TECH/HEALTH PLANS/QUALITY: Lonny Reisman, Active Health Management transcript

Here’s the transcript from the podcast I did with Lonny Reisman, a week or so back. Really interesting stuff for those of you interested in the future of patient care management.

Matthew Holt: So welcome to another forecast here at The Health Care Blog. I'm Matthew Holt, and today very exciting that we're talking with somebody's who's really been a technology pioneer and a medical pioneer in developing tools for active health management, and surprising enough, his company is called Active Health Management and I'm talking with Lonny Reisman. Lonny, how are you today?

Lonny Reisman: I'm well, thank you. How are you?

Matthew: We're doing pretty well over here. One of the first fall and somewhat foggy days in San Francisco, but at least we're not going to endure that terrible New York winter you're going to have to go through [laughter]. Anyway, let me very briefly give a sense to, in essence, what your organization does. And there are a couple of things that people who may or may not necessarily have heard of Active Health Management should know. First off is that you are in the business of taking data, all kinds of different data about medical information about patients, putting it all together and spitting it back out and using it to try and help and inform and change medical decisions by those patients and physicians. And the second one is that you've been so successful at that, that last year, Aetna decided to write a very big check, $400 million to buy you, and now you're part of that large insurance company. So with that it's a very brief introduction. why don't you say a little bit about what Active Health Management does, how you got started, and what kind of impact you've been having in the healthcare system and the part of it you're specializing in.

Lonny: Sure. Why don't I start with my background, which will give you a sense of how we have come to be here. I'm board-certified in internal medicine in cardiology, I'm a physician, and during the 1990s I was leading a bit of a dual existence. I was practicing clinical medicine here in New York City, had a fairly typical practice, but I also was consulting with a large human resources consulting firm, William M Mercer, and was charged with evaluating health plans around the United States, mostly from my perspective on the basis of quality but obviously the premiums and the costs associated for those health plans was a consideration as well. In considering what I was experiencing as a practitioner and what I saw as a consultant evaluating health plans, saw an opportunity to better take advantage of clinical data that were available in the managed care world which weren't being fully exploited. So specifically as I visited health plans I saw that they had the capacity to collect drug information, laboratory results, information about procedures and diagnoses and basically had the thought that if in fact that information could be used to support doctors and patients in making decisions, that in fact we'd be able to raise the bar with regard to the level of clinical excellence being provided to patients all over the United States. So fundamentally, the observation that I made, which ended up being relevant to what I was experiencing as a practitioner was that to the extend that the care that was being provided by me and others was fragmented, specifically I didn't necessarily know what other doctors were doing to my patients or for my patients, to the extent that all of the information about a patient or much of it could be aggregated at the health plan level, we decided to take advantage of that.

The other component of Active Health, which again sort of derives from my own experience and perhaps insecurity, is that I recognized early on in my career that it's very, very difficult to keep up. So there are thousands of articles, relevant articles, published yearly and the issue is how does one not only read and assimilate and remember those articles, but how does a physician relate the information in an article that they've read to the particulars that relate to a patient sitting in front of that doctor during the course of an office visit.

Matthew: They can't is basically the answer, correct?

Lonny: Can't do it, right, exactly. It's just too much. So the basic notion and this is as true today as it was in 1998 when we started the company was if in fact you could provide the treating physician with more clinical data on the member than they have access to—again the patients frequently see multiple doctors—and then if you could expose those data to thousands of clinical rules that represent incontrovertible standards of clinical excellence and use technology to highlight discrepancies between what was actually happening to the patient as manifested in their data as opposed to what should be happening as displayed in the literature, we in fact could pinpoint changes that needed to be applied to individual patients by doctors that related to everything from preventive care to diagnostic services to therapeutics to follow-up, and basically started the company with the notion that we would have those data, have a technology that would analyze those data and communicate first with doctors and then over the years with patients in order to again introduce this level of consistency to the healthcare system. And from there we've evolved into other sort of disease management like capabilities which I'll elaborate on. But the fundamental premise behind the company is what I've articulated.

