Alan Portela, CEO of AirStrip

Catalyze: I’m excited today to have Alan Portela. Alan has 25 years experience in healthcare and a passion for leading disruptive and continuous innovation. Alan is currently the CEO of AirStrip, a position he has held for more than four years. Before joining AirStrip, Alan was the President of CliniComp, Intl., and previously led the implementation of high-acuity EHR systems at the U.S. Military Health System, Veterans Health Administration and a number of prestigious healthcare organizations in the private sector. Alan has held senior executive roles with a number of innovative healthcare technology vendors and was among the leaders who pioneered Global Care Quest, an mHealth company that emerged from UCLA Medical Center Department of Neurosurgery more than a decade ago.

I’ve been fortunate enough to know Alan for a few years as he has grown AirStrip into one of the preeminent successes in the mobile health space. I’m so excited to have him here today talking about innovation; interoperability and data; and his experience at AirStrip, as well as previous to that. Thanks to Alan for joining us today, we really appreciate it. We know you are a busy guy.

Alan Portela: Thank you Travis for having me.

Catalyze: We’ll jump right in. AirStrip has really been at the front of innovation. There’s some interesting stories about the initial release of AirStrip—the initial versions of iOS and being very early into this space—with its innovative approach and taking a UI-centric focus, which now a lot of people are doing in healthcare. But before, I don’t think a lot of vendors really thought about.

Curious from your perspective: How does innovation fit in with mission at AirStrip and if part of the mission was driven by you, or was that part of the previous culture at AirStrip?

Alan Portela: This happens a lot with many companies. When we started about 11 years ago, we had people that founded the company that were very innovative and visionary. What these two people had, Cameron Powell, MD, and Trey Moore, the engineer, was a combined share of mission and vision in the fact that they were dealing with mobility in healthcare.

They introduced medical device mobility, but they concentrated at the beginning on iOS. It created a great opportunity where Steve Jobs invited them in 2010 to the WorldWide Developers Conference (WWDC) to talk about iPhone and real-time waveforms. That was a very incredible event because it brought an innovator on the venture capital side and that was Sequoia Capital. They were very fortunate that Sequoia, known to innovate starting out with Google, Oracle, Cisco, Apple—all the companies that we know today—they decided to invest in the company. Most likely what happens in situations like that, either you pick an investor that will be able to support continuous disruption or one that would like to execute on what you currently have. Sequoia is more of the continuous disruption to stay ahead of the market. At the time, immediately after their investment, they brought me in as a board member and also as the CEO. And of course, my passion is for innovation and continuous disruption.

There was a business review article on Harvard Business Review on “Big Bang Disruptors,” and I consider myself a big bang disruptor. The first thing I did coming into the industry, even though we realized we had a very good traction in the market on the medical device side, is I carefully studied the challenges that the providers were facing at that particular time and what trends we were seeing ahead of us. Of course Meaningful Use was important in the Accountable Care Organizations, but the upcoming Affordable Care Act (this was about two years before the elections), I guessed that Obama was going to win at the time. I’m actually a Republican, but I still guessed that Obama was going to win and then I started really preparing, [by asking the question]: What would be the changes if the Affordable Care Act kicks in? It was obvious that we were going to have more patients and we already had a shortage of caregivers, and the reimbursement rates were going to go down on the exchange, and private payers were going to try and match. That would mean providers were going to have to cut operating budgets. That was going to have a significant impact on innovation, and the only way to succeed is to look entirely at caregiver workflow—not only on the inpatient side, but also throughout the continuum of care.

I went to Sequoia and asked for additional funding to be able to look at electronic medical record data, to be able to bring imaging, to connecting APIs for video and secure messaging and others, and really look more at a dashboard that could be displayed on a phone or it could be displayed on a tablet. But a dashboard that could provide an agnostic view of multiple data types, of multiple care settings, for multiple members of the care coordination team. Fortunately again, and I keep stressing that: You get the right investors that will support your continued innovation. At the same time Sequoia decided to support that vision. That same vision attracted other investors – the same kind like Qualcomm, WellcomeTrust, and investors like West Health.

