Transcription: A Conversation with Niko Skievaski: Extending Systems of Record to Deliver Smart, Personalized Patient Experiences



Greg Kefer: (00:08)
Welcome to Digital Conversations. I'm Greg Kefer. Today I am joined on the phone by Niko Skievaski, from Redox. Niko, it is great to have you on the show. How are you doing today?

Niko Skievaski: (00:22)
I am great. Thanks for having me.

Greg Kefer: (00:23)
So Niko, you're the co-founder and president of Redox. You're in the integration business in healthcare. Maybe you can take that and explain a little more clearly what exactly Redox is, and what you do.

Niko Skievaski: (00:40)
Yeah, for sure. So I think a little bit of background here may be be helpful. I used to work at Epic, which is the large electronic health record company. And, you know, over the past decade, maybe longer than that now, health systems across the country have been adopting these electronic health records to be the system of record for their patients. One of the things we saw while at Epic was that each time you implemented it, it came with 400 plus interfaces that went out to other systems that integrated with Epic to help provide a whole experience for the patients and providers in the health system. And there were a couple of challenges that the industry was having with that. Number one was that a lot of those technologies were moving to the cloud with cloud adoption of new applications. You know, things were being built on the web, especially with patient-facing tools. It has to be outside of the data center of the health system. So a lot of the traditional technologies weren't designed to leave the data center. And then the other thing was, you know, more and more of these technologies were being created. Digital health has been a huge area of growth in our industry for the past few years. And so we were seeing more technology and more cloud technology, and that just created this opportunity to create Redox, which is this middle layer between the systems of record used at health systems and applications that are in the cloud that are potentially working across multiple health systems, delivering patient-facing tools or provider efficiency sort of solutions. So yeah, that's what Redox eventually became over the years that we've been working on it. Right now we support integrations at over a thousand health systems across the country. And that covers the wide range of digital health tools out there. We have about 350 different digital health vendors that we work with across those health systems. And we see about 10 million patient records a day go through our system. So it's gotten to the scale where we're actually processing a ton of data and enabling a ton of great tools that will hopefully provide a better health care experience for both patients and providers across the country.

Greg Kefer: (02:30)
Right. Are you just integrating to the EMR/EHR systems, or are you going beyond that into CRM and other middleware layers?

Niko Skievaski: (02:37)
Yeah. So it certainly started with integrating with EHR because that was the real need in the market. But what we hypothesized from the beginning, what we're starting to see a lot more of now, are applications integrating with each other. So for instance, you know, a health system might use an online scheduling app and they might also use a tele-health service. And both of those things probably need to talk to the EHR. So the provider knows when the appointment is, and that it's going to be telehealth, but we're starting to connect those things directly to each other. So the scheduling app will schedule a telehealth visit directly in the tele-health app instead of going to the EHR. So we're seeing more app to app integrations come up, which is really cool, to kind of see this ecosystem playing beyond like the EHR as the source of truth. Beyond that, we're doing a lot more in the traditional interoperability space. So we're integrating people with HIEs (health information exchanges) as well as nationwide networks like Carequality and CommonWell. So we're playing a lot more in that world, which isn't necessarily EHR integration. It's more kind of the wider interoperability space, right?

Greg Kefer: (03:35)
Yeah. It's interesting, your background at Epic, which is the, I guess the gorilla, if you will, in healthcare, right? It's the system of record at countless big medical systems. And you know, one of the things I've observed over the years is that these companies have made huge investments, you know, multi-billion dollar investments in these systems of record, and they're very good as record systems. But when you talk about extending, say an engagement layer where you want to engage patients as part of a patient engagement initiative, those systems often aren't designed as systems of engagement, right? But at the same time, it sounds like through something like Redox, you can wrap one of those systems with an engagement layer to extend the value of those investments. In other words, we don't want to delete Epic. No, we're not doing that. That's not going anywhere, but we are going to extend that by stitching in solution Y in the cloud to do these seven things that makes both solutions more valuable. Is that, is that a fair statement?

