In this episode, Griffin talks with Bob Huff, the Chief Technical Officer of Imagine Fertility (https://www.imaginefertility.com/), a software that seamlessly blends documentation with EMRs and a variety of third-party software solutions. Griffin and Bob chat about the impact that software with walls has had on everything from practice management to patient care and what the future holds for tech in fertility practices.
Griffin Jones: If you are interested in how technology is going to eat our field, then you wanna listen to my guest for today’s episode. It’s Bob Huff. Bob is the Chief Technology Officer of Imagine Fertility, software that helps with documentation, with eliminating double typing into EMRs, with electronic signatures, with payment processing. Bob was the CTO of RMA of Texas for a number of years. Bob, I’m really happy to have you on Inside Reproductive Health.
Bob Huff: Thanks,Griffin, I appreciate it.
GJ: One of the coolest talks that I’ve seen in our field was one that you gave at MRS a number of years ago. A preview of so many of the technologies that are coming both on the consumer side, in diagnostics, in treatment. Let’s start off a little bit general because one of the core takeaways I got from there was really seeing a compounding impact when a lot of these technologies are able to talk to each other. That’s something I want to go into further. What does that mean, technologies being able to talk to each other? What does that look like as it unfolds over the next five, ten years?
BH: Well, what it looks like today is inside a fertility center, you have so many tools that your office is using that aren’t integrated together, so you may have somatics during your patient intake, you may have your EMR, you may have another system for doing your payment processing, so on and so forth. So now you have somebody who’s sitting there who needs four or five different logins to do their job on a daily basis. Fortunately, with Imagine, I’ve had the pleasure of working with a few other third-party vendors. Being that technology is very advanced today, as far as what you can do over the internet, we’ve been able to do some single sign-on work with some EMR systems and some of the other 3rd party vendors, so that way the person has to sign into one online application, and that’s for everything. But an integration really means and also the third-party applications are really good at what they do. So applications like mine, like an embryo option, is really good at what they do, and we should let them be good at what they do.Whereas an electronic medical records system really is a walled garden of different options. They try to keep you into a certain fence post that they have posted for you, and you’re not allowed to move outside that wall at all. So you should really embrace those third-party companies who have really focused on one specific issue and have solved that issue and let them help, versus trying to lock them out and trying to charge exorbitant fees that I’ve seen from some developers so that our offices can service our patients in a timely manner. Patients are calling our clinics constantly, they need this information. Instead, we have to go to three or four different systems to get all this information, and then we’re afraid to fax it or email it because of HIPPA issues when the patient just wants to know.
GJ: That wall is slowing things down so much, I would say that Fertility Bridge won’t offer a software solution until we have the ability to integrate with more of these systems. I can’t just ask people to have one more damn system. You talked about billing, you talked about EMR, scheduling, which is sometimes three different platforms. Then on top of it, you add customer relationship management, a CRM, to that, and that’s separate from other types of patient sourcing. As a result, it impedes so much of what centers decide to do, because it’s logistically one more thing that their staff would just be overwhelmed with operationally.
BH: Correct. The software out there, a lot of people want to look at the price tags that you see on the software out there without doing the math on what they're saving in manpower and time. For instance, Engaged MD, we brought them into our clinic pretty early because we did the math on what the nurses’ salary was on what we were saving for them not having to do this class with a patient to teach medications. With our nurses, they’re bored out of their mind doing that class over and over and over again, four or five times a week. It takes an hour, an hour and fifteen minutes, sometimes an hour and thirty minutes, depending on the patient. This way, they’re able to knock that down to thirty minutes, and the savings on the payroll over the course of a week were astounding when we did the math. Of course, that nurse is still doing something else, but still, that time is filled with doing things that are more important, I would argue, like returning phone calls to patients after clinic.
GJ: I still see a lot of file cabinets in offices that go beyond just records. I still see a lot of paper trail when I go visit. I see a lot of clinics writing paper checks still. There’s software for just about all of this. Why aren’t people adopting it?