00Matthew: Now, that's really interesting because there plenty of people who have been saying for years that if we could just get the data and analyze it and do the right thing we could improve how it comes out in improved results, and in some ways that was the basic premise of the medical directors of many managed care organizations in the 80's and 90's. But there are two major pieces that I think you have done somewhat differently, and the first one is the business about, you know, the real, for want of a better word -- the real time or the active nature of your analysis. And you know, your goal is to do this quickly and to do this in real time, rather than to wait three weeks when the claims data comes in and seeing that retrospectively. So you have a pretty major technical problem then. Normally, how do you deal with, you know, putting that data together and figuring out what should be done. You also have the real basics of getting that data in in a timely manner. Now, most data you're talking about is in claims systems and can take a while to assimilate and there's problems getting lab data and getting other data... Now, how did you go about solving that problem?

Lonny: When I mention the specific streams of data that we have access to and then explain how we've managed to access that information, I think the first issue is that we're indifferent as to the adjudication status of a particular claim, meaning that we don't really care if it's a covered benefit or paid for by the plan. The fact is the patient had or did not have a particular service or is not taking a particular drug. Might even be a nutritional supplement which in no case would be covered, but certainly that information is important to us. So let me, on the drug side, to begin. We have access to at this point all of the PBMs or most of the PBMs, pharmacy benefit managers, in the United States. We have I think very, very positive relationships with them, and essentially, when a PBM is apprised by the swiping of a card in a pharmacy that a particular drug has been administered, we in fact get that information as quickly as a day or as late as a week or so after that information has been generated.

So one important source of information was drugs. Another important source of information relates to laboratory results. And through relationships we have with major reference labs, not only do we know what tests were done, which is an important thing, so for example diabetics need to have their sugar and something called their hemoglobin A1c test performed at least twice a year to monitor the adequacy of their blood sugar control. Not only do we know that the test was done, but in many cases we actually know what the level is, and obviously if the test is being done but the level is unacceptably high, that would represent an opportunity to in fact suggest to the physician and/or patient that perhaps something needs to change with regard to the way they're being managed. So effectively, in situations where you have access to laboratory results we can get the information at pretty much the same time that the doctor does, several days after the test was actually administered. So we have two important sources of data, drugs and labs where we get the information pretty quickly.

The third source are claims information, I think what you were alluding to — the difficulty with claims data—and that would really describe diagnostic information coded as ICD-9s for those of your listeners who are technologically oriented, or procedure data CPT4s. Two problems with that: one is that the information is sometimes late, because the doctor might not submit the claims in a timely fashion, but also the information may not be precisely correct from a clinical perspective. What I mean by that, and this particularly pertains to diagnostic information ICD-9s, is that the way coding is conducted today there is no distinction between a rule out  and a diagnosis. I'm thinking, for example, that you have Burn's Disease as opposed to you in fact categorically do have Burn's Disease. And obviously that does have huge implications with regard to the accuracy and the specificity of the information that we convey to doctors. So one of the real challenges for the company has been to validate and corroborate imperfect data along the lines of the example I just gave with regard to diagnostic data and translate that into reliable clinical information which can then be analyzed for the purposes of communicating a potential discrepancies between optimal care and what's happening to patients and physicians. The last source of data is the patient himself or herself and I'm sure people know very well about health risk appraisals. There's a lot of discussion about the importance of assessing risk and looking at lifestyle factors, we wholeheartedly agree with that but think that an HRA could be a lot more valuable in the context of the other streams of data that I just articulated. Though in fact the member talks about family history of a particular disease and we see early manifestations of that disease in say the laboratory data then obviously we can interact with that member much more effectively, much more aggressively in order to catch the disease at its earlier period in its evolution as possible.

Matthew: Now that sounds in principle and theory, the whole thing sounds very smart and great and I can imagine sitting around late at night when you're thinking this thing up going, "Wouldn't it be great if?" And some of these data streams obviously are available but at some point you had to start making these available in early days, and I know that fairly early on you started working with Empire BCBS. What kind of share of membership or how many people or I don't know what metrics you used, but for how many people were you able to get relatively good lab data, relatively good drug data, and in the early days they put it together so you could start saying we're getting viable decent results, because that's kind of the first part you did before. I'll let you answer this before the second question which is: now you have to go convince a bunch of doctors that some third party with a computer is going to come and influence what they're doing. So tell me about how you started and how you got to critical mass.