Niko Skievaski: (04:35)
Yeah, absolutely. And you know, to give some historical context here, the electronic health record was designed from the beginning as a way to capture documentation about what goes on and, you know, when you see your doctor, and the reason why it was important to capture that documentation was so that they could bill for it appropriately and send those claims to insurance, and insurance can ask questions and then they can get paid. And that's what it was primarily designed to do. And they do that pretty well. That's kind of the backbone. But if you think about all the different use cases within a large health system, right, they have all the specialties, they see tons of different types of patients. Those types of patients want to interact differently with the health system. You know, some want to call it on the phone, some want to use an app, some want to maybe have a text message relationship. There's all these different nuances to how you might want to engage a patient and all these different nuances to how providers will want to use that tool. Whether, you know, a dermatologist is going to be very different than a surgeon in the types of tools they need. So the diversity and types of tools necessary to provide technology support for your entire health system is huge. And what that means is that these large companies like Epic or Cerner or any of the large EHRs out there, it's impossible to provide great technology, great user experience for every single use case. And that's why a lot of health systems are really looking at it as the system of record backbone, and then adopting other solutions, digital health tools, to augment the user experience, whether that's their own internal users, whether that's business or clinical users, as well as for patients. So that's certainly a trend that has happened. We saw the sort of first wave of like, the health 1.0 wave, was adopting the medical record to digitize medical data. And then the health 2.0 wave, you know, probably started five, six years ago, probably around the same time Redox started, where they said, okay, we have the EHR in place now, records are digital, now, how can we actually use that data to deliver a better experience for patients and providers across the spectrum? So that's where a lot of our growth has come from from Redox. It was just this shift in the industry of wanting to augment the technology experience with tools designed specifically for each sort of niche area in the workflow.

Greg Kefer: (06:40)
Right. And healthcare is a gigantic industry that, you know, seems to have a lot of proclamations that we're going to do this, and we're gonna do this, although I do find that the desire to be more consumer-centric was around before COVID right? Everybody was talking about it, right? And of course, everybody says, oh, we're going to integrate this and this and this, which is probably why you've grown so much over the past several years. But at the same time, you see this innovator's dilemma emerging, where you've got all of these consumer brands, you know, Amazon and Apple and CVS and Walmart, all moving into healthcare. I was thinking about it this morning. You know, not that long ago, if you had to have something done health-wise, it was whether it was a shot or you had a headache or broke your leg. You always went to the doctor and suddenly you've got choices. And it seems if the industry is really going to have their feet to the fire, to, you know, get more personalized, become more consumer-centric in order to fend off these disruptors that are going to start nipping around the edges. Is that what you're hearing as well from some of your customers in terms of how they're moving forward with their innovation initiatives?

Niko Skievaski: (07:49)
Yeah. Yeah. Certainly you mentioned a couple kind of big trends in there that we can start to pick at. Certainly before the pandemic, there was a desire to become more consumer-focused for health systems. They said, you know, how can we actually make our interactions with patients more like how Amazon thinks of their interactions with customers or how Target does -- this really accessible user-centric view of the world. But I would say before the pandemic, a lot of health systems were kind of seeing that as a nice-to-have like, oh, it's a differentiator for us. It is a way that we can better compete with other health systems in our areas. Whereas the technology shift that we saw with the pandemic was, it went from a nice-to-have to a necessity because they had to fundamentally change the way that they deliver healthcare. Like you can't have patients going into the hospital or the clinics anymore because you know, the higher risk, but also that's where the COVID is. Like, we don't want to go into the hospital as a patient anymore, right?

Greg Kefer: (08:43)
That's right.