Another key for us is that a number of our pioneer customers, like Dignity Health, HCA, St. Joseph’s Healthcare, also decided to invest on that vision. If you look at founders, the right investors, right vision and understanding the trends, and the right customers that are willing to be the early adopters… the next thing you have to do is create a process, because you can not do it on your own. You can have a vision but you need to create a process and you need to create a culture in the company.

The first thing that I did was to look at all the development, resources and initiatives that we had and divided the allocation of resources in two to three areas. 45% of everything we did was around core implementations, 40% were in adjacent developments, and 15% transformational.

I was recently at a presentation from the CTO of Walgreens. He said that they enhance, evolve and explore. You enhance the core; you evolve into new adjacent markets; and you explore the next generation of transformation. We take the same approach, but I add percentages to that, knowing that eventually if you do your job right, you look at a four to five year period, most of your revenues will come from the 15% of transformational initiatives that you were doing five years ago and most likely your core is going to be 15% of your revenues today. So if you combine your core and adjacent, that’s about 85% of our revenues are from core and adjacent, which was reverse of how you put your resources. In my mind, that is a secret to continuing disruption. If you do it right, the formula always works.

Catalyze: Wow. I’d never heard that before. It makes a lot of sense. That’s something that you put into place at AirStrip and it’s still in place?

Alan Portela: Everything we do is that way. Of course today, our core is a combination of everything that we have done in the last five years, but I’m already looking at the transformational step, but of course, I’m putting 15% of our resources on that.

Catalyze: I’m curious about this in the terms of timing. When you went to look for additional funding, and broadened this vision and went beyond medical devices, when you set the focus of the company on clinician workflow that was two to three years ago? Was that before AirStrip ONE and before the platform?

Alan Portela: Immediately after I joined AirStrip four-and-a-half years ago, I started looking into this, and started looking at becoming a platform, for interoperability, care coordination and looking at all those multiple data types, I realized that the market was consolidating as part of the Affordable Care Act. The more healthcare organizations that hire others or collaborated with others, we were going to end up with a mess of systems of multiple systems. Mobilizing all those systems is mobilizing the mess. You are propagating the same challenge of lack of interoperability, so we needed to look at an agnostic, seamless, one view of all that data.

Catalyze: You touched on a topic that I think is incredibly relevant today and I know we talked about it a few times, but that’s interoperability, which is obviously a hot topic period. As systems consolidate and start to work with each other, and then payers start to work with systems, you are counting on clinicians have access to all of this data, interoperability becomes really more important.

Interoperability is a huge topic and there have been a lot of things thrown around as potential solutions, or potential approaches may be a better way to put it. I’d be curious to get your impression on what true interoperability is and if we are moving towards that, or not with some of the current approaches.

Alan Portela: If we go back to the trends that we saw five years ago when Meaningful Use was having a significant impact on the wide deployment of electronic health records, I have to give it to ONC for really coming up with that program. I have to also recognize that it was David J. Brailer under George Bush [currently CEO of Health Evolution Partners] that started that process, but he didn’t call it in Meaningful Use. So far, government had a significant role in this whole process, but what they did is to incentivize providers to really accelerate the implementation of all the EMRs. What happens is that as you do all that, with Accountable Care Organizations and the Affordable Care Act, we started really moving to a patient centric model from a hospital centric model on the reimbursement side, and from a fee-for-service to value-based reimbursement.

Where we are missing the boat here is that now we tell are telling our physicians and our care coordination teams that they are going to be paid based on outcomes. Now that they are going to be paid based on outcomes, they need as much information as needed to be able to make the right decisions and that information has to be real-time. What we are doing is we provided the incentives, the hospitals implemented the EMRs – all the data now is automated, but now ONC recognizes that interoperability is important and all of the sudden they come up with a 10-year roadmap between 2014 and 2024 with 25 clinical data sets that are the ones that had to be shared. Some of those are: Do you smoke? Well, it’s very important to know if you smoke, but also it’s very important to have the medications that you are on. When you get admitted to a hospital, it’s important to know what medications you are on in real-time and we need to look at your vitals to make sure that we are doing the right treatment for the patient.