Lonny: All right, so the first thing we acknowledged was that we needed at a minimum drug and claims information so that the diagnostic procedure and pharmacy information. And frankly it was largely a matter of will and having great partners like Empire Blue Cross and some of the self-funded employers who were working with us. And the expectation was that claims were coming in so we should certainly have access to that data if these doctors wanted to get paid and empire along with the employers we were working with certainly had PBM relationships so there was no reason not to get those data. The labs probably came a little bit later, but certainly at the outset and even today we won't do business with an entity that doesn't provide at least pharmacy and claims information. That's not because we're obnoxious or smug about it, its just because we don't think that we provide value without at least two of those streams and frankly there's no reason not to have that information available.

Matthew: Right.

Lonny: So that's what we started with and effectively we had 100% lab data and pharmacy data when we started the company with probably 2000 or so covered members.

Matthew: And those were probably either Empire commercial members or self-funded employers?

Lonny: Right, where Empire was the administrator for those members.

Matthew: So you basically had one major client, aggregating data from different sources. That was a good place to plug into.

Lonny: Right, and the self-funded employers have always been interested in these types of opportunities, and to this day continue to indulge us as we come up with new thoughts and new ideas and new approaches to manage and cure.

Matthew: Second part of that is now you got some data, you're running it through your system, its coming in fairly quickly in terms of you turning around on it in days rather than weeks. Now, somebody has to get on the phone or do something with the first doctor and say “by the way, we know something that you don't, and you should be doing something that you're not doing”. How did that go?

Lonny: Right, so the first thing we did was we let doctors in communities where we would be working know that we were coming to town, and in many cases I've actually met with major physician groups or academic groups to say we're coming, you may have some misgivings about this managed care thing based on prior experience. But we think we've actually are doing it well, we think we're pretty good, we think you're going to like what we do, and we think you're going to regard us as a resource. So the first thing actually involves demonstrating the technology, letting providers sort of kick it around and squeeze it and challenge it, and frankly to demonstrate we are very much of their world. And we've applied the same levels of scrutiny, precision with regard to false positives, with regard to anticipating contraindications to certain drugs, those sorts of things, that they would apply in their own practice. That sort of gets you kind of started, but what's really important is the nature of the communications and the value of the information that we send to providers. And the only way to, in fact, endear a company to the provider community is to provide real value, meaning that we're not generating lists and lists of patients who may or may not be in that physician's practice, may or may not have a particular diagnosis, may or may not benefit from a particular therapy, particularly when you consider all of the promobidities that our patients may have. So the way I think we won the hearts and minds of physicians is by being a resource, by being precise, by not wasting their time, and by presenting the information with an appropriate degree of humility, meaning that we don't know exactly what's happening during the encounter with the physician and the patient and there may be extenuating circumstances. There may be additional information that we don't have access to that in fact would basically eliminate the observation that we've made. And over time, we've done that well, we have a feedback mechanism built-in to all the communications as we talk to doctors. So, for example, if we didn't know that the patient was allergic to a certain drug, forever and ever more we will never, once we know that we won't suggest that drug. And it's those sorts of little issues that are very, very important with regard to, again, winning over the physician community. I think the best...

Matthew: Now, if I'm a doctor practicing in New York City, or in one of the regions where there's a health plan you're working with, what do I actually get? Do I get a phone call? Maybe I've been told about this program, but in terms of the actual scene where there's a patient in front of me, or one of my patients comes in - what, actually, do I get?

Lonny: Right. So what you get - first thing is, you don't have to do anything. That's an important point. We're not asking doctors to submit data; we're not asking questions; it's not at all like a fishing expedition. What you get is an explicit communication telling the doctor what our concern is, and a display of the data that reflects the information that we used on the member in order to arrive at the conclusion that we've arrived at. Now, in terms of the actual specifics of the communication, there're basically two: The first is, if there is an urgent issue - specifically, we think there's a life-threatening issue - we simply have one of our doctors or nurses pick up the phone and say, "Hey, Doc, from where we're sitting, based on the data at our disposal - again, which may be more robust than the data that you have on this patient - or based on the literature, we think that what you're doing or not doing could potentially be lethal for the patient. What do you think?" And, quite frankly, those generate the best responses of all, because, again, we do it with precision, and the doctors very much appreciate it.

