked for a lot of different vendors bringing new solutions to market to really solve some of the challenges that we're talking about today. So, we were talking about these challenges 20 years ago and bringing innovation, and we're still having challenges today and that's why I'm really happy to be here.

Tara: Well, thank you. Big topic is that we've got the first publication by CMS, request for comments. They're calling it Request for Information Health Technology Ecosystem.

It's what's helpful for patients, what's helpful for very technical coding? What's helpful for identifying yourself on clear ID.Me, and it's kind of all over the place and it already has. I think the comments are ending soon or may have already ended, but yep, it ends in three days. Seems like some things we've already solved. I'll just start with kind of my basic understanding or thoughts that I had years ago pre or during Obamacare, which was there was that initiative that everybody needed, EHR, and if you didn't get it within the specified time, you were going to get penalized.

And I was a baby attorney, day one on the job this came out and I thought to myself, that's great are they going to give us the EHR? Because isn't it going to be really hard to have EHR that 14 different providers are going to have? And, how's that going to work? How's that going to make it easier for me that I'm getting electronic records from a bunch of different people who don't talk to each other? So you said, we're back to that now or are we.

Elaine: We're still back to that challenge, and I think one of the things that I find most interesting about healthcare. Is that while there are standards that are enacted, and I'm sure you're hearing all about claim standards, X 12 standards, fire, all kinds of new standards, healthcare does not force adoption like financial services as an example, for adhering to standards, specifically on interoperability, and this is to me, the root of all problems. You know, EHRs, they all do things very differently. As an example, a patient who has diabetes has to have a H1C test done every quarter that's part of actually CMSs requirement to monitor and try to improve the overall health of patients.

Unfortunately, one patient might see their local primary care doctor. They might have a test on there. They may change to a different doctor, maybe because of an insurance change, and there might be 25 different H1C codes for that one patient over the course of a year, and also over the course of different information systems.

So, a lab system reference lab may have one code that they use. The EMR may use another code, and just that one example is very real and healthcare systems and providers are expected to be able to look at this data across time to provide better care experiences for patients, and it's virtually impossible.

Tara: I feel like we were already trying to address these questions, I mean, 2013, all the way to 2018 when we had huge innovators like Google, we were going to have Google Health and Amazon Health. Why did that fail? Why are we asking the same questions all over again?

Elaine: I think one of the real issues with healthcare specifically, and data and interoperability, is that a lot of these interesting companies like Google who solve communication problems around the world, across a variety of platforms, they're not able to infiltrate the challenges of healthcare because, there's a lot of hiding behind things like HIPPA. HIPAA was supposed to help everyone, and I feel it's caused a little bit of a stumbling block, and it's used as a way to prevent data from being interoperable and taking on new technologies that are solving problems in other aspects of the world that we live in, such as, you know, why can I have Venmo? And send money to anyone. And this is just a company that created a solution and a platform for sending money very easily to each other. Why can't we do something like that in healthcare? And it's because I believe, from my vantage point, working in into technology there are always lots of rules that organizations have put down in the guise of protecting the patient and protecting the patient information and it's actually causing more challenges.

Tara: Let's dig into this.

Elain: Okay.

Tara: So, digging into this, here's the first question, patient needs. What are the top things you would like to be able to do for your loved one's health that can be enabled by digital health products? Well, I've got a lot of answers to that, and it's not just my loved ones, it's me, you know, like I have all these various apps and then I download all my PDF medical records and then I basically stored in a Gmail account and I'm never going to look at it again. And so I'm not really, you know, in an ideal world, I could download it from all the various, my MyChart or like Follow, what's the other one? Follow Your Health and I'd put it into my MyChart, maybe it's my Google help and it organizes everything together and makes it very readable and searchable. Okay, that'd be great. And then, I don't know, maybe I just put it into ChatGPT and take care of myself, but just kidding. So I, I really do think for my loved one's health, and I do think that's where these comments are going for, is how can I take control of my mother's health when she lives four states away. I would like to be able to do all of that with her medical records. I don't want to navigate four different apps for her, I have to navigate for me, I'd like to not have to remember to FaceTime because you know your parents, they don't check in with you. They just go see the doctor and they tell you a week later. So, it's not like I know unless I have her location, which I do, but I'm not checking that all day long.

