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Compuware Corporation (CPWR)

February 15, 2012 11:00 am ET

Executives

Unknown Executive -

Larry Angeli - Former Vice President of Marketing & Healthcare Vertical

George Conklin -

Unknown Executive

Hello, and good day. Welcome to Compuware Corporation's Webinar, CIO Insights on How to Optimize Health Care Application Performance.

Today, I'd like to introduce 2 guest speakers, George Conklin, Senior Vice President and CIO from CHRISTUS Health. He will share his best practices for optimizing end-user experience across complex health care environments; and Larry Angeli, Vice President of Healthcare Solutions at Compuware Corporation, and he will share his insights on the challenges of managing business-critical applications. [Operator Instructions]

So without further ado, I will pass this over to Larry Angeli.

Larry Angeli

Thanks, Kristen [ph], and good morning, everyone. My name is Larry Angeli, and my area of responsibility at Compuware is our application performance capabilities in the health care industry. It's my sincere pleasure to speak to you today.

Before I pass the baton to Mr. Conklin, I wanted to say a few words to set the context for today's discussion on optimizing health care application performance. I show this slide, not for the shock value so much, but to indeed communicate that this is still, unfortunately, a common sight in the health care industry. In fact, for over 40 years, our health system has run on paper, physicians were required to study on paper, track patients on paper and indeed prescribe on paper. If these files could talk, they'd communicate that there are over 11,000-plus medical -- medication errors on an annual basis and over 100,000 deaths from medical errors. And all of that, despite the fact that we spend over $2 trillion a year on health care in the U.S., a full 17% of our gross domestic product. This situation clearly has to change and have to change. And in fact, in the last few years and certainly in the years ahead, the health care industry is undergoing a staggering transformation to move to electronic medical record technology and to improve patient care and safety. In fact, the federal government has now stepped in to encourage health care and the health care community to accelerate that adoption of technology, laying out a series of steps of both carrots and sticks to move the process forward.

So the net of it is that health care organizations are on an incredibly fast track to deploy technology to their clinician communities. And leading organizations, like the one that we'll speak with today, CHRISTUS Health, have learned that it's simply not enough to deploy these clinical applications. Rather, they must deploy them in a way to support the natural delivery of care and in a way that does not interrupt their process.

Kristen, can you switch the slide, please? The clinician community has an expectation that systems will run and operate and perform to their expectations. And because these EMR systems are now an integral part of delivery of care, Compuware studies have demonstrated that if these systems do not perform in production, there are material impacts in areas like clinician productivity and adoption. So things like slow log-ins, poor responsiveness, waiting for transactions to process have material impacts in the care delivery process. Today, in fact, we'll focus on a couple of those areas like clinician productivity, clinician satisfaction and clinician adoption.

In addition to that, there's downstream impacts as well in areas like physician recruitment and retention, in areas like revenue cycle, the processing of payments, and of course, to the IT departments themselves where often they're called into war-room scenarios across multiple IT teams to try and resolve these performance issues before they detract from the delivery of care.

Every year, Gartner issues a report to the CIO community in health care that calls out the key issues that IT leaders should be looking at, based on the state of the industry. In reading the 2011 report, the message is quite clear, organizations are investing a tremendous amount of time, energy and money in meeting the challenge of enabling clinical care with EMR technology. And the role of the CIO is to increasingly demonstrate value from these investments.

All of this in the course of an environment that is not standing still. And that's pointed out by the other 2 items in this report. Certainly, one, that users have higher and higher expectations. And for all of this, of course, we can blame Google, and I say that somewhat tongue-in-cheek. But indeed, the speed with which Google works to deliver results and searches has set an amazingly high expectations bar that users and, in this case, clinicians expect from the applications that they're using.