We were starting to see ONC’s very relaxed timeline on how companies have to comply—the EHR companies have to comply with interoperability. Now it’s not really committing a sense of urgency, and we are slowly moving into that and the vendors feel that they are obligated to increase the level of interoperability. That is going to hurt decisions and eventually of course, it’s going to hurt patients.

Catalyze: There certainly doesn’t seem to be much of a fire there, at this point for a lot of the vendors.

Alan Portela: We were looking at core development, adjacent and transformational. For us, transformational four or five years ago, the adjacent business was to get additional data beyond medical devices. Transformational was to be able to clean that data, de-identify, but also to be able to standardize it, normalize it around clinical nomenclature and then eventually to start applying algorithms to be able to take that data and make our caregivers more proactive persons and reactive when it came to adverse events.

Many analytics companies are coming in with a lot of very specialized algorithms to improve disease management and population health. With all that technology out there, we don’t have enough data available to us, because most of the vendors are siloing this data, because they have their market share.

Elections are coming up in 18 months, this is the time where the existing government needs to make sure that they look again, as they are doing, at what is the roadmap and what is it that we can do to help those decisions to improve outcomes for all patients.

Catalyze: You talked about four or five years ago that transformational bucket for cleansing data, mapping data and standardizing in terms of nomenclature. I imagine adding semantic meaning to data, by mapping things to some of the code sets that exist, which is a huge challenge.

It’s interesting AirStrip started as a mobile app company that was a view for obstetricians for maternal heart rate monitoring, but has evolved into a data company. Is that an accurate perception of where you see AirStrip is today? Is that where you see AirStrip going in the future, in terms of additional data or services on top of that data?

Alan Portela: I have to say it’s a pleasure always talking to you, because you understand what standardization is. You understand what semantic interoperability is, so it’s a pleasure to talk to someone who understands the challenges that we are dealing with.

The key for us, from the beginning, was to work with customers. I have to mention the customer like Dignity Health. When I presented the vision on a whiteboard, and it was just a drawing about the platform and who we were becoming and that we were going to impact workflow, and innovate, the CIO Deanna Wise said, “If you can do that, that would be the Holy Grail, but it is a very big challenge.” She said, “I’m in; I’m willing to invest and be your first customer to bring the AirStrip One platform.”

If it weren’t for people like Deanna Wise at Dignity, maybe others at HCA, or St. Joe’s, it would be impossible to get to where we are today. Providers are driving more innovation, and they are going to be the ones to force interoperability. If you look at who we are today, it’s very interesting, because about six months ago, we went through a big exercise as we are growing and growing, and serving our customers in different ways, we decided to create one sentence that will define who we are as a company. What is the product that we bring to the table? What is the problem that we are solving? And, the sentence is as follows: We are a mobile interoperability platform that enables care collaboration, and serves as a catalyst for customer innovation.

To give you some examples, the mobile interoperability platform is everything that we do on medical devices, EMRs, bringing API integrations, structured and unstructured data all in one platform. They enable care collaboration. It’s all about existing workflows automation; it’s not about reinventing the wheel. It’s looking at what people are doing today and trying to bring technology to automate that particular workflow.

A lot of people say well, you need to redesign workflows. Well, the big consulting firms have already done that for the last 10 years. Most of the hospitals today have the workflow analysis already assigned and already completed with clinical transformation. Now we just need to bring technology to automate those existing workflows.