Those are the basic topics that I'd be interested to hear what you have to say about any of those things. Elaine.

Elaine: I think. As a patient myself, right? I can think about how I want to communicate with my doctors, and some of them are more proactive, right? Using technology and communicating through technology.

MyChart is an example. Follow My Health, but you, you know, hit the nail on the head. You've got to go in and out of all these various different applications trying to help a loved one, four states away you are also dealing with different states have different laws, as you know.

Tara: Yeah.

Elaine: As an attorney, and it's not promoting interoperability. I can think of an example, just even physician credentialing. There's no interoperability happening on a national basis for providers identification and the credentialing information. One state might send literally almost like a CD ROM of data quarterly to the provider organizations to update into their credentialing systems and think about you concerned about a loved one, four states away, and you don't know if that doctor's actually properly credentialed to take care of your parents. For whatever, you know, ailment they have, there's dentists and dermatologists that are doing services that they're not really supposed to be doing. Right. They might legally be allowed to do it, but they're not actually board certified in that specific case. So those are just some examples that I feel that, you know, if CMS is going to take the role that they are supposed to have and be in the middle of all of this, they really have to figure out a way to take the politics out of it. And not allow for various interest groups to say we don't have to adhere to this standard because, you know, they come up with some workaround. And again, I go back to, I think there's some really good lessons in financial services about the exchanging of, you know, financial dollars information across a variety of platforms.

And, and I think that that's something that needs to happen.

This is an interesting approach. The, you know, solicitation of information across all these broad categories. I just don't know how they're going to synthesize it quickly enough to be impactful. And when I say that, it's because often times they will make a law or a ruling, or a statute, and it'll be enacted in 2024, but then you don't have to meet the requirement until 2027,

Tara: Right?

Elaine: And by that time, as we all know, in this world of technology moving so fast, technology has already changed. So, whatever they documented that should happen is no longer even a viable solution.

Tara: Yeah, I mean that's pretty typical for CMS, they'll probably take some of these comments and then they're going to come out with an initiative and then they'll probably say, okay, well we're going to just pick some of y'all across a region, so your hospital will just randomly get picked for this initiative.

Elaine: The interesting thing is, you know, back in 2016, CMS was given a billion dollars, right? To solve, you know, quality, improve quality, and reduce costs. And they were going to do this through the value-based payment. Methodology.

Tara: Right?

Elaine: And they said that they were going to save $3 billion by spending this billion dollars. Well, fast forward, they actually spent 5 billion and they came up with 50 demonstration projects for the value-based care that was supposed to improve quality. And of the 50, only four actually worked and reduced cost and could improve the quality. And then those four were expanded. But again, it goes back to, to me, a lack of forcing. Adherence. Right? And it's all voluntary. A lot of these programs are voluntary, and I think it goes back to healthcare is sort of this mystery, but why is it like this in the United States and it's not like this in other countries.

Tara: Well, tell me, what y'all are working on at WellStack AI that you think positively addresses anything that's been brought up in this very, very, very broad request for comments.

Elaine: What's very interesting is at the heart of WellStack's mission, we help our customers transform data into a usable asset, and this is really the core of a lot of these issues that are being discussed on the interoperability and data integration component of this request for information. We empower these downstream systems by leveraging artificial intelligence, large language models, and other technology that we pull together using some of the latest and greatest technology that's out there that's very agile and we're able to reduce cost and foster collaboration and by fostering collaboration that is allowing for, a physician and quality folks, for example, to look at all this data that's in all these disparate formats across that H1C example. And we sort of flatten it down to a unique data model and then we power up analytics so that they can look across a patient's lifecycle of a 360 view. And to do that, you need EMR data, you need claims data, because claims data is coming from a variety of sources, not just the one health system and not just the one provider. And also adding in data like SDOH data. All of these data components are coming from various sources, various formats, different cadences. And you have to bring that together in order to look holistically. And I think this is what my company is doing today and using AI to streamline bringing those 25 codes down to one code so you can understand, wow, Elaine's H1C has dropped over the last year. She's also, lost weight, she's also looks like she's in some exercise programs and, and you can get a look at, wow, this is really working we should implement this across our other patient population.

