This week I am talking to Colin Banas, MD Chief Medical Officer of DrFirst (@DrFirst) a company looking to unite the “Healthiverse” and shatter the silos in our healthcare data. Colin started out as a hospitalist working at VCU but quickly became involved in healthcare technology working alongside others to develop early implementations of electronic medical records and Computerized provider order entry (CPOE) before widespread adoption that came following the introduction of Meaningful Use.
He brings all of that experience to his new role with DrFirst, a company that started life as an electronic prescribing solution but has grown to much more with solutions around controlled substances, prior authorization, price transparency, and medication management and reconciliation
We talk about the origins of Prior Authorization, why it came about and the challenges of the system that consumes so much time for clinical staff already burdened with administrative requirements that take them away from patient care. As he shares, in one survey 20% of physicians said the process had contributed “serious outcomes such as a hospitalization or even a death”.
We discuss some of the potential ways to reduce the burden, including providing real time access to authorization requirements at the time of consultation, based on access to the full patient record and knowledge of insurance requirements allowing clinicians to discuss potential choices that are friction free for the patient.
We discuss how far healthcare lags behind other industries, the importance of digital health, a digital front door, open notes, patient engagement and how best to achieve success with an engaged patient that has demonstrated a higher medication adherence and improved outcomes.
Friction Breeds Innovation
Listen in to hear Colin’s views on consumerism, the value of friction in driving innovation and how to bring solutions to our fragmented healthcare system and the distributed un-integrated data and what you need to do to be a ‘Smart Healthcare System’.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by Dr. Colin Banas. He is the chief medical officer of doctor first calm. And thanks for joining me today.
Colin Banas
Thanks for having me so much.
Nick van Terheyden
So, as I do with all my guests, I think important to get a little bit of context about your background, before we get into some of the topics for discussion. You’ve had a long story background in the healthcare informatics space, tell us a little bit about that journey and how you ended up a starting down that pathway and then how it developed?
Colin Banas
Sure. So I, I started my my career at a large academic health system actually did my residency at Virginia Commonwealth University Health System and stayed on as faculty as a hospitalist and didn’t quite know what I wanted to do, but figured internal medicine and hospitalist medicine, which certainly opened a few doors. Immediately upon becoming an attending got a Master’s Degree in Health Administration, and started getting involved in a lot of things with my health system. One of the fifth most interesting things was my partner and I, Dr. Alister Erskine, we had the privilege of starting up a clinical informatics group, we call it the Office of Clinical transformation. So the basic premise was VCU was was up on an electronic record, since almost pre 2000. So prior to meaningful use, we were already doing cpLP and enjoying the benefits of EMRs. But we quickly realized there wasn’t a lot of clinical input to the electronic record, and there was a lot of dissatisfaction. So we got some money from the beam, we got some approval to start up this Office of Clinical transformation. And with that became came a lot of protected time to to improve the EMR. So think about order said management, clinical documentation, things like that. And as Alistair moved on to his next career, I was next man up. And so I assumed a mantle of chief medical information officer. And so for over a decade, I was in charge of a large Cerner instance, at VCU health. And really, really enjoyed my time implementing multitude of solutions, demonstrating the impact of electronic records, etc. And, you know, of course, a lot of bruises along the way when things like Meaningful Use came about a lot of regular regulatory reform. But as as I mentioned, before, I I stayed there for almost two decades practicing medicine, informatics, and then finally, about three years ago, it was time for the next part of my career journey. And so I joined doctor first as the chief medical officer in 2019.
Nick van Terheyden
You know, it’s interesting, you, you were there early, obviously got an opportunity to see the value proposition before an awful lot of money poured in. So there must have been some real positives to it beyond the meaningful use incentive dollars that sort of drove some, I want to say odd behavior, and maybe not the best, you know, outcomes in all instances. Now, you’re a doctor first, tell us a little bit about them. They’re a broad based company, they have a lot of solutions.