At the same time, health care workers are extremely mobile in their jobs. In fact, health care is the third-largest adopter of iPad technology behind financial services and the technology industries. This is indicative of the work, of course, that health care workers do. They deliver care in multiple settings and have to deliver it wherever the patient is. Again, this of course, presents unique challenges to the delivery of IT service for health care organizations. So at Compuware, we develop a set of best practices to help enable IT organizations navigate these challenges. Let me explain these to you briefly, and of course, that will set the context for the discussion from George and CHRISTUS Health, where he can talk about these practices in the real-life scenario at CHRISTUS Health.

We start by encouraging organizations to work on defining acceptable performance. And again, the clinician expectation is high. Therefore, it helps to develop specific goals and objectives relative to what's acceptable for the clinician community. Secondly, actually measure end-user experience. I've heard many stories about organizations that are forced to send IT personnel out to the facilities with stopwatches to actually measure the performance of the applications because they receive complaints via the help desk on performance. So to be able to measure that in real time to understand actually how performance is going on, how the end users are really experiencing the technology, is key to eliminating the guesswork and eliminating the stories and actually speak to fact-based truths about how the systems are performing in production. Third, of course, is to monitor the entire application delivery chain. As we'll hear later from George, there's a tremendous amount of technology that sits between that end-user device and the data center to deliver that application service to the end user. And that's everything from networks, to infrastructure, to the applications themselves, to the back-end databases. And of course in health care, Citrix is very prevalent and actually delivers and renders that service to the end-user. It's important to be able to understand the performance of every one of those elements in the overall application delivery chain to be successful in understanding application performance. Fourth is to use all the relevant data. Many of us already have capabilities that understand the performance of key elements of that delivery chain, like the network, like servers. It's important to integrate all of that information context again, to be able to understand the entire application delivery chain.

And finally, and perhaps most importantly, is to communicate back to the clinician community. And again, that brings the process full circle. It's very important that once you establish these capabilities that you take an active -- proactive approach to communicating how the solutions are performing, communicating service levels to the key clinician community that you're servicing.

With that, allow me to turn it over to our keynote speaker, George Conklin, for all of the change that's going on in the industry, organizations like CHRISTUS, are truly leading the way. So I'm so pleased to have Mr. Conklin with us to share his experiences in this area. Thank you.

George Conklin

Thank you, Larry. Appreciate being with you all this morning. I'm going to give you an overview of the CHRISTUS organization first and some of our key strategies. Excuse me, I am dealing with a little bit of upper respiratory deal. But the main focus of the presentation is going to be around how we, CHRISTUS, are handling the IT infrastructure to be able to support our strategic directions. So what we'll talk about, as it says here in the overview slide, is the impact to the application performance, and Larry has already underlined some of those, and how CHRISTUS IT and our business teams are optimizing that customer experience or seeking to do that in any case. And then, at the end, I'll wind up with some discussion about some of the best practices that we've developed or are in the process of implementing to help to ensure our web and application performance is optimized. Next slide, please.

Little background on CHRISTUS for those of you that are not aware of who we are. This slide shows the main concentrations of our hospitals. We are mainly present in Louisiana and Texas. We have one facility in Santa Fe, New Mexico. We also have 7 hospitals in Mexico, spread around in northern and central portions of the country, and a large number of long-term acute care hospitals, stretching basically from Texas all the way on East to Georgia. 9 home health and hospital facilities, hundreds of physicians supporting almost 7,000 physicians across all of our marketplaces. So a large complicated organization. Our net revenues for last year were about $4.2 billion. And we're on course again this year to continue to grow that revenue base. I show this picture for another reason as well and also mention the fact that we have 7,000 physicians that are part of CHRISTUS Health. Like many of you on the call today, we're a voluntary health care system. And what that means is that physicians who are credentialed to practice in our facilities also practice in other hospitals in our towns. We do employ today roughly about 250 clinicians across all of our marketplaces, and that's physicians and physician extenders. But the bulk of that 7,000 number that I mentioned before are not employed physicians. So these physicians can take their business and go elsewhere if we're not providing them the very best in services. And that's frequently a threat that's registered to us if the applications do begin to slip. And in some cases, we've actually seen doctors move patients from one area to -- or one of our hospitals to another hospital because our performance of our applications hasn't met their expectations.

