By MATTHEW HOLT
I recently interviewed Subha Airan-Javia, the CEO of CareAlign. CareAlign is a small company that is working to fix the clinician workflow by creating a tool for all those interstitial gaps that the big EMRs leave, and now get moved to and from paper by the care team. In this interview she tells me a little about the company and shows how the product works. I found it very impressive
Full transcript below
Matthew Holt:
Matthew Holt, quick THCB Spotlight. I’m here with Subha Airan-Javia. She is the CEO of CareAlign, which is a pretty new company that is doing physician workflow in the hospital and outpatient center. Subha, nice to see you.
Subha Airan-Javia:
Nice to see you as well, Matthew. Thanks for having me.
Matthew Holt:
Of course. So you showed me this couple of times I’m pretty intrigued, and this is in the “how do you fix the doctor’s workflow”? So those of you who remember Bob Wachter’s book, The Digital Doctor, all about how Epic and Cerner were imposed on American physicians and all the extra work it gave them, you’ve fixed that through CareAlign.
Subha Airan-Javia:
Well, definitely trying, yes.
Matthew Holt:
All right. So why don’t you tell us a bit… So for those people, and most people are not physicians and most people who are working in IT don’t get to use Epic every day or don’t get to figure out what the life of a resident or attending is. So why don’t you just give us a bit of the background? I think you’ve got a slide or two here to show us what’s going on.
Subha Airan-Javia:
Yeah, and while I pull that up, two quick things I’ll say is number one, I don’t want to just pick on Epic because it’s really about EHRs in general and not just one specific one. There is a lot that’s changed with how we practice and our platforms just haven’t kept up with it. The second thing is-
Matthew Holt:
In fact, many people say that Epic’s the best of just not a great bunch.
Subha Airan-Javia:
Yeah, no, it’s great. It’s great. I use it and I’m thankful for it. The other thing I’ll mention is that I think that we need to think about the clinical team as being more than just doctors. There’s nurses, there’s therapists, there’s pharmacists and I find myself consistently thinking it really takes a village to take care of patients and to take care of them well, and all too often our tools are very siloed into what do the doctors want, what the nurses want, what do these people want. I don’t think there is enough collaboration between all of us together. And then you extend that to be not just the clinicians inside the hospital, but the clinicians in the post-acute care setting and in the outpatient setting, we’re all one big team of people, and throw in the patients and the caregivers, we should have more transparency with what we’re all doing to take care of patients.
All right. So now let me show you what CareAlign’s about. So really it’s about how do we get clinical teams to work better together, because the way that we practice medicine has drastically changed over the last couple of decades. We no longer have one team or one clinician who knows everything about a patient. We have dozens and dozens of different teams and specialists and here I’ve shown what it’s like to take care of a patient who goes in and out of the unit in the first couple of days of a hospitalization, but this has exponentially increased when you think about outpatient and in post-acute care settings. This has been really great. I don’t want to say this is bad because we have better duty hours and we’re able to provide great specialized care for patients, but the challenge is that now the left hand doesn’t know what the right hand is doing.
There’s so many people it’s hard to stay on the same page, and we have secure messaging, which is usually one-to-one or it’s transactional. We have some efforts in the EHR, but they really haven’t fixed this problem of collaborating and working together as a team, which leads to situations like this real example of a patient who was admitted with pneumonia. On day four, her intern came in the morning and said, “Oh, I think she’s ready to go home based on what we’ve talked about.” So he went out and he put in a discharge order, and for those of you who don’t know, there’s a lot of pressure for people to discharge patients before noon oftentimes,
Matthew Holt:
At that point, you’re showing a lot of paper here. Where did that paper come from? Is that a printout of the order list, the patient list from EHR?
Subha Airan-Javia:
Exactly. So the intern has printed a list of patients from the EHR in the morning. That is the gold standard of every single system is we print a list of patients.
Matthew Holt:
So . there’s a mobile version of Epic don’t they have a version with the patient information in it they could be using?
Subha Airan-Javia:
So yes and no. Some systems do, some systems don’t. Even those that do, they are not designed for this workflow. It’s usually geared towards outpatient scheduling or for the OR, but it’s not about what do I need to do as a team? What are the tasks that need to get done? What is the data that I need to be able to see? You can’t make changes in anything, certainly not for a phone. So no, they don’t solve this problem.
Matthew Holt:
Okay. So back to your attending who has now showing up with her piece of paper.