Tara: So, if I am, let's say a 5 to 10 hospital health system, am I using these solutions or platform in like RevCycle across the board? How does that, where's the implementation occurring?

Elaine: That's a great question. So, our approach is we have created a unified data model in this data model, many healthcare organizations have created data lakes I'm sure you've heard all about that. It's all the buzz. So, they're taking.

Tara: Yeah. Tell us about it. Yeah. Yeah.

Elaine: So, a data lake is a place where clinical claims data, all this data is being stored over a period of time. It could be five years, 10 years, 15 years of history. One of the challenges is healthcare presents a challenge because the data lake has all these disparate formats and all of this disparate data that can't really be commingled. The only way to be able to do that is to create a unified data model that then allows you to access it and power up, which is our approach. We power up analytics that are specific to use cases, like you mentioned RevCycle. You talk about quality metrics and reporting, and then population health. So, you know, accountable care organizations need to look across the 360 view of a patient and the continuum in order to try to improve outcomes by implementing specific programs.

Tara: So, it seems like the ability to do that, to essentially get more information out of the data would not only help me as a health system to treat patients, but really to comply with any kind of incentives or whatever's going to come out of these comments.

Elaine: Right.

Tara: Because if it's similar to how value-based was rolled out, it was okay, value-based. That's great. All of you six in Texas are now going to be subject to these value-based reporting core requirements. This type of product would help me get to those reporting requirements, which ultimately is supposed to be, those reporting requirements aren't supposed to be onerous.

Elaine: Right.

Tara: It was supposed to like help us start using processes to treat the patient better.

Elaine: Exactly, yes. And I also think another component, so you're thinking about the data to improve quality of care, but I think we also have to have healthy financials for these. Health systems.

Tara: Yes. Agreed.

Elaine: Right?

Tara: Yes.

Elaine: And so this is why claims and moving claims data faster. Reducing the denial problem. And in order to reduce denials, you have to have information supporting documentation that's coming from the EMR to say, this was a downgraded DRG, and it was supposed to be at this diagnostic related group, which is what determines the payment for a specific procedure.

And health systems have to be financially healthy so that they can stay around and be able to provide care to the community.

Tara: Well, that's an excellent point because I'm a huge believer of trying to address the revenue leaks because you do need resources to be able to invest in these other programs. But, when we talk about removing revenue leaks, CMS likes to spend a lot of time enforcing, frankly, some attempts at trying to remove revenue leaks, So we have to be very careful when we're trying to address revenue, but at the same time, they want us to do all of this value-based. At the end of the day, both sides, government and health system. We want to have clean billing, but we acknowledge that billing itself is such an administratively onerous process and there are all these complications, so we should use AI to make it clean. We have to get CMS on board with that cleanup process instead of them thinking maybe this cleanup process is just a way for us to get more money and not code properly.

Elaine: Right. I agree. AI is a great application and something that we use in our analytics to help with this, you know, coding and, and it's, the DRG downgrading and they do have to get on board, I think, because from my perspective, what I've seen over the last, you know, 15, 20 years, the pressure financially on these health systems.

Tara: Yes.

Elaine: They've borne the burden of the value-based care programs, right? And they're supposed to help, they buy into it and they believe in it, but they're placed, you know, a lot of the payers are making a lot of money in these health systems. If you look at their margins, they're going down and down and something has to change. I believe that AI can be very helpful because there is a lot of paperwork. There's a lot of data, and AI can sift through it very quickly and, and find these anomalies and bring it to the surface for these providers. But they should be able to recoup that loss and it should be more encouraged by CMS, I think and it's not.

Tara: I would love to see a place where we have efficient billing, efficient value-based care, and the system that's able to do that the most efficiently just, you know, like you should be able to do well as a nonprofit health system or a for-profit, but really a nonprofit health system when you've got very well placed value-based care, and , AI should get us there. I think we could go on forever about this, but I want to end with a good fantasy question, which is, you know, the world is your oyster. You get to, since you have such a good understanding of, how AI can be used in a clinical level, not just an administrative burden level, what would be the first three things you would do to make a change?