The second kind of communication would be a letter for something, you know, preventive. A screening test. A mammography or a pap smear. And that's an area where we don't need to yank the doctor out of his examining room, but assume that once the letter is presented to the doctor and entered into the chart, they'll respond to that. And then, in the middle, there are situations that are highly important - I think most people know about beta blockers after a heart attack, for example - where you don't have to intervene this second, but certainly, within a period of days or weeks, you'd like to see a change. In those situations, we generally do both the phone call and the letter, but basically, communicate the information to the doctor's staff so as to not unnecessarily alarm them or disrupt the flow of their work.

So those are the ways that we communicate, and then, subsequent to issuing one of these - we call them "care considerations" - we track the members' data to see if, in fact, the change that we've suggested has occurred, so a good thing shows up, or a bad thing goes away. And in addition to that, in the written part of the communication, there's a survey, where the physician has an opportunity to say "thank you, " to tell us that our information is incomplete, to express themselves in other ways, for example. And, obviously, as we learn more clinical information from that feedback, that gets built into the system, so as to be able to more intelligently communicate around that patient, to whatever doctors, as we go forward.

Matthew: And, for a typical physician - I mean, they're presumably not getting very many of these communications, given that not that many of the patients they're seeing will be in the program - but do they get one every so often

Lonny: Yeah.

Matthew: So now you've got the physician getting information about the patient, and presumably that's now in their work for when they're understanding it. Tell me a bit about the business side of how Active Health made money out of this, and then let's get on the path a little bit about your working with Empire as your core client, but then you end up becoming a subsidiary of Aetna. So give me a bit about the story about how that happened, and what your corporate development was like up until a year ago.

Lonny: I think, in the beginning, the reason we were able to get venture capital funding, and get the thing launched in the first place, was because there was an interested partner in Empire. And there were also large self-funded employers who were interested in this sort of capability, and understood that managed care, certainly in 1998, not only didn't have this capability, but, frankly, didn't have this orientation with regard to assessing the clinical adequacy of care. So, basically, it was a combination of Empire's interest - Mike Stocker was the CEO of Empire at the time - and his personal interest as a physician, but also the appeal that the product had to national accounts, as Empire was building its national accounts business. So it really worked for all of us. And the fact that we had a big health plan and major employers interested in this wasn't lost on the venture capital community, so we were able to raise money to get it started. As we grew, we continued to leverage the large self-employers that we had relationships with, who would then go to other carriers, who they might have been working with, and said, "Hey, we think this is an interesting thing. We would like you to implement the Active Health Program for our employees." And that had two advantages: One, it helped us grow with the business, and it introduced us to other health plans; and secondly, as the health plans were observing the experience on these self-funded lives, they discovered two things: One is that clinical care, clinical outcomes were improving; and secondly, from a financial perspective, it appeared that this intervention was actually saving money.

So over the years, it was imperative - this is an obvious point - that for all the humanistic and sentimental appeal of this approach, it needed to also save money. And a number of the plans that we did business with conducted their own analyses, which resulted in them applying this technology to their fully insured book - it was their nickel, as it were. And in addition to that, we actually published a randomized prospective clinical trial in a peer review journal - the randomized prospective clinical trial being the gold standard, frankly, in all of science. It's the sort of trial that's applied to, say, new pharmacologic therapies. So, given what the plans were experiencing with regard to financial analyses, given what we were able to publish and demonstrate on our own, not only did we continue to grow among the self-funded employers, but we further insinuated ourselves into the fully-insured books of the health plans that we were working with.

Matthew: And how many plans do you have as customers at the moment?

Lonny: At the moment, we probably have hundreds of employers - again, the self-funded employers might go to any particular plan, and there are literally hundreds - and I'd say there are probably 15 or so health plans that, again, are either using our capabilities in the context of Medicare Advantage, where they'd be fully at risk; their commercial fully-insured business, where they'd be fully at risk; or their commercial self-funded business, where they're not at risk, but they're providing administrative services for planned administration.