BH: Well, some of it’s a lot of old school trains of thought, that they don’t need to pay for a medical records system, that they’re perfectly fine with their paper charts, they’re perfectly fine copying, scanning, and faxing these things. But when you come down to how much time is saved with an EMR or with a billing system, it’s really worth the price you pay to play in that arena, with the amount of time that you spend. Your scale becomes huge with what you can achieve with just one person versus a bunch of people pushing paper around the office, the cost of storing all that paper at a company like SafeSite or… just to sit in somebody’s storage unit for seven years is ridiculous. The paper has got to go, especially with all the liability issues on paper with HIPPA. The liability on electronic medical record systems and email even have come significantly down on the HIPPA issues.
GJ: How much of that is because certain platforms- EMRs, billing systems, scheduling systems-- won’t remove their walled gardens, and how much of it is because any one of those companies should be a lot better at doing the other things. For instance, an EMR that has a billing system that people want to use if they’re also using their EMR that also integrates fluidly with scheduling, becasue right now a lot of people have to create a profile in Somatix or whatever billing system before they schedule a patient in the patient portal. So how much is it because these players don’t remove their walled gardens and how much of it is because they should be including better services for the others, whether it’s scheduling, billing, EMR, in what they offer.
BH: The issue with a program like an EMR system is that when you build an EMR System, all the focus is on getting the medical science right. That’s the most important thing that an EMR system should do. In our field, it’s doubly complicated, because they have to do lab workflows and cryo inventories so that work in a fertility EMR is just grossly huge on that point. And the EMR should be 100% accurate on the health science, that’s it’s job, that’s what it should do, but in order to capture revenue as an EMR system company, you have to start offering products for billing, for scheduling, and whatnot, so they try to capture that revenue by being the walled garden. The days of that have really come and gone. Those days died probably around 2015 when we started seeing the rise of big data after the financial collapse in 2008. These massive databases that are now available and different ways of transmitting information, the internet, there are so many secure ways to transfer information over the internet, via an ATI call or there’s just no excuse for having--- to try and shoehorn your customer into one little corner when there are so many different ways that things can work together.
GJ: I think that’s totally backfiring, and people aren’t opening their ATI to allow products to integrate at a consumer level. I only use our receipt system because it integrates with Quickbooks, I only use our time tracking system becasue it integrates with our project management system. Just like clinics, I don’t want people entering one set of data here and another set of data over here. I think that in a 2019/2020 world, that you’re putting yourself in a very vulnerable position if you’re not willing to lower that garden because the workload is just so cumbersome for the client.
BH: Yeah, I agree. We use a lot of applications based on a lot of our core choices, like Quickbooks. What integrates with Quickbooks-- we only want to use things that integrate with that system, so we have a lot of choices to make as well, but there’s no reason why anybody should have to be shoehorned into just a few small applications that are very specialized because it integrates with one certain vendor. Data is very standardized, especially in our field with the HL7 information format that can be applied universally to everything we do. There’s a standing format, as long as you accept that format, you can read any kind of record from patient demographics to lab test, to reading PGT reports. So there are already lots of these data standards out there, and the fact that a lot of these companies are not complying to these data standards is a little alarming because it would allow the flow of this information to just be free.
GJ: From a marketing standpoint, I can tell it’s definitely keeping us from getting the best data. There’s no EMR to my knowledge that integrates with a CRM. We have clients that have a CRM, they’ve got EMR, they don’t integrate with each other. It would be really nice to see from the beginning of becoming a patient, to see how they go through the course of treatment, and also have that integrated with billing os we could see financially how that turned out. Right now, it’s attributing from Google Analytics, okay we’ve got these leads, doing self-reporting from patients coming in to make another calculation, triangulating those different data points, and not having a revenue tied to particular figures, but rather comparing totals.
BH: Yes, I think specifically on Google Analytics and talking about marketing spends, it’s very hard for a fertility center to tell exactly where their traffic is coming from. Most of them are going to attribute it to their referral traffic from their OB/GYN relationships. But for instance, in your business, talking about Pay Per Click ads, YouTube advertising, etc, it’s really hard to capture those patients that come from those sources and how do they turn into a vaginal oocyte retrieval. That’s really the statistic that a clinic is looking for, is what happens from when the patient gets to my door to the patient getting to the followup appointment, and from a follow-up appointment to a VOR or a frozen embryo transfer. Those are the three points that a clinic really needs to see. Sorting through everything that gets through their dor is very, very hard and where it comes from. And having that data to make a choice on where you actually do spend your marketing dollars, it’s very hard for a clinic sometimes to commit to marketing when I know that it works, for instance, we were doing TV commercials here in San Antonio and McCallen, and our traffic increased fivefold to our website, just from the TV commercials running through a Spurs game. It was expensive, and it was really hard to talk someone into doing that, but I think marketing dollars should be monitored, but are usually well spent.