Niko Skievaski: (08:44)
The more things we can do virtually, the better. And so it turned from this nice to have into a necessity. And so we actually saw technology adoption become far more urgently adopted because of the pandemic. Obviously, tele-health is the big example there, but everything else around that too, to try to make the virtual experience that much better. So health systems are now frantically trying to figure that out. And they're in a tough spot because, you know, 2020, basically every large health system in the country is going to lose money because utilization went way down. 2021, they're probably they're going to struggle to break even. And so they don't have a lot of money to be investing in this type of transformation that's necessary. So while they struggled to do that, and while consumers are fundamentally shifting the way that we interact with health systems, it leaves an ample opening for all of these big companies to attack the healthcare space. And if you look at it from their perspective, healthcare is the last frontier. It is the largest industry in our economy producing about 20% of GDP. It is terribly inefficient. About a third of that is estimated to be waste. And so these big companies, big retail, big tech, see it as this last frontier of, if we can make a meaningful entry into that space, it can be a huge market, and they have the expertise at consumer experience and health systems have expertise at medicine. And so it's kind of this battle going on now of, you know, big health systems are hiring people from the tech and consumer world to try to change their organizations. And, you know, Walmart and Amazon and Google are hiring people from healthcare to try to come in from that direction. So yeah, it's going to be a really interesting landscape as this unfolds.

Greg Kefer: (10:22)
Yeah. I think you really touched on something there too with the pandemic being just this fire that was lit because yeah, you're right. I mean, in January of 2020, we were talking about another year, talking about how we've got to be more consumer-centric, but you know, it used to drive me nuts that the steering committees that meet once a quarter to make decisions and it takes a year and a half to make an investment decision on technology, for example, where that's not happening at the big consumer companies. They're doing it at lightspeed. And that leads me to my next question or talking point with you. And that is really about this notion of patient engagement, which has been front and center on the mouths of the influencers, the opinion leaders in healthcare, that we've got to be better at the way we interact and engage patients. You know, the industry is shifting from fee for service to a value-based and outcome model. Everyone's got mobile devices. Technology is maturing at a rapid pace, even apps -- there's too many healthcare apps, you know? No one's downloading one of the 300,000 apps out there. Portals require passwords that people don't remember. And you know, I'm gonna out myself a little bit here. You know, the company I work for does conversational AI chatbots, which happened to use Redox as a way to personalize those experiences so that it knows that my name is Greg and that I had Dr. Smith as my primary care physician. And I have a prescription to some painkiller or something like that. And you mentioned virtualization because of COVID, which of course, you know, talks about this notion of a virtual waiting room, for example, where you check in and you fill all your forms out, and those would write back into an EMR through an integration, I would assume. But do you see that? I mean, do you see innovation areas across all your clients where they're trying to get at that patient engagement dimension, or are they nipping around other edges?

