An Interview with George Bosnjak

Brian:

Welcome to the Augusto Health IT Podcast, where we talk to industry leaders about their vision for software design and development, and about mobile and cloud in healthcare. I’m your host, Brian Anderson, CEO of Augusto Health IT. There’s a lot to cover here. So let’s get started.

This is episode number four. Our guest today is George Bosnjak, industry guru in the world of health IT. George and I met through mutual connections here in West Michigan. We’re currently under, in this state, in this area of our world, we’re under stay home, stay safe orders by the state government because of the COVID-19 pandemic.

And so, this world of health IT is this really relevant space right now and George has an amazing amount of insights and depth in that space. And I just wanted to share his knowledge in this space and interview him to bring more visibility to this world of health IT and health information networks. And so, welcome, George, welcome to the podcast.

George:

Great. Thank you for having me.

Brian:

Tell us a little bit about yourself. What’s your background?

George:

My health IT journey started about 11 years ago. I had a really great opportunity. I was working with a group of Chief Information Officers leading very large companies here in the West Michigan region and had an opportunity with a few of them who were leading some healthcare organizations to join a startup, looking to basically connect clinical information across a couple of regional hospitals and be able to deliver those back to providers at the point of care.

And, 11 years ago, that was a relatively new, exciting technology. I think it’s still pretty exciting technology what the group is doing, but I had an opportunity to start there. I grew that organization from having three hospitals to connecting over 129 hospitals and 6,000 offices and other groups in the healthcare continuum, representing about 11 million unique patients all across Michigan and the Great Lakes region.

So, I was very proud and excited to lead the business development arm at Great Lakes Health Connect, which is today now a part of MiHIN, the Michigan Health Information Network. I had a good stint working on building a network on payer reimbursement models, basically a new technology of how we set up better reimbursement for providers to be able to get a repayment for out of pocket costs for individuals.

Basically we were looking to take that same health information sharing, network growing idea and be able to allow the ease of hiring and the moving of providers, which is very obviously pertinent to today, where we’re having doctors having to move around, show up at different hospitals and jump in and provide care where they best can.

We’re basically looking to move that from a paper, phone, and fax process to have that as a connected network where we can move providers, have that credential, they can get to work quicker, faster, serving patients. We can do that all electronically and in real time today. So pretty exciting stuff.

Obviously, a terrible case that we’re all currently existing and working under, but there’s a lot of groups that are doing the best they can to improve the situation and jump in and serve. And we hope that we can do that today and into the future.

Brian:

That’s great, George, there’s a lot to unpack there. It’s pretty interesting. 11 years ago, you started working for what’s called a HIN, or a Health Information Network, or a Health Information Exchange. When you first started, was that what it was called?

George:

Yep. We were designated as the sub-state kind of what they would call a regional health information exchange, which quickly grew into a statewide exchange covering really 90% of the acute care beds in the state. So we were a statewide or regional health information network and then had some partnerships and connections where we started moving information all across the United States, kind of in the Midwest region to start, but had the ability to move that.

So, yeah. We were a health information exchange, then went to being a statewide exchange and now they’re part of a state designated entity and a large group there. So that’s what we were and what the growing process looked like.

Brian:

Yeah. So, 11 years ago, as you got involved in this process, there were only three hospitals in your network. So you’re like, “How do hospitals get information to a health information exchange?”

George:

Yeah. So, at that time, the marketplace for EHRs was a little bit more diverse than it is today. So you had more of the Epic, Cerner, Meditech, McKesson split, where facilities could be on anything from that to the smaller ones were on CPSI.

So each of them were operating their own little information bubble on clinical records and really, to their credit, the leadership of these three facilities said, “Hey, we’re not going to compete on clinical information. Ethically, having all of the information on that patient available to the provider at the point of care is what we all have to do.” And they were all committed to it.

So, really what that took was a large upfront investment and a belief that we’re going to connect to a trusted, neutral, third-party in the middle, all of us, facilities and systems that do absolutely compete in regions. They all want to grow bigger and serve better, but they weren’t going to compete on this.

They decided that we’re going to share and find a way to connect, make sure that a lab result from hospital A looks like a lab result from hospital B, so that the doctor out in the field can take the best care of that patient that they can.