The third component of the sentence, “serving as a catalyst for customer innovation,” doesn’t mean that we are going to have to develop a lot of things. Sometimes, you go to a customer and you say, “What will make the biggest impact today for your care?” And they say, “Well we collaborate with a number of organizations in the country and we work on a number of NICU patients where we have other hospitals supporting us because they have the right level of expertise. If you can give me all the medical device connectivity, from my neonatal intensive care unit. If you can bring me the EMR data, specifically on the NICU real-time. If you can connect me with video, and also bring an API for images with agnostic quality and allow me to use third party secure messaging, you completely transform my life with the way we take care of babies.” That is part of our core functionality today. It was transformational four years ago.

So, it’s really looking at how can we apply our mobile interoperability platform and visualization tools, because those apps, when you talk about applications four or five years ago, we call that visualization tools, because not only are we visualizing data from multiple systems, but now we are visualizing data that is produced from analytics engines, and it is data coming out real-time. Many analytics companies are collecting data that is retrospective, but real-time? You are going to see that it’s a big challenge.

Catalyze: That is my second question, too. The analytics companies that you guys are talking to or working with, are they doing real-time analytics based on the data that you are pooling from devices, EHRs, and all these different sources?

Alan Portela: Well, I always go back to the providers, because they are my customers. Providers are AirStrip’s customers and I think I learned this lesson from Judy Faulkner [founder and CEO of Epic Systems]. I try to work with those customers that have the right vision—the ones that really fit the profile of what we are trying to do—because they are the ones that are going to give us the right feedback on what our next transformational initiatives are. But also, they are going to be the ones that are going to work with the existing legacy vendors to make sure that we all collaborate. There are no frictions or overlaps.

When I talk about working with a provider, I don’t get the data from the EHR. I don’t get the data from the medical devices. I provide the tools for those providers, so they can create with the use of our platform and visualization tool and the collaboration with their medical device and EHR vendors, then all of us can work in an ecosystem that works. Of course, some are open and some are not open on the vendor side, but you will see that in the next two years, since there are so many forces coming from the outside, that the providers are becoming so big from collaboration and consolidation that you will see that the vendors who will not open up, they are going to be history in the next 12 or 24 months.

Catalyze: So you do see that shift coming in two years? We are pretty close to a tipping point where vendors have held a lot of that power and that’s enabled them to kind of keep those silos. So you clearly see this shift where providers now do have the say, or starting to have the say where they can go to whatever vendor it is to actually get data opened up?

Alan Portela: Exactly. If you combine that, plus political forces on Affordable Care Act and the move to a value-based reimbursement… If you react to all of that, the fact that some EHR vendors, not only on the inpatient side, but, especially on the ambulatory side like the AthenaHealth’s of the world, many EHR vendors are starting to say, “We’re in.” And they are talking to those providers and they are saying, “I don’t want to be part of the problem, as you are consolidating. If you ever entertain placing everything with my solutions, I’m open. I want to be part of that transformation.” Even though EHRs have become a commodity, there’s going to be an opportunity for those vendors to sell more, basically taking the customer base of those that are not open. It’s going to open up again, even though [EHRs] are a commodity, because the ones that don’t open up, they are going to be history.

Catalyze: They are going to lose their market share, and that’s a big opportunity. That makes sense and we have seen the same thing. You are just seeing it at much bigger systems than we are. So that’s good to hear, because I think everybody is anxious to see us hit that tipping point.

Alan Portela: You see in the industry a number of organizations that are created around interoperability. But in my view, the moment you start combining vendors and providers, it could become very political—depends upon who is driving those organizations. There are some other groups that are being created that are just around providers. There is a group called the Center for Medical Interoperability. It was created a year ago; it’s based in Nashville. The goal is to first start with medical device interoperability, but look at the big picture. And it is just providers that they are getting together, realizing that they have a huge buying power and they can make a significant impact. We have to really look at all these different organizations out there and they are going to have probably one of the most important roles in the industry. But it is only those that are provider-centric that they come to all of us vendors and force us to open up.

Catalyze: Another topic related to interoperability. Not sure if you want to touch on it or speak to it, because I know we talked previously, but I’m curious to get your take from an AirStrip perspective and maybe from broadly just your perspective in the industry on FHIR, the new standard, or emerging standard I should say, around interoperability and restful endpoints and things like that and to read EHR data. I’m curious to get your impression of it if you can share anything as to how AirStrip is looking at FHIR.