GJ: The point about referrals, what’s interesting is if you take one single point of attribution which is how most clinics track incoming patients now, they ask for one referral source. Very often it’s from a dropdown menu or it’s just a fill in the blank, very often it’s not in the EMR, it’s not in the scheduling system, it’s sometimes just in the patient’s chart, but if we’re just looking at one source, we still see for most clinics that the highest volume of new patients is MD referral. And much lower would be internet then word of mouth, if we’re just looking at one patient source. But if we open it to multiple patient sources, that is to say, if we open it up to multiple attribution sources, people are coming from several as opposed to one, every time-- not some of the time, not 75% of the time-- more patients are searching online than are being referred by an Md. When we’re looking at exclusive attribution, MD referrals is the highest. When we’re looking at multiple attributions, the internet is the highest. What’s the reason for that discrepancy? Patients are getting multiple referrals from their MD and/or they’re verifying, validating that against what they’re researching on their own online.
BH: Well, my experience has been that a patient goes through about four or five different webpages. They’ll go through the entire first page of Google researching a clinic before they make a commitment. The other portion is that patients that come in through Pay per click are usually lower quality patients that won’t turn into a conversion. We’ll see them for a new patient appointment, they probably don’t have benefits that cover fertility treatments, and once it gets to the point where we have to have that conversation with the patient that this cycle is going to cost you $14,000, they self-disqualify at that point and don’t come back for a treatment. Pay per click, for us at least, had been a very poor source of conversion. Now, sometimes you have to do that, just because the guy down the street is doing that, right? Mutual competition within a market is going to force you to make some choices on your marketing spends. But from what we see, the top three pages on a website is going to be my doctors, my success rates, and what is it going to cost. Those are the top three items, and usually, the patient makes the choice based on those top three items. There’s really only three things a fertility clinic can complete on. One is the success rates, the science is very tight these days, and you don’t see very much variance between clinic to clinic. Plus with SART guidelines, you can’t really compete on success rates, right?
GJ: People do all the time, which is why I don’t think it’s as much of a differentiating factor as people want it to be. Because every single place, it seems, is crafting the story that serves them and everybody has the best success rates if you look at their website.
BH: But you can’t compete against each other on success rates, according to SART. But everybody puffs up their success rates and with the changes to the SART reporting, they try to use the stats that best reflect the best numbers. So I don’t think the consumer is getting the best data there directly from the website. Next thing we can compete on is the price. But competing on price is a rush to the bottom, and I have very much seen that patients get what they pay for in the fertility space. So reduced price usually ties to reduced success date, which means you need to be a better prognosis candidate for a fertility procedure, so we can’t really compete on price at all. Everybody I know is scared to disclose what their pricing is because they don’t want the guy down the street to know what they’re charging. Although they know. (laughs) And the third thing we can compete on is patient experience. That’s what we were successful at in RMA of Texas, and I think that’s what they continue to be successful at, and that’s continuing to care about the patient. I think that patient experience translates to their website. And being web guys, you and I, we know that the most popular trend you’re seeing right now are whites and blues on everybody’s website, everybody’s redesigned their websites to be very clean. All their logos have been redesigned to be white or blue-- blue signifies trust and the white is associated with clinical. But clinical is not warm, but it does give you professional, so the look of being professional, but the feel is just not there sometimes on some of these websites I see from practice to practice.