And really having that trust and support of those facilities off the bat, great technical expertise on connecting and building out, at the time, all HL7 interfaces was super successful. The real challenge is how do you get that out to all of the doctors, the thousands and thousands of doctors that are operating the one, two, three pediatrics down the road that has just a little bit

of the information that needs to get there, but you still need to have that delivery model.

So, building and expanding and chasing that long tail of the network is what we did over the eight years of growth that we had.

Brian:

That’s interesting. And how did it evolve over time? Does every entity now have an EHR? And is it almost standard now that they plug into an HIE?

George:

Yeah. Almost all of them absolutely have an EHR. You have to. I mean, I’m sure that there’s a few very, very traditional doctor’s offices and provider offices that maybe don’t. In general, it’s upwards, 80%-90% adoption rate of what you’re going to see. And certainly every inpatient facility has a very robust and very functional EHR today. Totally normal across the board.

Usually, there are a couple of different ways that they can connect. So, originally when we first were getting started, there was no requirement for facilities to connect, but there were the meaningful use standards, where you had to deliver certain types of information that were designated as important to public health. Things like syndromic reporting.

Today, well, the pandemic that we’re currently in, the flu syndromic reporting that we were doing historically that all facilities did, today, that would be part of the process of reporting out all of this pandemic.

I can jump back to it later, but we have really, I think, a pretty good story about lead results in Flint during the crisis there, where we were taking lab results and matching those elevated lead levels and making sure that those were all done.

So, today, every EHR certainly usually does connect to some type of exchange. Now, there’s large exchanges where it’s a vendor specific exchange or the state’s mandating you to connect to an exchange, or you’re part of a large Hospital Association America or you’re part of Tenet and they connect to a large national exchange.

So, there’s lots of different landscapes out there, but there’s about 100, give or take a few, regional and statewide exchanges that I would say almost any large facility is connected to in one way, shape or form.

Brian:

That’s interesting. So, the progression is that just over a decade ago, there was this… You joined the very early startup phase of a health information network, and then that’s grown. The industry as a whole has implemented more EHR systems, health, electronic health record information systems.

So almost every office now, who used to be on paper, now is using a system to manage their office. And that system is, in some cases, in most cases, connecting to a health information exchange and sharing key information with that exchange.

George:

Absolutely.

Brian:

And so, it’s tied into our bigger national agenda around healthcare and making healthcare and health IT much more prevalent in our health system, because it used to be very paper based, it was very like a laggard in terms of the adoption of technology for health information. Right?

George:

Absolutely. Yep. It absolutely was. And there were a lot of reasons for that, traditional forms of education, privacy and security reasons that were always important. But yeah, certainly healthcare was a little bit slower to adopt some of that electronic forms of information sharing that other industries have been doing for decades.

Brian:

Right. Right. So, now there’s all these health information exchanges and you mentioned the different kinds. There’s some that are vendor specific. So an EHR system might provide a health information network that they can connect their systems together in maybe a more proprietary way.

And then there’s state mandates and there’s other types of exchanges like a hospital system, again, kind of exchanging information between the whole system in a way that’s, you don’t connect to a third-party or you could pass more information. And so, information around health is moving around fast now, and it’s a massive amount of information. Maybe you could comment on that.

George:

Yes. I mean, the amount of transactions that come through on clinical results from just the facilities in Michigan, it’s in the billions and billions of pieces of result information. The amount of transactions and some things that we were running through, just for our little exchange here in Michigan, was approaching nearly half the size of all of PayPal transactions.

So, if you could imagine and you think of these big giant companies and there’s got to be… Well, just connecting all of the results information from all of the patients in real time and moving all of that, just for one state, was like I said, billions and billions of transactions every year that we were tracking.

Brian:

Yes, yes. It is a massive scale. And it’s pretty cool to hear West Michigan companies handling that kind of data. It’s not just a Silicon Valley thing. This is every area of the country that has this kind of data flowing.

So, what are some of the newer regulations that have emerged? There’s this regulation called TEFCA, maybe you could comment on that and what a QHIN is in this world.