Matthew: Two parts I want to talk about Aetna. The first part is, what decision did they take, that they wanted to get into the business of owning you, rather than using your services? And secondly, did that put off a bunch of their competitors, with them saying, "Well, hang on, now we have this Aetna unit coming and selling their services, but it looks pretty close to the core of what we should be doing as a health plan."?

Lonny: That's exactly right. So I think the first point - why was Aetna interested, and why were other plans interested - was because, I think, the health plans have acknowledged that they have a very important and potent role to play with regard to care management and promoting the public health. So I think - certainly, from Aetna's perspective - this is fundamental to their mission. One of the interesting, and perhaps unusual, aspects of the relationship with Aetna is that they have permitted us to continue operating as a freestanding entity. So although we're a wholly owned subsidiary of Aetna we are free in fact to work with health plans that compete with Aetna. That brings up two issues which are probably of some interest. One is why would some of Aetna's competitors want to work with an Aetna-owned entity and why would Aetna want to potentially dilute a competitive advantage that they have in the marketplace. In terms of plans that have continued to work with us, I think it's because they have seen the value we provide. They don't believe they could get that value elsewhere and to the extent that their customers and their own internal analyses support the continued use of active health, why wouldn't they? The fees that we generate are not large compared to the premiums being collected by those health plans so if we can impact their ability to market them or in control costs, it's a sensible proposition for them. Having said that, there are certain plans that have said we're not particularly comfortable with this Aetna thing. We're going to pursue other directions. Frankly, my expectation is that as long as we continue to maintain our edge and evolve the products as we have been, those plans will be back. That's something we work very hard to do with regard to supporting the business that we have. But we really do have an expectation that those who have decided to look elsewhere and might experience other vendor will eventually return to us.

Matthew: As they say, you had to say that, didn't you?

Lonny: We actually believe it!

Matthew: I would hope you would believe it. Let me be slightly cynical about two things. The first one is I wrote an article earlier this year or last year called The Yin and the Yang of Health Insurers. Because you have within health insurance companies people doing exactly what you do which is looking at the health of the population, trying to do things better, more cost effectively. And we know that if you look at the original purpose of the managed care movement, it was, how do you rein in the practice variation, the bad care and all that stuff? And given that we don't have widely distributed electronic medical records and that the data you're using is the best data that exists, it strikes me that what you're doing is really central and you can point it out and say this is a great thing and that some of these management programs really are improving and are conserving costs.

On the other hand exactly the same health plans have been shown to take similar types of data as you're using, look at who is the more expensive group and who do they not want to insure next year, or use it for underwriting purposes. And they've changed their business model to be far more risk avoiders than risk takers or risk managers. And frankly, Aetna has one of the worst reputations in the business for doing that. They literally came out and said that they went from being a big managed care plan with a market share focus to getting rid of a significant number of covered lives by looking at the pricing and the risk they were taking instead of going down and looking for a more profitable customer. So a cynic would say, well now they have a great tool for managing care of people they already have but now they have an even better tool for figuring out who they should and shouldn't be insuring. So how do you reconcile that? You come from the medical management side of the world and yet we look at the health plan world and we know that this is going on.

Lonny: I think that the reconciliation is that none of the tools that have been developed by Active Health are being used for clinical underwriting or for making distinctions among populations about who to insure or who not to insure or how much the premiums should be raised. The way we work with Aetna and with other health plans as well as the self-funded employers is that we are presented with a population and to the extent that we can look at the data on that population and do the types of things that I've described that will promote an optimal state of health for that membership we do it and presumable that results in lower health care costs. So in terms of the other side of the equation, that's not something we participated in and I don't expect that we will. We are focusing on the people who are in the plan at the moment.

Matthew: Well that's fair enough. You're staying away from that side. I want to be open about it. I understand that Jack Rowe when he came into Aetna in a series of pressures on him and had to do what he did and now Aetna is a much more profitable organization than it was when he got there. But as I've written and several other folks—Jamie Robinson in Health Affairs—have written it's not necessarily an increase in the public good but that happens to be the way our health care system is set up and I think many of us in all parts of the political spectrum think that that may not be a particularly good thing. And there are some plans—we'll point out Blue Cross of California—that are doing pretty egregious things in cancelling insurance. To my mind, we should separate them away from medical management. The problem that we get to is that people say, "Well it's a greedy health plan, and now they're using tools like yours to interfere with care decisions.” I can understand how the politics and PR makes it very tricky to distinguish those two parts.