Elaine: I think that AI shouldn't be such a mystery in the healthcare world, right? It's being adapted. It shouldn't be looked at as the enemy. I think it should be embraced. Obviously, there's things about AI if you get out into the Wild West where it's going out on the internet and finding answers. But there are AI solutions that stay within the ecosystem of the healthcare providers or the payers data systems and it doesn't ever venture out and it's comparing, you know, the contract between the provider organization and the payer and sifting through it.

That to me would be great because it would help us some of these claims and denial problems. I also think that CMS could really step in. I didn't really see anything addressed in this RFI to do something with regards to the amount of time that lapses or the amount of cycles that happen in these denials.

I think from my customers that I see the whole denial process is broken, and I think it's also broken for the payer too. And I think that, that is something that could be focused on and AI could be used to find these similar threads of challenges that are happening in the processes and maybe reduce the back and forth.

Tara: Did you like? What about the comments? Have you looked at any of these comments? Do you have any thoughts, opinions? Snarky comments? Maybe? I don't know.

Elaine: You mean the comments that were out on LinkedIn?

Tara: Yeah. The comments and response. Yeah.

Elaine: Yeah.

Tara: Oh yeah. The comments on the LinkedIn CMS posts, those were interesting. I mean, there's some comments here just I think already, they maybe have already, they have today 238 comments in response to this.

Elaine: Oh, I have not seen those comments. That's actually really stepped up over the last couple of days.

Tara: Yeah, there were some vendors, very self-serving comments to sell their products.

Elaine: Yes. So yeah, I did notice that and it was like, I was like, okay, this is quickly going to not get to the point and it's going to be just a big marketing exposition.

Tara: Yeah. That's why I think it's kind of funny because, I mean, I know you represent a vendor, but you know, it's kind of like chicken or the egg, right? Are they in the best place to understand what's going on? Is. The government is the health system. How are we all going to work together to figure it out? Because you know, each system is different, each provider is different. So is there a one size fits all? Is there one product that works better for others?

That's why I think AI just seems so difficult, but at the same time, it's supposed to be generative, so maybe it's more adaptable.

Elaine: Yeah, there are some amazing AI solutions out there, right? Like if you think about ambient listening, right? In a provider's office. So that takes away the burden of the provider having to spend hours and hours writing up the notes in the EMR. So that's one example. Just even as a patient experience for my own self booking an appointment, right? Calling and trying to get through a call center. AI is also, is used in that capacity to book an appointment, cancel an appointment, reschedule an appointment, and one of my health systems that I go to here in the Atlanta market, they're using AI tremendously there and it's, and it's much easier for me to book an appointment that way than when I call another health system and I have to talk to an individual in a call center and they ask me a lot of questions that I actually, I'm not even capable of answering. I was trying to book an appointment with an existing doctor at a health system and I think they're trying to organize and regiment the entire process and in the end, they created this stumbling block and it was dealing with a human asking me what my diagnosis was for the problem that I wanted to go in and see the doctor for and I said, that's the whole point of getting the appointment with my existing physician to ask this question, and they said, well, I can't book the appointment unless I have the diagnosis.

Tara: Oh my gosh. I could have a whole other episode on the redundancies of having to give my personal information on Freesia, on the phone, on the documents that I'm going to hand write at the desk. I mean, it's like seven points of interest that you need to know what my group ID is for my payer.

Well, thank you. Is there anything else that, I mean, any opinions you would like to share? Anything else you'd like to tell us about WellStack?

Elaine: We are, you know, a fairly new young company. We've taken some technology from an existing solution where we were doing services and we've really productized it and we're getting some amazing results for customers of ours, like Hartford Healthcare and the Guthrie Clinic. We have saved Guthrie using some of these applications we've talked about with RevCycle and also quality analytics by using that unified data model. And reducing the time. It would take an analyst, maybe three months or so to actually bring some of this data together for just one single view in one analytic solution. By using AI and advanced technology we've got this unified data model and we're just powering up various applications for analytics, and they're really seeing the needle move, and that's really exciting to me.

Tara: I really appreciate you coming by. This was our first non-Parker Hudson guest that we've had, so you know, in our nice new studio with all its upgrades. I hope everyone's enjoying the amazing sound that we have.

But in any case, thanks again for listening to Redefining Health Law.

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We'd love to hear from you. Thanks for listening, and until next time, I'm Tara Ravi.