George:

Yep. Absolutely. So, the TEFCA guidelines are a set of, similar to, I shouldn’t say similar exactly, but as a national mandate, similar to Meaningful Use that came down and said to facilities, “You will participate and share information in this manner. Here’s our guidelines.”

The TEFCA guidelines have been out for actually about two years, where people could review them, there was input from HIEs, from health systems, from vendors, for all of these rules and regulations that came down.

And basically what it does is try to dictate how we’re going to build a national network of sharing information. That there will be a higher level of hub exchanges, which will be those QHINs that you’re talking about, where they’ll be, and it doesn’t designate a set number, but say five to 20 nationally, where all of these facilities, if they’re not connected to an exchange, or if an exchange is a sub-regional exchange, they’re all going to have to feed into these larger hubs.

There’s going to be a highly encouraged consolidation of who’s aggregating this data in either, you’re going to have to find ways for these organizations to play and to interconnect much better, which a lot of them had already started doing up to two, three, four years ago. And how do we begin to connect and share that information? And systems are figuring that out. Or you’re going to be forced pretty quickly to jump in and solve that problem because you’re going to get forced out.

Basically the federal government has said, “We’re not connecting to 100 different exchanges and 100 different vendors and thousands of different health systems. There needs to be central hubs that make sense.”

And they have some guidelines as to who those QHINs are. It can’t be a single vendor organization. So, they basically, if you’d say, “One vendor and we’ll connect all of our vendor specific tools,” you can’t qualify as a QHIN.

It can’t be a single state sort of sub-regional, sub-state exchange. You need to have a multiple state, multiple region footprint to be able to be considered a QHIN. It can’t be one national system, so a large hospital system that’s covering 20 plus states and has 40, 50 hospitals. They still have to have some interconnectivity and sharing happening among different types of organizations.

So, there are some rules and setups as to what qualifies and how can you be a Qualified Health Information Network. And I think that they’ll look to, my guess is they probably were going to roll that out this year, probably even maybe at HINs this year, they got canceled. But given the current environment that we’re all operating under, I think that that’ll be delayed at least until the fall here.

Brian:

Yeah, it’s interesting. So, it’s like this consolidation, all these different health information networks, they’re consolidating into these QHINs.

The QHINs are going to have more of a direct relationship with each other. So they’ll be passing information back and all the regionals and other health systems will just connect to the QHIN and the top level information will be passed. And those QHINs will have the kind of relationship and responsibilities for things tied to the state and federal governments from a reporting perspective. Right?

George:

Yep. That’s it in essence. What they’ll do will be a lot of what you said right there at the end, that reporting structure. How do we feed information back to the ONC? How do you feed information back to the Department of Health? And these large, super regional exchanges will be the ones that’ll be responsible for that.

Brian:

Yeah. Let’s just talk about some of the things that they’re capable of doing. So they’re getting all this data, all this data is flowing back and forth between all these entities, but what’s some real life scenarios? Maybe just talk about those from like, we have this COVID-19, we’ve got interesting problems all over the place.

George:

It is. So, I’m personally a big believer, obviously, in health information networks. The group I’m working with today, we’re very much moving credentials is a health information network and how do we move that around?

But there are some great examples of where health information networks stepped in and provided real value in times of need. When Hurricane Harvey hit Houston, there’s a group down there called Houston Health Connect, which is a regional health information exchange that had connected all of the hospitals and had basically the medical records for individuals stored in one place and shared across the region.

So, when they had to start setting up tents for people to be seen in parking lots, and in football fields, because hospitals were getting flooded and people were displaced, it was very difficult for individuals to get access to their internal EHR. And if they had patients coming from all over the place, who knows if they were a patient there before.

So, basically Houston Health Connect came up and set up the availability for these clinicians and others that were seeing people at these field hospitals and field clinics to be able to pull up that community record of that individual.

So if someone showed up, it didn’t matter if it was a provider that had access or not access to the EMR of the hospital they normally went to, they had the community record and they could pull up that individual’s information and find out what are the basics? Or what are they allergic to? What medication are they on? When was their last test? What are some of the underlying clinical issues that this individual might have?