GJ: You just went down three rabbit holes that could be episodes in themselves. Attribution, cancellation rate with attribution, or online acquisition, which merits a different discussion about nurturing funnel, you talked about pricing strategy, which can work but you have to go all in-- that’s a whole other topic. We got there becasue we were talking about the data that goes into making these decisions. The better data we have, the more quickly we can make these decisions and more effectively. I feel like in my career I had to spend a lot of time going back to solve some of these attribution issues and return on investment schemes just to prove what I knew was effective marketing from the beginning. We just finished a really successful video campaign for one client a few months ago. It’s doing really well, it’s bringing new patients in, patients are talking about it, it’s super emotional. I couldn’t get to that point where we could say to a client, “Let’s invest this,” until I had the mode to prove this is how many phone calls these videos are generating. These are how many contact forms they’re generating. This is how many people are coming in because they’re seeing the videos, we’re playing around with landing pages- some have them and some don’t. It’s like… we had to do all of that just to prove what is really good marketing to begin with.
BH: A lot of this knowledge, a lot of doctors and practice managers feel like are anecdotal. So they sometimes don’t make the investment they need in their technology infrastructure that would give them the actual insight into what’s actually happening, from the time the patient makes their first phone call to the time that the patient is hopefully leaving with a baby. Things like phone systems are really important to invest in. It was one of the first things I changed when I came into RMA of Texas because I saw how underserved we were with our phones. One of the important things I did with our phone system was we made sure we could assign different phone numbers to different marketing campaigns so that we could attribute everything that was coming in to what marketing dollars we were spending. Plus we wanted to measure how much we were picking up the phone. We were using a Via system with actually a really nice live dashboarding suite called Xima Chronicall, out of Utah. The price wasn’t bad and it did everything we wanted it to do. It did call recordings, so we could record all our patient interactions, it did live dashboarding so we could see how many calls were coming in, when they were coming in, and where they were going to. We could see how much we spent making phone calls back. That’s when we discovered a lot of patients just want to talk to somebody. They’ll call in repeatedly, two or three times, just to get a live person instead of leaving a message and getting a call back. Implementing an almost call center structure was very important after we saw that statistic because the patient just wants to talk to somebody live-- they don’t want to talk to an IVR. I’m preparing a talk about phones-- just about phones, that points out how long we’ve been struggling with the interactive voice response, press one for this, press two for that, as businesses since the ‘80s. It’s really important for us to see and attribute those acquisition numbers to different sources.
GJ: For people listening, that software isn’t that expensive, either. If you have a lot of call volume, it might be $200/month. If you’re using something like CallRail which will give you the data you just described. No practice should be running any kind of digital marketing campaign without it. You need to see how many phone calls are coming from any given platform or campaign, even though it’s not the only source of attribution that you’re looking for. What are other softwares that every clinic should have to make their lives so much easier that very often you see many not having?
BH: A CRM is very important these days. I see a lot of clinics who are not using any type of CRM or PRM is what I would like to see out there- a patient relationship manager. There’s definitely space out there in the market for that as well. We need to see how well we’re actually communicating and serving our patients. As an industry, I don’t really think it’s that great across our clinical teams. Why? Our nurses are overloaded. The nurses do everything. We like to think they have extra free time and they could handle this or that, but they really, really can’t. If you sit and listen to the voicemails and you go through all the phone calls that come into the practice throughout the day, the nurses are really overloaded. We need to be able to monitor how the interactions are going with the patients. And I think the future of that is going to be a relationship management hooked to the EMR. Something like a Salesforce that has a great API is something that we should use to monitor that. Of course, you might need some custom development, APIs aren’t that hard. A good developer can hook to an API in fifteen to twenty minutes. You’re not looking at vast sums of money on an API. But if somebody tries to quote you a crazy number on something like that, they’re just quoting you a crazy number. I think that relationship management is something a clinic really has to be focused on these days.
GJ: To the point about nurses, we had Monica Moore on an earlier episode about nurse retention and compassion fatigue and she said exactly the same thing.
BH: Yeah. We need to monitor how the quality of the communication with the patient… a lot of times when the patient finally leaves the office, you’ve just told them that they’re infertile and that they’re gonna need treatment, and they just got sat down at a front desk to be told that a cycle’s gonna be $14,000, $15,000, in some cases $20,000 or more, and they go home and they have to process this information. And because we’re so busy, and the patient’s at home and they make a phone call, we’re not really great at returning those calls to make sure the patient’s processed everything correctly and answering questions and really taking a deep dive into the questions the patient has once they’re at home.