Subha Airan-Javia:
So the attending has her own separate piece of paper, which when she sees the patient, she thinks, I don’t think she looks as good as I would like her to look on her day of discharge, and she remembers she has a history of a GI bleed, so she says, “We should check up blood count for hemoglobin before she goes home.” So what does she do? She writes it on her paper to say, “Let me talk to the team about checking her hemoglobin.” Well, as she’s walking out of the room, she fully intends to tell the team, but before she can, she gets called into an emergency. Happens all the time, and so the reminder is now trapped in her pocket. No one else can see it. The intern can’t see it, the nurse can’t see it, the social worker can’t see it, and that means everyone else is working off of this discharge order that was put in the morning. Sure enough, patient goes home has pretty significant GI bleed. Fortunately, it was fine at the end of the day, but had to get readmitted, have all these procedures done, and at the end of the day this is obviously not the quality of care any of us would want to provide or receive as a patient.
Matthew Holt:
This is a real case. This happened in your hospital or a hospital you know?
Subha Airan-Javia:
This is in a hospital I know, yes. This is a real case.
Matthew Holt:
And this happens all day, every day in America?
Subha Airan-Javia:
I can guarantee you, when I show this to the clinicians are like, “Oh yeah, this happens all the time.” Not to note that everyone is happy with it or likes it, but it’s unfortunate and it happens. Communication failures are the cause, or at least related to 70% of preventable medical errors. It’s crazy and I think for a lot of it feels like it’s too hard to fix, and so they just accept a lot of them as status quo. But the reality is none of us would want this to happen to our family. And that’s really what CareAlign is designed to address is, I tell teams this all the time in the hospital that we’re human, we make errors and unfortunately medicine is not an exact science, but we should not make preventable errors and we certainly shouldn’t make errors that are related to a process or to a system. We should be able to mitigate those and that’s what we’ve set out to do.
Matthew Holt:
Okay, so show us what it looks like.
Subha Airan-Javia:
Yeah. So I’ll just frame it really quickly. What I’ll mention is that we built a lot of things into CareAlign. We can’t just fix this with one quick thing. We built a lot into it, but one of the key components that really help address this is enabling team-based care, like I said, with shared task management. It’s almost like a project management platform that you would have for a developer team or for any large enterprise, but for medical care where you can have shared tasks with your team and templated checklists. Atul Gawande,talks a lot about how checklists are really important. Well, it’s really hard to operationalize that in medicine without a platform that does that. And in this example, the attending, instead of writing on paper, she could have dictated or written directly into CareAlign on her phone or any iPad or computer laptop that she wanted to check the hemoglobin and everyone would have seen that in real time. She wouldn’t have had to waste time now telling everybody to do it. So this happens. Some people say, “Well, isn’t this slower than writing on paper?” If you think about writing it on paper and then having to call and tell five different people or text, it’s way faster. In fact, people do this over 20 times a day per patient in CareAlign, because it’s saved so much time. Great.
So now I am on a live demo site of the application where I can show you what it actually looks like. So we’ll just log in and I may not have mentioned this yet, but CareAlign works on any internet connected device. That’s a big difference between what the EHR apps do, which is a phone, tablet, laptop, you can use it anywhere. And really simply, this is a list of my patients and what I need to get done, not just myself but as a whole team. So I can see who are the patients that I’m worried about, and if you’re integrated, what I’m showing you is a totally non-integrated version so you can use it today and just start with your patients, or you can integrate with any EHR and this information would come in automatically, which we’ve done. But the idea here is I can just click on a button and say, “What do I need to get done for this list of patients today?” And what it does is you can see it’s separated these patients now and expanded them and for each one, I can see the highlights. What is the one liner that I need to know about this patient? And I can update it right here and say, “This is a new update.” And now, instead of me writing it on paper where no one else can see it, I’ve written it in the same work space but now anybody can see it.
I have a place to keep updates or FYIs of things that I want to make sure nobody misses like, “Hey, this person had chest pain today, or, “This person tends to do bad with this medication. Make sure you avoid it.” And then the tasks, and this is where every clinician has their own paper with their own tasks and there’s no standardization with how we do them. There’s also no insight into who’s doing what. So by having it all here, I can see, okay, these are the things that need to get done for this patient with hypertension and diabetes. We need to check his blood pressure.
And as things get done, I can say, “Oh, okay, great. This is done, completed.” I can write and say, “Scheduled for 6:14,” and I know that it’s done. And now I don’t have to waste time telling people, they can just see, all right, someone took care of this, which you wouldn’t be able to see if I wrote it on paper. I can say, “You know what? This task isn’t going to get done before I leave the hospital, so I’m just going to change this and make it a night task.” Falls off my list. I don’t have to worry about it. But if I now look at my night team, my night list, on call lists, I can see, oh, this is that one task that needed to happen. And the night team can write, “Oh, it was at goal. I didn’t give any extra meds. I’m going to check it off.” And they can say this is something that happened at night and they can make it a certain color, and now I have an update for the night and everyone can now see that. So there’s a lot of data that had transitions of care as when errors happen, and this is really helping make sure that we have the information that we need at our fingertips.