Colin Banas
Yeah, it’s it’s a great company. It’s actually people may not realize, but the company is actually 22 years old at this point. We were the first company to go public in January 1 of the Year 2000. And it started as an A prescribing company. So again, prior to big EMR implementations and the expectation of e prescribing, our founder and CEO Jin Chen, had a vision for getting rid of paper and the prescribing process. And so we cut our teeth in E prescribing and also innovated a lot of things that came along with it. So think about a prescribing controlled substances, prior authorization, price, transparency, all of the things that we are starting to expect as commonplace in the E prescribing and EMR world. Doctor first was was pioneers in that space. And then when I described the company what I really like to say is that the sweet spot for the company stems from this This origin in a prescribing and so we have a lot of solutions now in the medication management space. So things to make med rec easier and safer things to make patient adherence improve, we have patient engagement solutions, for example. And then of course, things that make providers lives easier, like price transparency at the point of making the prescribing decision, prior authorization, anything that can help reduce the friction in healthcare, and also improve the outcomes and improve the experience.
Nick van Terheyden
Yeah, I’m, I’m all about reducing friction, although, as I pointed out, and one of the pieces I put out not too long ago, friction is sometimes good. You know, in the cases of complex cases, you want time spent, you want people to actually delay and not sort of race through but for the most part, friction is painful, it causes aggravation. Let’s focus a little bit if we can on prior authorization, and I am sorry, I’m just as a physician, and as a patient, I look at this and say, Why do we have this whole process that just seems to get in the way? of everybody?
Colin Banas
Yeah, I think it’s a great question. And I think, I think the standard answer is that it’s born out of a cost, cost saving measure from pharmacy benefit management, managers, PBMs. I think there’s a desire to make sure that costly therapies are indeed appropriate, that appropriate, prior medications or therapies had been attempted before jumping all the way up to tear. But I think it’s, I think it’s become a little bit, maybe not even a little bit, I think it’s become a lot of a hindrance at this point. And I’m not sure the clinicians, for sure, are extremely frustrated. So if you think about all of the things that clinicians and clinical teams are having to do, already, in the name of regulatory reform, in the name of appropriate documentation to make sure that billing needs are met, and that you can survive audits, etc. You know, prior auth is just another another source of severe friction. And I like to reference, there’s a survey, it’s about a year old now from ama surveying physicians about their experience with prior auth. You know, there are, on average, a lot of practices are devoting multiple FTEs to managing prior offs. So you can think about those FTEs can be used better elsewhere. I think 94% of clinicians have cited prior off requirements as a delay, resulting in a delay of patient care. And one of the staggering stats I saw from that survey was that upwards of 20% of physicians had thought that prior off delays had led to serious outcomes such as a hospitalization or even a death. So compound that with the fact that we have not made a lot of headway in making the prior auth experience easier. It’s a lot of phone calls. Still, it’s a lot of paper, it’s a lot of faxing, back and forth between payers between pharmacies. And so it’s just it’s an area ripe for the potential for innovation, for sure. But it’s also a serious source of discontent for providers. And of course, you layer on the last two plus years with COVID. The burnout proposition prior auth floats right to the top as something that providers wish would get get better if not go away.
Nick van Terheyden
So let’s make an assumption. It’s not going away. I mean, I do recognize that from an economic standpoint, just open checks that you know, have no no stops on them to prevent misuse. And, you know, sadly, we always seem to run to the bottom that the poorest performing behavior is the one that we protect everybody against and cause all of this friction as you described. So let’s stipulate that it’s going to stay with us. I mean, I’d love to believe that it wouldn’t, because I’ve had personal experiences that you know, have absolutely caused tremendous pain and aggravation. But if that’s the case, can we make it better?
Colin Banas
I think we can. And I think one of the one of the things that the digitization of the medical record. You know, one of the promises that we’re holding out for is that this data, this digital paradigm that we’ve now that we’re now living in, can improve these things. And so, you know, a couple of things that are, you know, right off the bat, and some of the things that doctor first is able to do is, you know, show providers in real time, if a prior auth is going to be required, and actually show them alternatives. So perhaps, you know, treatment a, has a prior auth, and a copay of, you know, $40, but treatment B, no prior auth, and copay of $10. You know, that’s, that’s the promise of price transparency, and allowing providers to make those decisions in real time, at the point of making the prescribing decision. And also, with the patient in front of me, either in person or increasingly virtual, you know, we can we can make those decisions and make better treatment decisions that will that will get the patients on therapy and keep them on therapy. The other thing I’m holding out for is a shift in in what the technology will be able to do in terms of automating the prior auth process. So if you think about digital records, you know, lab values, prior medications, in the medication history list, for example, there’s really not a reason that we can’t craft these systems to mine this information, again, at the point of making these decisions, and perhaps avert the prior auth altogether, because you can the system can tell Oh, yes, you know, Collin has tried these three prior therapies, therefore, this one is appropriate, or the lab values do line up with this, this particular need. And so that is the next level that I think we’re all holding out for, but independent of that, if we could just do it digitally, you know, all of the time and avoid the faxing, avoid the paper, avoid the phone calls, I think we would get a lot of joy back in the care of our patients.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick, the incrementalist I’m here with Dr. Colin Banis. He is the chief medical officer of doctor first we were just talking about prior orphan the electronic process, I think, you know, I gotta say, as a patient, I would be delighted to have a whole discussion if it feels a little bit like the home improvement sector where you’re picking a floor, you pick a floor, and then find out that it’s six months into the future. And if you’d known that you would have picked another floor, I think very similar in healthcare. Right? You know, you’d say, well, I’m willing to try that if we can actually make some progress. You’re saying that that’s possible? Why aren’t we seen? I certainly haven’t seen that what’s happening? What’s preventing that from being the case?