Alan Portela: I think first of all they came out too quickly with the name. They should have called it SHIR as “slow healthcare interoperability resources.” I do believe that the “F” is for “fast,” but it doesn’t apply here.

It’s aligned around what you see on the ONC roadmap. When you look at standards out there, on the ambulatory, you have CCDA, which is very limited data, but it’s enough for ambulatory information for historical data and then you have HL7 that most of the vendors support on administrative and ancillary data like lab results, with urology results, but very limited info on HL7.

FHIR is a subset of what you have on HL7. It’s very promising, but there is limited data that you get. Probably you will get the same data that the ONC is requesting for 2017 that is 25 clinical data sets, but you are going to have only that data, and forget about the ability to write back into the data sources. What happens here is that FHIR is promising; it’s a slow healthcare interoperability resources standard, but knowing that we are moving to value-based reimbursement, I think that we owe it to the industry to realize that many of the top vendors have developed very strong Web services tools for their own customers to query the data, but they are not opening up the tools to the rest of the industry. We need to create a temporary layer that takes advantage of those strong tools that they have developed for all of us to collaborate on.

Catalyze: We have similar views on FHIR and done some work with FHIR, as well and compared it to HL7 and CCDA and some of the other standards. And yes, there are significant limitations in FHIR. We look at it as not really a solution to interoperability, at least in the current definition of FHIR.

Catalyze: Shifting gears a little bit. I want to talk about the AirStrip Innovation Marketplace. I am assuming it relates to that third piece of the sentence, talking about being a catalyst for your customers or providers, but could you talk a little about the Innovation Marketplace and the types of customers, or different groups, that you bring into that marketplace?

Alan Portela: A while back I was reading a whitepaper from PriceWaterhouse. They call it “Owning the Disease.” The whole white paper was about creating platforms and an ecosystem of technologies, providers, payers, pharma – all around being able to support the management of a disease vertically. The moment we had our AirStrip ONE platform with integration and visualization tools—the moment we realized we could streamline and de-identify—it became apparent to us that what we needed to leverage from what we created at the beginning of the company. Look at what medical devices or sensors are going to exist on the ambulatory side that can produce those real-time waveforms so we can start monitoring patients with diabetes, heart conditions, COPD or high risk pregnancies outside of the hospital.

We were very fortunate that about two-and-a-half years ago we received a methodology patent for re-rendering medical devices on mobile devices natively. So basically any device that produces a waveform, continuous waveform that requires a diagnostic quality, we have a patent for that, so we said, “If we can start looking at those specific clinical conditions or chronic disease – the reason that I make the distinction is that a clinical condition can be a high risk pregnancy and not a chronic condition, so if you look at diabetes, at heart failure, at COPD as chronic diseases and then, if you look at high risk pregnancy, we started saying if we move outside of the hospital and we pick the right sensors, what contextual data do we need as we need it on the inpatient side from activity monitors, blood pressure cuffs and scales, but also, what algorithms can we bring into this model, so we can start looking at the data that comes out of those devices, since we don’t have enough doctors to monitor these patients? We need to bring algorithms to help us to discern which are those patients that require special attention.

I call it vertical integration into each disease or clinical condition. I realized that 15% of the transformational effort, it was a monumental task. I was feeling great when I was looking at interoperability and the things that we were doing, but this became monumental. I said to myself: Well, innovation has to come from the outside and with innovation I have to start tapping into academic medical centers, and other companies creating incredible tools and algorithms for disease management.

The first one was MedStar Health in the area of Washington/Baltimore. They came to us and we developed a workflow algorithm for early detection of myocardial infarction for patients that are coming in an ambulance, so we can help the ED doctors to quickly determine if the patient coming in an ambulance has full blockage of the artery, rather than having to wait for the cardiologist on call. So we partnered with them, and we are working on taking those algorithms and visualizing them on top of our tools.