Matthew Holt:
So this that you’re showing us, none of this is in the standard way that someone would enter notes into Epic? There’s not a task management, group task management field like that in an Epic or a Cerner or an Allscripts, is that correct?
Subha Airan-Javia:
Right. So what happens is if your EHR has it, that’s probably the biggest change that’s happened in the EHRs over the last 15 years is they’ve created a handoff tool or a rounding list tool with it, or module within the EHR. Usually it’s for free text boxes, you type in whatever you want to type in and then you print them every morning. You write on paper all day and then you try to update it, but they don’t have anything like this. So I’m now going into a specific patient’s page. You can think of this almost like a Google Doc for a patient, but structured around medicine, and it actually structures everything into that same one-liner and data box, but what are the things I’m managing for a patient? And I can see within each problem what I’m doing and there’s all this overlap between what we write on paper, what we write in our note, what we write in our discharge summary, what we write everywhere.
Our concept is why don’t we just write something once and never write it again and we’ll use it five times? So now all I have to do is say, create my progress note, it asks me what I want to bring into my note, I click “Next” and it puts everything together into a note for me. And then all I need to do is copy and paste it into the EHR or there’s a lot of pieces building paper progress notes, so people can copy and paste this into a PDF, which we have a whole library of PDFs that they can print and put in the chart. But it really gets to if I write things once, then I’m going to keep things updated more. This is how we drive documentation improvement. And the thing I hear most often is people saying that they get their documentation done in half the time with us, which is something you almost never hear.
Matthew Holt:
So they don’t have to go home and do it in their pajamas after dinner, that’s what you’re talking about.
Subha Airan-Javia:
Exactly. Yep, so that’s totally standalone how people can use this, and actually we just launched a version of CareAlign that they were calling direct-to-clinician, specifically for outpatient and post-acute care or small groups where they can just sign up and start using it today.
Matthew Holt:
So a small outpatient physician group could all grab this, they can get their nurses and that assistance and we’re also on the same platform.
Subha Airan-Javia:
Yeah. Honestly, even a large group. It scales well, so as big as you want.
Matthew Holt:
But you’re usually already in a very large hospital using it at Penn and Crozer
Subha Airan-Javia:
Yeah, that’s where we were born.
Matthew Holt:
So then let’s go from the demo and then just show me what’s the experience then for people that are using it when it is integrated with an EHR, because that’s obviously sort of the big question is what happens next? If you wanted to integration, what are the advantages of doing that?
Subha Airan-Javia:
Yeah. I would love to show you that. What I am going to do though is since we can’t show real patient information, I’m going to show you slides of what that looks like.
Subha Airan-Javia:
So give me just a second and I will pull that up. So now I’m on a slide which shows you how CareAlign looks when it’s integrated. So you can see all of the right side, the workflow, task management, documentation, same. On the left side now, you have all of the data integration, and this is the same if I were to be on a desktop or if I were to be on a phone. It basically just collapses down to this one view so it’s really mobile, really flexible. But the idea here is there’s a lot of different sections. I just need to click on this one button, which is what I want to know every day for patients is my rounding list, and it pulls up their latest, vital signs.
Subha Airan-Javia:
There’s a patient who’d been in the unit for months and months and months and I can see all of this data coming in and I can say, “Oh, what’s been happening with the blood pressure over the last day, three days, one week?” And it pulls in all of that data in real time for me, instead of having to go find it. You were asking about the EHR apps. Most of them show maybe the last three vital sign values. That would take me only back two hours for this patient, whereas here I’m looking back for an entire seven days of data where I really need to be able to make decisions. Looking at their labs, similarly this is how we write labs, instead of writing it in a grid, which is how most EHRs show it.
Subha Airan-Javia:
And then again, I can trend any lab value, one week, one month, six months, and you can see this gives you… this is a perfect example of how a picture’s worth a thousand words, that it really tells you a different story than if I were to just try to look at the numbers individually. And then I often say that being a clinician, sometimes it’s like hunting and gathering for data and this huge trove of information. A big part of what we’ve done is how do we make it easier to just find the information we need? So we’ve made it really easy to just search and I can say, “Has this patient ever had this lab value done?” And immediately pull it up for me, which most EHR mobile apps, you can’t even do on, you can’t search for labs or for studies.
Subha Airan-Javia:
So same thing for any radiology imaging study. I can click on it, I can view the entire result, again, search for anything that I need to look at. So it really changes. I think the best example is like having email on your phone for the first time. So maybe I’m dating myself, but the difference of being able to say, “Oh, I’ll just send that email now or I’ll look and see if someone has an email now,” versus going to a computer. So really, it’s about having access to the data that we need and there’s a lot of work with health information exchanges and CCDAs to exchange data, but we exchange them as basically PDFs or individual files. It’s not how I need to see it as a clinician to be able to make a decision about a patient. We don’t even do that for our credit card statements. I can pull everything in individually and see what happens, but I can’t trend the patient’s lab value across all of their different visits and I need to make important life and death decisions about it.