And that was all available because all of those hospitals in the Houston area decided that they were going to share information, but they were going to make an easy portal for individuals to see a consolidated patient record.

And when tragedy strikes, like what we’re dealing with now, it was great that that infrastructure was in place that they could treat those patients with the most up-to-date information at the point of care. And that’s something that happened looking backwards.

Today, obviously, we’re facing another crisis. We all see pictures of setting up field hospitals in civic centers and tennis courts, you name it, any place where individuals can show up. And the ability to be able to get information on those patients, because you don’t know where they’re going to come from. If you’re a clinician that’s normally working at one hospital and patients are showing up, they may have never ever seen you before and been to your hospital before. But they live in your community.

And those individuals, if they had went to any of the hospitals in those communities where that record would have been shared and explained, that doctor, that nurse at least has some background information on that patient when they show up, it’s easily accessible, it’s not hid behind the system’s firewall, it’s not stuck on a Epic or a Cerner.

It’s a true community record where, at these times of emergency, it should be available to all of those individuals that are working at field hospitals and anywhere at the point of care.

Having that infrastructure in place can be extremely helpful and positive in these trying times.

Brian:

Hey, in your experience, is that like that portal that got developed? So, Augusto is a development company, we do custom software development and we’re always interested in working on problems like that.

So, how are those systems developed? Are they built by the HINs? Or are they built by… Who builds those systems? And then another question is, is like, hey, if you’re an individual, or if you’re a company, how do you get access to this data? What are the relationships that have to be there to do business with HINs?

George:

Got it. So, usually all of these portals and other things, health information networks are, while they do have technical expertise in-house, usually they’re not development shops. Some of the larger ones are, and do have that talent.

But there’s national vendors, groups like yourself, that they would bring in and basically try to mirror what an individual patient record might look like inside of an EMR. How do we present that in a safe, secure platform online that we can give access to others? So usually an outside group, technical experts will come in and help build that while taking in all of that clinical information.

Brian:

And who’s the backer of that? Like in the Houston example, who would have been the people that said, “We need this,” and funded it?

George:

So, that varies across the board. So states all got a chunk of funding and still get some minor funding for building these exchange networks. That funding, which was about 10 years ago or so when it started, had waned.

So, each state had designated entities and was building these exchanges. So there were some that were funded state and federally. And then there are some that’s like Great Lakes, that grew organically where those hospitals, they paid us to aggregate and store and share that information. So, the users of the data, the contributors of the data were actually the individual organizations that were financially supporting it.

So our 129 hospitals and 6,000 plus offices and 30,000 docs were the ones that were all chipping in a little bit to be able to keep the network up and running and afloat. So, some, like I said, are state and federally funded, obviously the QHINs and all of those will get more state and federal funding. But some like Great Lakes were independent, fully supported by their members.

And to really get access to that sort of information, it is fully HIPAA compliant and HITRUST certified. So there has to be a clinical reason whether it’s a treatment, payment or operational reason why your organization would need to be connected to that, or to share to that. And that ranged from what you would think big hospital systems to doctor’s offices, to clinicians, to regional labs that would have access, payers, people that are trying to organize that care would all contribute in some way, shape or form.

Brian:

And do you see a future in healthcare where that information or HINs are providing more of a framework for apps to be built, developers more in general? There’s always this sensitivity around the data and the security of the data, but it’s also super helpful information you could build some amazing, helpful applications for people. Where do you see it going?

George:

Yeah. There is a huge, fine line there. So some of the things that we had that were really interesting opportunities that we thought that were kind of that app, sort of what you’re talking about of, you have this big asset of clinical information, patient information that you want to protect and you want to keep secure, and your goal is the treatment of the patient. But that could be used in unique ways to solve problems.

One of those was clinical trials. Clinical trials always struggle to find patients. It’s a challenge. You need a specific age, you need a specific demographic, you need a specific diagnosis, you need maybe specific blood types, specific lab results, specific comorbidities. And finding patients that meet all of those criteria in a quick timeframe that are willing to be part of a clinical trial is a challenge. That’s why they’re expensive to do. That’s why it’s hard to do.