Then we partnered with the University of Michigan. They developed algorithms for hemodynamic decompensation from grants that they received from NIH and the Army. They were doing studies for kids in Afghanistan that were hit with the shockwave of an IED and the internal bleeding. With the internal bleeding, they couldn’t detect if patients would have severe complications, but they came up with algorithms that would read waveforms so they could detect within 40 seconds if there is compensation; there is loss of blood and there is loss of plasma.

We started realizing that there’s a world out there in the academic world that they are doing things that never go to market. We decided to create a translational business unit, so we could start look at body sensors. We could start looking at algorithms that now we can help those organizations to take to market, and of course come up with agreements that give them back royalty, because as we know, healthcare organizations need to figure out new ways of making money, because taking care of patients with Affordable Care Act is not going to be so profitable. You need to be able to take their translation to transformation. So I would say that my 15% of transformation is now divided on 60% is transformation and 40% is translational on initiatives coming from the academic world.

Catalyze: Wow. I wasn’t aware that those were the types of marketplace partners, but that does make a ton of sense, because those academic centers have done a lot of this and I think they probably aren’t very good at commercializing it and probably not very good at finding ways to actually do the implementation with access to the data, especially in real-time.

Catalyze: Is there a listing of some of the participants in the innovation marketplace? Is that something you guys have created in terms of University of Michigan, MedStar, MD Anderson or whomever it might be?

Alan Portela: At this point it is the University of Michigan and MedStar, but we are going to be talking to a number of others, other academic medical centers and definitely you will see the press releases as they come on. We are doing incredible things in both areas of body sensors and also on algorithms.

Catalyze: Honestly, it’s fascinating to watch AirStrip evolve. The 15% transformational…you start to see it after following you guys for four or five years and you can kind of see these things coming now, or actually like you said, they are in place now.

I want to be respectful of your time, Alan. I know you are a busy guy. Are there other specific things you want to cover in terms of innovation or funding or selling into large enterprises as a new or young company that we didn’t touch on?

Alan Portela: The key always as we mentioned is to continuously disrupt yourself; that’s very important, but also to recognize that in any company you get to a point where you need to bring resources from the outside to help you on your vision and to help the internal team – the previous team to go to the next level. And that’s what we did at AirStrip. We built an incredible team of innovators and people that are very strong on executing on innovation. It created a whole culture where everybody rose to the occasion.

It’s always the combination of the right investors upfront, of course the right mission and vision, the right customers that are willing to innovate with you and invest in your company, and of course the team. The team that you put together and how you educate your own team to get into this new innovation culture is very important. So, I just wanted to deliver that message.

Catalyze: Alan, thank you for your time. I may follow up with you separately to talk about some of the stuff we talked about previously. I’d totally forgotten in terms of sales, building a sales organization and your thoughts around that, but in terms of this, I really do appreciate this, Alan; this is super helpful.

We’ve interviewed some CIOs and some Chief Innovation Officers at large centers and we really wanted to bring in the vendor, start-up, entrepreneur perspective, and you, obviously, were right at the top of our list, so we really appreciate you taking the time.

Alan Portela: Well, thank you, and one more comment that I wanted to make is that I’ve been in healthcare for 22 years, and healthcare IT and this is the first time, thanks to programs like this, where we are able to deliver our ideas and the message of what we are doing. This is the first time that I’m getting the calls from those CEOs, Chief Innovation Officers, from organizations that are not even customers and they call me and they say, “I want to be your partner. We have some ideas, and we want to be your partner.” So I’m having fun. This is actually the best time in my professional career and even though we are in a difficult moment in healthcare, I think that if we all played right that this is going to be very exciting.

Catalyze: That’s great. Alan, you are one of the really good guys that I’ve met in the industry, so I’m very happy for you to hear that this is such a great time for you. Glad to hear that AirStrip continues to do so well.

Alan Portela: Thank you. Take care.