Lonny: That's why it's so important that we win the support of the physician community not by a PR campaign but by virtue of the nature of the information we send to them a bout their individual patients where they, in fact, write back to us, "Thank goodness, thank God (literally) your system is there because I couldn't possibly keep up with the literature or a don't know what the guy down the street is doing with my patient." That's been our focus and that's where the value is. From the patient's perspective it's a similar thing. A couple years ago we started communicating with the members on these discreet clinical issues than over the last couple of years have introduced a form of disease management which is different from the sort of one at a time approach to disease management. It's much more multidisciplinary. But the point is we've won the trust of the membership, they understand what we're doing with their data and to the extent that they have appropriate concerns about how else the data may be sued or where else the data may go, we've been very disciplined about security and privacy and I think we've conveyed that and won the trust of the membership. We probably have about 13 million people on the system currently.

Matthew: Yes, I think it's a fine line to walk and you clearly have to be very open about it and clearly you're doing the right thing. I might be a bit cynical. The only thing I say is that if your stuff works it ought to save money but it also seems to be that in the past few health plans have been doing pretty well even though health costs have been going up. I'm not sure how that equation gets squared.

Let me touch on this very last point. Wemberg and a lot of other people look at the system and say if we did things properly, not only could we save a few percent here or there, but maybe a third of health care is waste motion or ineffective. Do you perceive that tools like yours could create really significant savings? I'm not just talking about slowing premium increases a bit a year, but making significant changes in the expense of dealing with populations. Or do you think that we need another systemic change to get that?

Lonny: I think what we need and I think that you were alluding to this earlier, is better sources, richer sources of data. So right now we are not in a position to say that someone with a headache needs and MRI versus a CAT scan versus a PET scan versus nothing. We just don't have enough information about their headache, their neurological exam, those sorts of issues. As we in fact begin to hookup with EMRs, as we get involved with regional health information organizations, which we are doing, as we get involved with hospital systems, as we launch the PHR and get more specific data about the member, as we get those richer sources of data, A and B, the medical community and the health care industry define standards around many of these issues with greater precision. Right now we are limited to areas where the evidence is incontrovertible. There are lots of areas where frankly, it's not. As we get into better standards and better data I think we will be able to influence those variations with even greater results than what we've seen so far. I very much view as what we have done as being significant but really very much a beginning. I would expect that within the next five years or so with technologies that we are introducing into the care engine, in terms of interfacing with EMRs, CPOE systems, getting more information about the member via PHR, we'll be able to apply more robust standards with regards to what is clinically acceptable or optimal to those data, and I think our ability to significantly shift costs to be greater than what we have experienced to date.

Matthew: Let's talk a bit about the PHR. This is a product you're releasing that is not actually out and in use yet. I assume you've had it in beta. This is an interesting one. I have a personal interest because I was involved in a company that sold these things. Unfortunately we didn't sell enough of them back in the 2000-2001 period. We were at that point pretty competitive with Well Med. Your PHR, presumably your first announced client is going to be Aetna, is that correct?

Lonny: Correct. Then we'll be launching this in February.

Matthew: I have a hysterical email from Aetna in 2001 explaining why they couldn't possibly talk to us for another two and a half years because they had all this other stuff to do about here. That was rather discouraging to get when you are a starving startup that a big company wants to buy your thing but it will be three years.

Lonny: I can understand.

Matthew: Empire which is a big client of yours on the care management side has gone with WebMD's product, which is their WellMed product with a bunch of other stuff added on.

Lonny: Also Empire is now owned by WellPoint, so there's consistency across all the WellPoint plans.

Matthew: So to be fair, you've come to this from a very different angle. Although there's still a very low penetration of personal records amongst Americans, you could argue that there are some very established players in the PHR market and you are coming somewhat late to the market. So given that, I don't know if you were already in the conversation when Empire went with WebMD in the first place. What do you bring now that's sort of better, different, and why have you moved into this part of the market?