Now, you have this data lake sitting over here where all of that information is flowing in a hub at real time. Could you set up an application where you have a set of clinical trials that are sitting out there that you know these are the SLAs for each of these clinical trials and that as that information flows through a flag gets sent to that provider and says, “Hey, Sally, who’s in front of you would qualify for this clinical trial. Maybe you should send her some information on it.”

So that’s one of those fine lines of that’s helping, but you’re proactively filtering and finding information. So, I think one of the good things about those health information exchanges is they always put data protection first, patient data, we all see the news and you see any time data gets out, it is a huge liability and frankly would end the existence of a health information network. If they had a leak of information of some sort, it would be very difficult to earn the trust of others to continue to share data with you.

I was blessed that we never had any issues whatsoever in the nine plus years that we were building the health information exchange here in Michigan. But there is a fine line and I think it’ll be interesting to see, after what ends up being with COVID, what are we willing to do?

Because there’s going to be changes. There’s going to be changes in how we, from my perspective now, how do we credential docs? That process is going to change. We’re going to need to get more efficient, we’re going to need to get faster at how do we identify, and patients will change what we’re allowed to do with data to be able to find information to map people. I think it’s going to, hopefully there’s an infrastructure in place that we can make the next leap after this to be able to tackle these things better in the future. But it’s still yet to be seen.

Brian:

Yeah. It’s such a big problem. The data’s flowing now and now you’ve got privacy and security and legal and you’ve got trust issues and there’s all of these things that are…

But that data is so valuable too, it can do things like you just said, in real time, you could build a list of people that match a clinical trial, or you could notify people, or you could do all kinds of interesting things with that data that you just couldn’t have done before. It would have had to take people filling out applications on paper or doctors knowing in their heads that this was something that was an option for this person and getting… How hard is that with how busy they are every day?

So, there’s just amazing things that data can do. So it will be interesting to see if it becomes more of something that can continue to be used in the development of applications to serve people.

I’m wondering, and this is probably a naive question, but like as an individual, if I wanted to get my information from a health information exchange, is that something I can do?

George:

So, some of them, you can, some of you, you can request that. In general, even though exchanges are aggregating and storing and moving that data, you want to think of them as the pipes that are moving the information around. The owner of that actual data is still the hospital, your doctor, the health system, yourself are actually the ones that own that data. So, usually that record, you would have to go to your provider. For most exchanges, I know for us, release of information was always, we would set them up with whoever the clinical provider that sent that information in.

So, that may change in the future. But as of today, most of them try to defer back to the hospitals just because the individual patient, anytime you go in there, you’ve got to sign those 10 pages of paperwork. Part of that is release of your patient information. And that’s handled through that. So usually, no. You as an individual can’t go to an exchange and say, “Give me my record.”

Brian:

Interesting, Hey, I want to transition to the stuff you’re working on these days, because you work in this space, you’ve got all this stuff. How are you translating that into what you’re doing today? And what are you doing today?

George:

Yeah. So, what we’re doing today is similar to what we were doing 10 years ago, where there’s an inefficiency in the system and a way to build a trusted network where we believe that sharing and making the accessibility of information will lead to improved patient care.

So, with Professional Credentials Exchange, I’m very excited to be partnering with some statewide and some regional systems here in Michigan to basically build a first of its kind in the country distributed ledger, so blockchain enabled, which adds that layer of trust, credentialing network.

So that provider credentials can move and flow where individuals move. Today, that process of re-credentialing a provider so that they can start seeing patients can take three months, five months, six months sometimes. I spoke with a group out of Chicago last week that said it took them 19 months to get one doctor to be allowed to see patients in one facility. And that’s just, we just can’t keep that, you just can’t have that happen going forward.

If anything brings up even more to light at the current crisis where we’re calling retired doctors out of retirement and saying, “Hey, if you can come help, come help. If you’re in a facility or in a state or a region where it’s not flaring up, get to the East Coast and get to New York, and how do you help?” Well, how do you prove that those providers are who they say they are?

Historically, it was, call up where they worked before, call up their school and get all that information and sign off. Well, we’re looking to build a way to digitize that information, all that credentialing, their licenses, their education, their employment history, so that’s that blockchain trust verification on all of that, that as the health systems and payers upload that data, that it can be shared across the network so that docs can get to work faster.