GJ: And that’s if they have actually come in for the visit, how many people are we losing before they even come in for a visit. If you look at centers’ online forms, for example, there’s not real-time scheduling, so they’re essentially sending an email message for the practice, someone at the practice calls them back, gets someone on the phone less than 50% of the time, usually 25% of the time, leaves a message, and of those messages gets 25-50% of those calls back. We’re losing 25-50% of people that would have some inclination to schedule an appointment if we had a drip-through patient relationship management system. To me, that means having real-time online patient scheduling. What do you think about that?
BH: Yes, what I’ve seen a few centers doing, which has been really successful for them is having online chat on their website, which is crazy in this day and age to think that we don’t have this on everybody’s website. But I’ve seen where they have a person dedicated to just answering those questions and getting that person scheduled for an appointment, and getting their new patient paperwork done and out of the way. I don’t know if you know this, Griffin, but if you look at the new patient paperwork packets we’re handing these patients are 25 pages. So onboarding these patients, just getting them on board and in the clinic, it takes 45 minutes for them to fill out the paperwork to get it to the point where we can hand it to a doctor. A phone call with a patient is taking 45 minutes to an hour just to get them in as a patient. If we can frontload that and get it done inside at home, we don’t have to do this inside our practices and the patient can show up for their appointment on time instead of showing up, putting in the packet which is paper, scanning them in, having the doctor sit and review it, now the doctor’s late for the appointment becasue they have to sit and review this 25-30 page packet of paperwork, and that just ends up making the doctors’ schedule off all day long.
GJ: What so many people in the field are talking about as sort of the biggest existential threat is the investment of private equity into corporate practice groups. Many practice owners of independent practices or just competitive practice groups will view that as the biggest threat. The thing I’m paying attention to the most- I’m way more concerned with what Silicon Valley is doing than what Wall Street is doing. The reason for that is everything we just talked about. That there are all of these different points that the patient needs in order to be able to connect with the practice that right now, a lot of practice infrastructure isn’t equipped to meet. That with a few million dollars in seed money for the right app, you can bypass that process entirely and now these new players just come right back to the clinic and sell who would’ve been their patients right back to them and then they decide which clinic they’re going to.
BH: Well, think about who our patient population is now. Millennials. We have the two largest years of birthed Millenials who are now our patients. They have aged into our treatment bracket, right. What are Millenials? They are entrepreneurs by nature. What I see is that if we’re not willing to adapt in our own practices and we’re not willing to take a hard look at some of these things, our patients are creating these things even so far as opening their own fertility centers, in some cases, to create the experience that they don’t think you’re giving them.
GJ: I think that’s spot on. What would you say is coming when you look at the big picture of technology. Now go a hundred yard, hail mary pass on me, with artificial intelligence and what you think could happen in the next thirty years or so and what you think is happening in the next three or four years.
BH: The next 3-4 years I see a lot of the lab processes getting automated. We already see wide adoption of vitrification machines in labs. Once those are really integrated and tied in, we’re also seeing a kind of a race to the bottom in the genetics market as well. These machines were over a million five years ago, and now they’re just over hundreds of thousands of dollars now. The technology as far as genetics is getting cheaper and cheaper and cheaper. At some point, just like the vitrification robots, we’ll have some sort of an array in office at some point with the genetic systems. I really see that coming in the future. With AI, I already know that there is a company who’s trying to develop AI and integrate it into EMR. To try to use large data sets like the somatics genetic data set, or the 23 and Me data set, to try to make the best treatment solutions for a patient based on their genetic profiles and their hereditary makeups and whatnot. These are ultimately trying to help the doctor make some decisions on whether to increase Lupron or stop stimulation and maybe do PGT on what they have currently in inventory. I already see AI starting to make the impact or to make a pass at getting into the fertility centers. I know that we’re really scared of AI and we don’t want something to replace a doctor, right? So right now we’re in the early stages of AI coming into the world where we’re really trying to see how much we can use AI to break the system, but I think that’s going to stop reining in the next five years, and we’re going to see it developing into an assistive technology, not a replacement technology. We want to assist the doctor, not replace the doctor. We want to assist the nurse.
GJ: Well, assist them until you can replace them. (laughs)
BH: I don’t think human-to-human interaction will ever be replaced with a machine. I’m a technologist- I’d be comfortable with it- but as far as something like this- like fertility and trying to become a parent and achieve these dreams of becoming a family, I don’t know that we’ll ever see machine replacement completely off the human interaction.