Lonny: I think the reason we've moved into the market is for any number of reasons, I think most of which are obvious. We need to further engage the member. We need to engage the member from two perspectives. One, as an important source of data - all about lifestyle, risk factors, and family history, over the counter meds and those sort of things need to be provided to us. But also because we think we have something to offer the member that the other PHRs don't offer, specifically that additional contribution relates to care considerations, these actionable steps that the member can take once we have in fact analyzed and interpreted their data. Not in isolation, but in the context of all the data that we have about them. So as I have experienced other PHRs, I think they provide certainly valuable services, a data repository, and information can be distributed and shared and that's a wonderful thing except that I believe as I mentioned earlier that the information still needs to be distilled and analyzed. Frankly that's the unique capability that we have. So as a member generates 20 to 30 digital pages of electronic information about themselves, that will be no easier to read or interpret by the patient or doctor than frankly a big fat paper chart with 20 or 30 pages of data in it. So I think the ability to apply these decision support capabilities to those data and direct the member specifically to conduct certain actions, either on their own or in concert with their doctor, is what is going to achieve a level of stickiness if you will in commitment to using our PHR.

Lonny: The other component in our PHR, we talked a little earlier about data lags and delays. The care engine at some point, probably mid-year, will have the capability - we are data testing on this now, to instantaneously analyze new data that are presented to it. So if a patient is sitting at their PHR and they put down that they are taking St. Johns Wort, or Motrin, or a lot of Tylenol, the system can immediately tell that member well gee, all that Tylenol in the context of your abnormal liver function test is probably a bad idea. Go and talk to your doctor. Here's a link to content that explains the risks of Tylenol and hepatitis. What I'm trying to convey here is the notion of instantaneous feedback that again is specific to the unique clinical characteristics of that member and give them more advice about lifestyle or exercise. Those are important of course, but sometimes people are looking for more and can address other issues more readily if they do the search of the things that we are providing through the PHR.

Matthew: So it sounds to me, and I may be belittling it a bit here - that where an organization or a patient for whatever reason doesn't have a PHR, and you're working with a plan that could use one, yours obviously because it's built by you in conjunction with your care engine fits very well into that and can spit data back and forth to the member and receive information very easily. But also theoretically this could work very well with another PHR, if one of your customers had another vendor's PHR and wanted to incorporate the same sort of data. You could presumably do this back and forth with them if your clients wanted that to happen as well.

Lonny: Right.

Matthew: That sounds pretty similar to some of the things happening in the EMR world and some of the other things that you mentioned.

Lonny: Right, and in fact a certain HRA - Health Risk Appraisal - we are working with our sponsors or our planned sponsor partners and to the extent that they are pleased with an HRA they have, but they understand the point that I just made about presenting that data in the context of all the other data streams that we have an analyzing it. They basically get the best of both worlds, they can continue to use their HRA but we will in fact download the information from that HRA into our system and do the sorts of analysis that I spoke about.

Matthew: Do you have your own HRAs?

Lonny: Active Health has an HRA, Aetna has an HRA, and then of course we have the relationships that I just alluded to.

Matthew: Right, so in other words - I may be overstating the case. I know you want to suggest that your PHR is new and special and different in the capabilities that it has, but most of the different and interesting capabilities come from your core ability to put multiple data streams together and represent that information back to relevant people, be it the patient, the physician, the plan or whomever else. You're essentially building off your core, rather than introducing sort of a distinct product line.

Lonny: Yes I think it is very much an adjunct to what we have been doing before. To be specific, the PHR can't be purchased without purchasing the HRA as well. There are other issues, for example there's a lot discussed about auto population of data. As I said earlier the data that are generated by your doctor, particularly the ICD9 codes—not due to anyone's fault it's just an inadequacy of the data and the standards that have been established around diagnosis—there's no distinction between a rule out diagnosis and you've got it. It frightens me to consider that someone might see their data, see some dreaded diagnosis listed which they don't have but now believe they have, and you can imagine the potential consequences of that. I think there's a real need to be precise about what you present to the member. In addition to the analysis of this data, our ability to corroborate and validate information is very important. That's just one example; there are several others that I think once we are out in the marketplace that will really distinguish us from some of these other offerings.