Colin Banas
I think I think there are there are companies, again, like my own that are making positive steps in this direction. I think one of the things that plagues Pryor off is how fragmented the various PBMs and requirements are across the industry. And so it isn’t yet a one size fits all, depending on you know, what the patient’s insurances? What’s on formulary, etc. And so, there is a there’s a tremendous amount of fragmentation that needs to be overcome across the data sources. And I do think things like, you know, API requirements that are starting to, to show there to appear, you know, at the patient level, and within the next two years, we’re gonna see them at the payer level as well. I do think these API requirements are going to open up the data stream to allow the consolidation of all these fragmented pieces that that are so present right now in the prior off and price transparency realms.
Nick van Terheyden
You know, you bring up an interesting point. So during COVID, which has been I don’t think there’s been a single time I’ve been on social media where COVID hasn’t been the top trending topic for the last two years, at least. But during that time, we’ve seen a couple of pieces of legislation and in fact, the most recent which was no surprise billing, and the requirement to essentially give a I think what it was called was a good faith estimate of the price of care. Do you think that’s going to bring some positive movement to this whole space that will allow for a better prior auth process?
Colin Banas
I think this is this is all part of marching in the in the right direction for And I’m not a big fan of this term, but it does fit it’s consumerism, right? So how can we give the patient you know, rather than the consumer, how can we give the patient the information they need to make these decisions. And so, again, I mentioned API’s, you know, patients are now able to, to connect to electronic records and pull their own data back and possess it and send it on its way where however they beam, things like open notes, the open notion, open notes Initiative, where patients can see their progress notes and helps them stay on treatment plans. Another example of patient empowerment. And so price transparency, no surprise billing, it’s all this progressive march towards making it a more consumer and more patient friendly ecosystem, you know, a lot of the things that we’ve come to expect in retail, in banking and aviation, the, you know, the experiences that we have come to expect in those areas, and our ability as patients as consumers to make decisions, because we have all the information, we’re finally getting there in healthcare, I think it’s just, you know, the I think the typical saying is healthcare lags 10 years behind these other industries, it might even be closer to 20 based on some of the the pace of change. But, you know, the fact that these things are finally making their way into legislation and expectation, again, I think it’s all progress towards this March.
Nick van Terheyden
I’ve got to say, on the one hand, it’s depressing to hear the 20 year lag, and I can’t disagree with you. But I’ll take the optimistic view of that. And that just is, what an opportunity to accelerate and bring us up to the space because we don’t check our experiences from the rest of the world at the point that we enter the healthcare system and say, Oh, well, no, I expect to be filling in paper forms for the fifth time and going through that experience. So you know, that’s the good news. How do we go about effecting that? What are the sort of key elements to deliver this in? What do we need to see healthcare systems doing to allow for that frictionless experience that everybody wants? I mean, I think the healthcare systems want to deliver I can’t believe for one second, they want to make it a painful experience.