GJ: Never is a long word. How is machine learning decelerate?
BH: Machine learning doesn’t decelerate by itself. It has to be innately controlled, and it alternately has to be taught on how to teach itself. So these data sets have to be built and rebuilt and relearned over and over again as we start to adjust to what the market wants. Becasue ultimately the market is going to drive these choices of development staff who’s making these things. AS we see things like doctor replacement or things that are suggesting a little too much to the doctor on how they should proceed being rejected inside the clinics, they’re going to change their learning algorithms and have to reteach a new AI, but that’s really the 10-15 year mark. Because we’re just kind of getting into where AI is reliable.
GJ:I just hope AI replaces the doctors before it replaces creative marketers.
BH: Isn’t that the truth. I think we’re going to see AI assisting in our day-to-day workloads. Responding to some emails, or notifying us that we need to respond to emails, or that we need to make some of these phone calls back to patients, I really think that’s where AI is going to shine, where it’s taking the load off on these day to day tasks that our staff already doesn’t want to do. It’s things like processing new patient paperwork, inspecting responses from patients, to advise the doctor that this is a patient from Mexico and at risk for Zika, etc. I think those are the places that the next 5-7 years, AI is going to start to come into the light. At the same time, in our market, we’re so specialized in our practices, we’re about seven years behind what a general practitioner or even a dentist has inside their practice, technology-wise. The EMRs that we see in our general practitioner or even a dentist’s office is 5-10x more capable of doing things that our fertility EMRs are capable of, from signature processing to new patient experience to online scheduling-- really, we’re behind the times.
GJ: Why don’t we conclude with your thoughts on how technology’s going to impact the field and how it is impacting the fields-- with a little plug for Imagine Fertility and how you all came to be because of this thesis.
BH: The biggest frustration we had as a practice is that nothing really integrates. Nothing integrates and nothing is focused on the patient experience, as far as system design. A lot of the EMR or other systems are designed by an engineer who thought it would be great to build something for this field, and they’re trying to tell you how to work. The way Imagine Fertility came along is that we said we can’t work with any of these workflows that we have. How do we build something that we want, and how do we set the fenceposts as far as we want them to be, so we ended up building our own systems that allowed us to customize exactly what we wanted-- how the patient flows through our practice. We ended up focusing on the financial portion of the journey because that seems to be where a lot of our patient fallout is at. A lot of patients self-disqualify and ghost the practice after they find out what the price tag is on what treatment they have to undergo if they’re not in an insurance-mandated state. We’re starting to see insurance cover more inside the practices, but as the patients are demanding it from their carriers, but still a lot of this is still self-pay, and it’s out of pocket. It’s a very hard pill for our patients to swallow, so we wanted to focus on financials so we could find some way of expanding care out to B and C markets, so to speak- not just your A or your individual who’s someone who lives in a fancy zipcode. We wanted to focus on that, so we could educate our patients on what their insurance is and what it’s not, what their portion of it is, and tie it together with what are your options past this. That price tag, again, is really hard for the patient to swallow after they’ve just been told that they’re infertile and they're gonna need some sort of treatment. It’s really hard to have that conversation. We need to be able to provide a solution to the patient in the form of different financing companies, how to save them money on their medications, which is a whole other topic. With that, we decided to open up our own API because my front office staff is typing the patients’ demographics into twenty different systems-- this is ridiculous. Because of our programming experience, we were able to build an API, we were able to integrate many different systems, including most fertility EMRs, and the traffic just flows freely across the EMRs and I have integrated with other third-party vendors, so that if you’re connected to Imagine, we can connect you to the other third-party vendors without having to have this repeat entry of demographic information. That’s how Imagine has really changed the interaction of the practice with the patient and how we made the workflow more efficient in the practice. Plus, with everything being time-stamped in different queues, it really becomes easy for someone to do their daily work without having to remember what they have to do, without having to go through emails, which is something I think we need to get off of inside the practice is email communication from one practice provider to another, it just gets lost in the day to day noise.
GJ: Bob Huff, thanks for coming on Inside Reproductive Health.
BH: Thank you, Griffin, anytime.