Matthew: It will be interesting to see. Lets just pontificate forward a little bit. We have a world in which the data streams that you talked about, pharmacy data, labs data, IC9 from claims and hospital data, is the data we have to work with for most of America. But let's assume that we have an uptake in the use of electronic medical records and we have got one of these large installations in the Kaisers of the world and clinics but also a gradual growth of EMRs take off from the rest of providers. Is your vision that down the path for those kinds of companies that have gone down the path  with a typical EMR vendor like Epic or Cerner, that Active Health Management is going to be a core traffic control engine that works within all those other types of applications. If we go to a world where most physicians are using clinical records five or ten years down the track for example, being optimistic, where do you guys fit in?

Lonny: I'd like to see us if you imagine there are multiple pipes, serving data to some sort of a centralized depository, I imagine us as kind of the governor on that pipe with the capacity to analyze information that is flowing across the pipe as it relates to other similar types of data on that same patient, to do the same sort of things that we have been doing but with a much more efficient mechanism for extracting data. So getting much more complete information from the EMR, from the CPOE, from a radiology system, but also kind of someone to shake hands with on the other side at the EMR or the PHR where they can be the recipient of the distillation of this knowledge that we've been talking about. So information is being exchanged. I think that's currently what people talk about most. The real context, what we would like to add to that health information exchange is this capacity to provide analysis, to distribute the results of that analysis not only to the appropriate participants in a community - the doctors, the patients, the physical therapists, but also to create other links with regards to scheduling, work flow, plan design, which is another issue we can talk about, adjusting plan design to work with a patient's unique needs. But basically being central to the simulation and distribution of opportunity that relate from that new piece of information that was generated a millisecond ago.

Matthew: I guess the one other point that I'd add to that is that you are also looking at—the question is are you looking at it, but I assume so. You have folks like the Continua Health Alliance who are talking about the massive distributions that we are going to get, maybe not in two years or five years but in ten or twenty years, from sensor devices in the home and on patients that are going to be reporting back information much more regularly, maybe daily or maybe continuously, from all kinds of different medical devices, like diabetics with their continuous blood glucose monitoring and that kind of thing, which has all got to go somewhere, all that data. That's really not a data stream that anyone is dealing with at this moment. Shouldn't you be thinking about that too?

Lonny: Absolutely. Biometric devices like in this third feed that we are already investigating partnerships with. Right now in our disease management approach, we obtain that biometric information through either the PHR or HRA as it currently exists, or through interfaces through the nurses. But imagine the value of not only knowing someone's height and weight and BMI but their blood pressure, their peak flow, their sugar levels, and one can go really on and on. So whether it's ultimately genetic information or biometric information, in my dreams I would love to enhance CPOE on the inpatient side, look at hypo dynamic data, look at inpatient data, intervene in a positive way being a resource where patients appear to be misdiagnosed or drugs going beyond some of the metabolic and drug interaction issues. What I was referring to before is that we are still at the beginning. Ultimately we are scavengers for data, we will take as much as we can. We need to be able to communicate with the appropriate providers. Where I see us ultimately is being central to a community so we don't represent just a slice of a doctor's proactive but in fact are an integral part of what they do. In one related issue, as we sort of achieve or obtain ubiquity, of the malpractice implications. So if in fact we can prevent some of the errors that translate into adverse outcomes, you can imagine that leads into a totally different discussion.

Matthew: Absolutely. I think what you are talking about if you imagine the data flow and imagine the possibility for essentially changing the way healthcare is practiced by supporting physicians, patients and everyone else with all this different data. There is enormous potential and the role of traffic cop and analyst around that data is going to be very interesting. You're obviously in a nice position at the moment and I look forward to seeing how it all plays out. So my guest for the last fifty-odd minutes on The Health Care Blog podcast has been Lonny Reisman, the CEO and founder of Active Health Management. I'd like to thank you very much for taking part in the podcast and it's been very interesting hearing about your organization.

Lonny: Well thank you, it's been a pleasure talking with you.