When they show up, you can log on, pull down all of those credentials, they’re all trusted, they’re all verified, they’re all hashed. Blockchain is a new technology and a lot of you have maybe heard of it in the financial world and other worlds, but really we think this is the first really great application of blockchain.

We think there’ll be others down the road, but for making sure that provider credentials and verifications are fully trusted, that that diploma that you see is exactly what was verified and what was sent from that medical school, it’s completely electronically trusted and signed off on. We think it is the first really good application where we’re going to start being able to get docs working faster, where all of their health information, all of their education and employment information will follow them.

But really it’s a lot of what we have been doing for the last 10 years is, you see an inefficiency where organizations could be communicating, working in sharing information more efficiently. And when you add efficiency, patients get seen faster, patients get treated faster. Really the one thing we’re all working for is, we want the healthcare system and health outcomes and the healthcare experience to be better for patients.

We’ve all had to deal with it. We’ve all been to a hospital. We all know someone who’s been through a healthcare experience. And sometimes those are difficult and sometimes they’re trying and anything that we can do to add technology to make that efficient, make that better, make the outcome better, we love doing it. I don’t know if you can’t get motivated about that.

Brian:

Yeah. Serving people and making it easy for doctors to move between health systems and stuff.

George:

Basically, yeah. If a doc is moving from one area to another, whether that’s responding to an emergency or they’re being hired or they’re getting hired out of school, there’s a long process of checking all of that background information, just because it’s difficult to find all of it and to call and fax and have someone return and mail that information to you, fax it to you that’s notarized. All of that, it’s just a process that takes time today.

Brian: Do it in real time.

George: … this exchange is doing it, we can move it in real time. We can add that efficiency, that doc can get working, those resources that that hospital have checking background can be doing patient-centric health. So, that’s really what we were looking to do. We’re excited about the partners that we have here starting for Professional Credentials Exchange.

Launching our pilot right now, we’re in the middle of running it. And we hope to have a couple of white papers and some information out at the end of the third quarter. So, fall, early winter of 2020. And then 2021, we will be fully going to market and launching a Credentials Marketplace that can move credential datas and get docs hired and moving and working in real time.

Brian:

Yeah. That’s great, man. State-of-the-art at healthcare startup business here.

George:

It is, I love it.

Brian: It’s really cool.

Super early, super interesting problem you’re solving, you got backers, investors, you’re working on it, piloting, you guys have what sounds like a really solid roadmap. Where can people find out more information or get in touch with you if they wanted to be a customer at some point?

George:

Yeah. So anyone that’s really in the healthcare ecosystem where you’re having to get a doctor or a nurse or anyone in your group working, you can go to procredex.com, that’s P-R-O-C-R-E-D-E-X.com. There’s a link in there to be able to fill it out. All of that information goes straight to me.

We’re an early startup. So me leading the development is the one and only person that you get to deal with. So I’d love to talk to anyone in the healthcare ecosystem that’s interested in how we’re using blockchain to solve credentialing and building another network. And if there’s any questions on some of this stuff we covered earlier and my background in health information exchange would love just to chat about it.

Brian: Great, George. Hey, thanks for your time today on the Augusto Podcast. And it was great talking to you, great listening to your insights in-depth in this space, man. It seems unique to me. Are there a lot of other people like you out there?

George: For the work that I did in the exchange space, there’s a limited amount, maybe a dozen of us. It’s a really unique, specific space. But absolutely thank you, Brian, for your time today. Thank you, Augusto. You guys are doing really cool work in this area, and I know that you’re committing resources and time and energy into healthcare technology and I love seeing it. I wish you and your team the best of luck. And I know that you’re doing great work, so keep it up.

Brian: Hey, thanks for listen ing to the Augusto Health IT Podcast. Augusto Health IT is a custom software design and development company with a focus on healthcare. If we can help you on your next project, or you just want to say hello, contact me today by calling 616-427-1914 or visit www.augustohealthit.com. Remember, you can always find this podcast on iTunes, Spotify, Google, and YouTube.