Niko Skievaski: (12:15)
Patient engagement is such an interesting area and, you know, I'm an economist by training. So I always think of the sort of core market failure that causes the lack of engagement. And this is something that is kind of a basic thing that really opened my mind to some of the challenges with it because in the healthcare market, as a consumer, we don't actually have direct demand for healthcare the same way we have demand for food or clothing or other things like that. We have what economists call 'derived demand'. Our direct demand is for health. Like we want to be healthy, but we can't buy health. You have to buy healthcare. And so we assume that buying healthcare will help us be healthy. And that's this problem. It's this sort of a wrench in the gears at the base of the market that makes engagement really, really difficult. So if you relate healthcare to fintech, for instance, like we have a direct demand and use for money. And therefore we log into our banking apps. We log into our investment apps. We think about money more often because we understand the value that we get from money. But when you think about health tech, you can make the same sorts of applications that would be helpful in a fintech setting. And they don't work in healthcare typically because by the time a patient is engaged, it's often because they're in trouble, they're down the rabbit hole in a chronic condition, or they have an acute situation going on when it's the time to engage with them early and prevent some of these things from happening. The patient isn't engaged because they are healthy. They perceive themselves to be healthy at the time. So, it's a challenge that I think is really, really interesting. And one of the things I love about working in healthcare is just how difficult that is to solve. But getting back to your question about what are we seeing, absolutely. We're seeing this race to figure out how do we actually engage these patients that are fundamentally difficult to engage because of this market failure here. And market failure sounds harsh, but as an economist, that just means the reason why patients aren't in engaged in the sort of traditional way. The move to value-based care, I think is front and center in this, in a fee-for-service world, you don't care if a patient is engaged, they're going to come in and get a surgery, they're going to come in, and be sicker, but the more that they stay in the hospital, the more that they utilize the health system, the better the health system does, the better the doctors do, the more they get paid, which of course does not align well with reducing costs in our industry. And that's why we've got to move to this value-based model, which requires us to figure out how to engage those patients before they're sitting in the hospital bed, before they're sitting in the waiting room to actually change their behavior and get them back on the right track. And that's why this challenge has become front and center. So, I think some of the best minds in the world are looking at why humans are engaged in technology and trying to apply that to healthcare. Chatbots, I think are a great interaction, you know, because they feel like you're talking to a human, but the bot part of it makes it scalable because of course we could sit humans in a room and have them text patients and have those conversations, but it's not scalable. And so the bot aspect of it makes it scalable. And then, you know, you might always fall back onto a human if the situation becomes necessary. So it's those sorts of interactions where I think we're figuring out how -- and when -- we can engage patients with technology in a meaningful way. And that's the sort of innovation that we see bubbling around the edges and with the pandemic, it goes far beyond like the video telehealth presence, because every interaction that a patient has could be made into something more engaging, it could be made into something stickier in a way where a patient can actually improve their health performance and potentially prevent a chronic condition from forming. Which of course is a huge burden on health systems as well as a health burden on the patients themselves.

Greg Kefer: (15:44)
Yeah. It's funny, you touched on something really interesting there and several of our clients, big hospital systems that have this idea you touched on, scale. And this idea that, and again, you see this with mileage clubs and airlines or supermarket clubs, but this idea of building loyalty over the long term. And you know that you want to have a relationship with these people because they're not always sick; they don't need you unless they are feeling really bad. And some lucky people go a whole lifetime without ever really needing to go to the hospital. And the only way to do that, you know, short of hiring an army of people to sit in a room and text or call is to use conversational AI or something. But there's a dimension of personalization, which kind of circles us back to where we started here, where you need data that sits in a system of record, like an EMR so that it knows more than just, Hey, I tried to talk to you a month ago and you ignored me, but more about, Hey, you're due for a hepatitis vaccination, or something. And the only way you're going to get that level of smarts is to work in concert with these big systems of record that have all that rich data.

Niko Skievaski: (16:50)
Yeah. I think that's a great point. And, you know, from the loyalty side, you not only need to engage patients to get them to come to you when they need you and to intervene earlier, when, they might need some preventative screenings or other measures, but you also need to engage with them in a way that's super accessible because they have options now. We're seeing Walmart's open clinics and, you know, you can pay out of pocket for an office visit for like, $80 and your insurance co-pay is like $50. And if you have a poor user experience at a health system, where you can use your insurance, then they might opt to paying a little bit more to walk into a Walmart and see that provider day of, because it's difficult to schedule with the health system. It's difficult to figure out what's necessary. It's difficult to get on the calendar because they're scheduling a month out. So all of these things are points of that user experience that detract from engagement with the health system. And as patients have more and more options, whether it's retail clinics, whether it's telehealth services, direct to consumer telehealth is booming right now, there's a lot of different options out there and consumers are going to be making those choices. The other big trend too is, you know, I'm a millennial and we're technology natives, right? We expect more from technology and I am willing to pay a premium for having convenience. And what that means to me is like, I'm not going to get on the phone and call a health system. I'm going to do what I can do on my computer, and do it as easy as possible on my phone. And what that means is that as our demographic gets older, we use the health system more and more and more. I didn't use the health system basically at all until probably four years ago when I had my son, and millennials are having kids these days, which probably blows the mind of a lot of older people. But that's, that's when you start interacting with the health system more, and then as I get older, I'm going to interact with it more and more. So the demographic changes in our society are also going to demand more engaging tools and more accessible care from a technology standpoint.