Colin Banas
Yeah, it’s, it’s a couple things. One, you know, friction does breed innovation. So to some extent, I guess it was necessary to endure the pain in order to get to the other side, in a sense, but and I do want to give a nod towards the regulatory reform, that is forcing, nudging, setting these expectations. I think, if you go all the way back to the origins of meaningful use, I think this was the expectation all along. But it didn’t quite happen, it sort of became this, check the box phenomenon, implement, implement, implement, try to collect the checks and not get penalized. And so additional regulatory reform had to come along, to push the bar further. And, you know, there’s nothing like a regulatory mandate to move something up the priority list for a health system. And so I think you would agree, you know, the, the IT roadmap for for most health systems is chock full, and there are there are, you know, decisions in priority that are being made constantly, and things are shuffling and of course, in a regulation comes around that sort of move things up. So, in concert with regulatory expectation, I think what we’ve started to see is the smart health systems have made this a priority above and beyond what the regular regulations are mandating. And they are, you know, so you’ve increasingly heard the term digital front door, probably in the past two to three years and improving the patient journey, so that we can give this more consumer like experience that we’ve come to expect in other sectors. And so that starts to become a differentiator, I think. And so, the smart house systems who have prioritizes above and beyond what is required, are going to start to reap the benefits of more efficient care, increased patient attraction and retention. And so I think there’s nothing like healthy competition. To help kick start this. Also, I think the providers are finally starting to expect it and require it as well. And I think there’s nothing like clinicians with with a need to help push these things along as well.
Nick van Terheyden
Yeah, I’m just going to add burnt out clinicians with the need that are going to say, enough is enough. I agree with you 100%. So great opportunities, I think, you know, a number of confluence of regulatory, I love this concept of friction breeding innovation. I think that’s one of the reasons that we see so much innovation in places that you wouldn’t expect. Now that that’s the case, there’s clearly some opportunity to help solve some of the other problems, medication adherence, adherence for me is, you know, just this huge issue, you prescribe something, then no idea whatsoever that it was actually delivered, used, whatever, you even got some thoughts around that.
Colin Banas
I do. And, you know, one of the things that doctor first is able to do in the patient engagement and adherence space is, is continue to touch the patient in an automated fashion after the prescribing decision has been made. And we do this with secure texting and an app like solution. So if you go back to this notion of friction, we’re not making patients go get an additional app. We’re not making patients do a new login, new registration, but we’re delivering them the experience that they’ve come to expect. But we’re doing it over SMS and I think the literature is overwhelmingly supportive of the fact that SMS is a preferred medium for communication. People look at SMS people respond to SMS, people don’t ignore SMS, whereas sometimes a portal message message or notification can get lost in the shuffle. And what we’ve been able to do by touching the patient after the prescribing decision, we can we can remove the barriers that prevent adherence. And so there’s really three biggies cost is a big one. So you know, if a prescription copay gets over that 50 or $100 threshold, patients are 50% likely to abandon it. And so in our solution, where we touch the patient, we’re gonna serve up copay assistance in an automated fashion. So we will show you, the patient what your copay is based on some of our technology. But we’ll also couple that with copay assistance cards or farmer coupons in real time that you can take in person to the pharmacy and get that reduced price. We also deliver educational content. So sometimes people don’t get on therapy, because they don’t know why they are supposed to be taking this medicine, or what side effects they could expect. And so we’ve automated educational content as well. And I think the third big barrier is patients forget, I definitely have been guilty of having a prescription sit in the outpatient pharmacy and forgetting that it was there. And so this third thing that we’re able to do in this technology is that nudge and that that ability to remind and set reminders, to go pick up that medication. And so the constant in concert, those three things in our technology, which we call RX and form, we’ve been able to improve, firstly, first fill adherence rates from 10 to 20%. In certain disease states. And that’s a big deal in terms of impacting patient outcomes, preventing unnecessary readmissions, and things like that. And so that that is an area that I’m particularly excited about as we enter into 2022.
Nick van Terheyden
Yeah, I couldn’t agree with you more on the whole texting as a platform. It’s kind of interesting. The statistics on this are absolutely overwhelming. I think email is that about three to 5% response rate. I don’t know that this is true. This is guesswork, I’m going to say portals at the same level, but texting is 95% Within five minutes. It’s extraordinary. It’s you know, now, I’m a little bit hesitant to even mention that because now suddenly jumps into texting and will probably start ignoring it. But I agree with you 100%. I think that sort of cost education and the reminders that you know, that collection is really going to help change and it’s so important because it’s such a big problem that you know, is an unrecognized I think, by patients not so much by the clinical team. Unfortunately, as usual, we run out of time. Exciting times, I think for you for doctor first I think tremendous opportunities Excited to see you know some of the removal the improvement of the process that you’re bringing to the space just remains for me to thank you for joining me on the show column. Thanks for joining me
Colin Banas
that you so much for having me. It was a true pleasure.