Matthew Holt:
So in terms of the notes part of it, and you showed the creation in the standalone version of creating the detail. Now, how does that end up back in Epic or Cerner?
Subha Airan-Javia:
Yeah. So the way it ends up, I’m just going to show you a mock up here, is basically when you’re integrated, you can open CareAlign right within the EHR, either in a sidebar on the side or in a full screen, and essentially just like I showed you, you say, “Create my progress note.” It puts it all together and then if you’re integrated, you can just do with a doc phrase or a shortcut text and it will import the data in, or you can actually copy and paste it in. So even without any data integration, you can use this next to your EHR and paste it in, which we have entire health systems doing. People without CareAlign often will do this on Word documents or in Google Docs to be able to put their thoughts together and then paste it in. And I’ll just say this really quickly which is that copy and paste or copy forward is a problem with how we document, but the difference here is instead of bringing in something that’s 24 hours old, you’re bringing in a plan that’s been edited throughout the day or throughout the two weeks since your last visit by multiple people, so it’s actually updated.
Matthew Holt:
So Subha, this sounds great. It looks really exciting. You built this at Penn, right where you’re based and you have the folks over at Crozer using this as well. Give me a sense, how many users are on this? What are they saying about it? What’s some of the responses you’ve had?
Subha Airan-Javia:
Yeah. So this was, as you said, we created this actually at Penn medicine. I used to be an associate CMIO there and this was just built to solve an internal problem. We launched the company only because of how impactful it’s been. We have been live there for about five years, even with an Epic implementation. About 3,500-4,000 unique users a week, almost 200,000 sessions a month, about 8 million actions a month in the application. And what I find interesting about it is that it’s all voluntary. No one’s doing this because they have to or because they’re forced to, they’re doing it because they find value in it and they feel like it helps them. I think my favorite quote by far was an attending who said that we would have to pry it from his cold dead hands if we tried to take it away from him. But honestly the reason why we started the company is because a vast majority of people using CareAlign say it saved them an hour a day and that they can each point to a time when CareAlign prevented an error in their practice, so they feel safer taking care of patients with it.
Matthew Holt:
Fantastic. And then as the company, you’re relatively early in the process of becoming a company from rather being a cool academic project, but give me a sense. You’re in a couple of other places where they’re not integrated with the EHR, which I guess, give me a sense for how that’s going and then what your theory about this new product release for the ambulatory space is going to be in terms of the guerrilla marketing, if you like, of CareAlign.
Subha Airan-Javia:
Yeah. Well, so I’ll be honest. I wasn’t sure how well CareAlign would be received without integration since that’s the only way I had ever used it at Penn, so that was a bit of an important validation point for us. We now have multiple different hospitals who are using it the same way, without any integration, completely standalone, and we saw very similar quick adoption curves, which was one service started using it and then without us trying, it spread to the rest of the health system. And they’re able to do everything other than looking at the vitals and the labs, so it’s now become a cornerstone at these other places as well. I think what’s challenging, one of the challenging things in medicine is that the clinicians who we’re designing for, which is a change in the health tech industry, I don’t know if I said physicians, but the clinicians, they’re not the decision-makers in health systems and so that becomes a challenge, but that’s what we’re showing is important is you need to have platforms and tools for your employees and your workforce actually do work well, especially when it comes to patient care.
Matthew Holt:
Yeah. So the second question is you have this new product, which is the direct-to-clinician version,without going through an institution, what’s the sense there?
Subha Airan-Javia:
Yeah, we are very excited about this particular model and we’ve seen good response already. Usually, people are looking for a way to manage tasks and documentation, but basically the idea is that any clinician, any group of nurses, physicians, doctors, therapists, we’ve had counseling centers and group homes look into using CareAlign for this, but basically they can just sign up and start using it today and start putting their patients in and managing their tasks. And what’s nice is they can use it as a simple task management platform or they can use it as a documentation platform, there’s a lot of flexibility there. But I think because this is a new product, people don’t really know or may not understand how it fits into workflows, so it gives people the opportunity to try it and see if it works and see how they like it and let us prove our value.
Matthew Holt:
Fantastic. All right. Well, I’ve been dealing with Subha Airan-Javia, she’s the CEO of CareAlign. Always great to see a new interesting product to help improve that social workflow and hopefully reduce a bit of the burnout and make lives easier for our frontline workers. So thanks for your time and good luck with the rollout.
Subha Airan-Javia:
Thank you so much, Matthew. I appreciate your time.