Greg Kefer: (18:49)
Yup. Yup. And they sure as heck, aren't going to put up with, you know, like, let's say, you know, you get this snazzy thing to fill out all your forms virtually before you go to the waiting room versus the clipboard, ...would you please take a picture and scan all those, convert them to PDFs and upload it to your portal. That's not going to fly! I'm sorry. That's wouldn't fly with my mother either, by the way. You know, my mother would be able to figure it out, but a millennial would just say, forget this I'm going to Walmart, right?

Niko Skievaski: (19:12)
Yeah, yeah. Or worse off, like I've been asked to fax something, and I'm like, I don't know what that is.

Greg Kefer: (19:20)
Exactly. Yeah. I tell you, I think that, you know, the health systems, the providers are definitely aware that they need to move here and certainly COVID has lit a fire, but I think the generational point you just made is spot on too. And you know, it's gotta be a seamless experience. And ultimately I feel like the industry has done a great job at digitizing. It wasn't that long ago where I went to the doctor's office and there was a wall of the color-coded manila folders. Remember that you're looking at it going, wow, like I'm purple and what happens if you're yellow, you know? It was incredible. But you can't automate until you digitize that. And I feel like the industry has done that. And I think through what we've talked about, where the Redox layer allows that digital record system to be opened up so that you can do some of these cool things we've been talking about is key. And I guess the real question is just how fast can they move? I mean, it really is a matter of speed because Walmart is opening clinics at their super centers all over the Southwest right now. That is, that is a threat. If I'm a hospital in Georgia right now, I would be terrified of that, because they're coming.

Niko Skievaski: (20:25)
Yeah. Well, and you know, nothing we're talking about right now is cutting edge technology, right? These have all existed for a decade or so in other forms and other industries, but the economics haven't been there to incentivize this adoption until now, I think. And, and you know, if we were doing this a year ago, I probably would have said the same thing, but I mean it way more now, because the pandemic has changed everything. I can't imagine being in a leadership position at a big health system right now with the struggle of taking care of a complex disease that is overburdening your health system, while at the same time, knowing that your financials are in total shambles and figuring out how to actually stay afloat while going through this. It is a really tough position that they're in. And, you know, everyone's been talking about how healthcare needs to be disrupted forever from a technology standpoint, but right now they are getting disrupted by this pandemic and the ones that adopt technology and figure out how to do this and engage their patients and do it virtually and provide this great user experience will come out the other end of this and actually succeed. The ones that don't, might not make it. And we'll probably continue to see lots of consolidation in the industry where certain health systems, certain hospitals will be acquired or potentially, even go out of business because they weren't able to figure this out while making ends meet in a really challenging time for healthcare.

Greg Kefer: (21:46)
Yeah. I couldn't agree with you more. We're singing in the same tune and you know, if you listen to this podcast, we talk about that all the time. But Hey, Niko, it's been terrific having you on the show. You've got your own podcast -- normally you're on my side of the block. What do you do? What's your show?

Niko Skievaski: (22:05)
Yeah. So, it's called the Redox Podcast. We got really creative with the name. Basically what we do is we interview folks like you, people who are making technologies in the space, and we try to highlight the bright spots where technology is making a difference. Typically the people who like to listen to it are folks who are in the innovation world, and in healthcare. So a lot of health systems, a lot of other technologists, and startups, and people in that world.

Greg Kefer: (22:29)
Cool. All right. Well, we'll flip seats one of these days, but, thanks for coming on the show. This has been Digital Conversations. Thanks for listening to Digital Conversations. If you liked our show, you can always subscribe on iTunes and feel free to like retweet and share on your social networks. This and other episodes are available on iTunes, Spotify, and Linkedin.com. We'll be conversing again soon with a new episode so long.