So it is extremely important to us that we align our services to meet physicians' needs and to optimize those needs across all of our markets. As you might guess, this is a complicated picture, one that creates a significant amount of complexity for being able to gather information.

As you can see on this picture, the question really now becomes, particularly as we begin to evolve our health care delivery systems into one now is "Where is George Conklin's information? Is it in radiology? Is it in physical therapy? Is it in the lab? Is it my personal health record? Where is my information?"

CHRISTUS has developed a strategy under a broad umbrella of what we call Compass [ph] 2020 that has 3 major components to it, one of which is really germane to the conversation today. That's the first one of the strategies, and that's clinical integration. Our intent across all of our markets is to become the clinically integrated health care delivery system of note in that market. And what that means is, not necessarily a focus on acute care hospitals, but more importantly, a focus on a full array of services that are going to be needed to network together to be able to deliver services to individuals, employers, government insurers, whomever. So this is a step toward our becoming an accountable care organization, or an ACO, at some point. For the time being, we've decided not to move in that direction. But it is a step in that direction, because in order to be a successful ACO, it's our belief you must be a successfully integrated clinical system. So this is the -- a first level shot at some of the complexity. My information can be spread anywhere within CHRISTUS, can also be spread anywhere within one of these clinically integrated networks. Remembering before, when I talked about the 7,000 physicians, 6,800 of whom are not our employees, we'll be linking up to a variety of different information systems from a variety of different locations, not having undergone the kinds of standardization that we've undertaken within CHRISTUS.

So how do we find that information? How do we bring that information together? And as Larry talked about, how do we bring information together quickly to the point of service so that clinicians can make the best decisions possible? Also, if you remember the fifth element of the picture that Larry showed before, being able to communicate the relevant information means picking the weed out from the chaff, all the information that's not necessary for a particular clinical activity needs to be picked out. The last thing that a doctor wants to see is everything that's been collected about me in every location in which I've been a patient. So how do we pull all that information together? How do we bring it quickly to that clinician? And how do we then allow that physician to be able to provide the best in services? So that is the struggle that we've got today. So we move to the next slide.

What you see here is a simplified picture of what our network looks like today. We have a large data center that we built in San Antonio and opened in 2008. There are hundreds of servers, close to 2 petabytes of data stored across those hundreds of servers in that data center environment. We have a large array of web services, mobile components and a lot of facilities for optimizing the wide area network that we operate across all of those markets that you saw before. We also have, at this point, about 40 cloud-based applications that are both private and public cloud applications that we operate across CHRISTUS to help deliver clinical care. So data being spread into a variety of other locations than the source data in our data center.

Lastly, and this is a new activity for us, a significant portion of that over 2 petabytes of data that I mentioned before is image data that we've captured on our pack systems since about 2001 when we started collecting -- implementing pack systems. One of the things that we are starting to move towards now is a virtual architecture for the storage of that information. So we are implementing a VNA product, currently in our data center but in a private cloud within the data center itself. Ultimately, it is our intent to try to carve out as much of that storage as possible and remove it from our floor and move it out to the public cloud through secure connectivity.

So a very complicated picture that you see here that leads from the data center through [Audio Gap] where you're going to be dictating to particularly a physician, what device she or he should have, what kind of cell phone, what kind of tablet they should carry. Instead, we need to define what the security specifications are around those devices and the ability to be able to implement our security policies on those devices but not in the specific device itself. We have a wide array of devices; Android, Windows, Apple operating systems out there that we're connecting up to today.

One of our other big areas of investment at this time is with the patient portal. We are beginning to implement that in our markets so that patients can interact with us all the way up through having their own personal health record and access into their medical records through the patient portal. And then finally, we have a growing base of activities with employees. Now, this, on the lower right corner of the slide, that might imply CHRISTUS employees, which it certainly does. But we also have initiatives underway right now, beginning to work directly with employers in our markets to become the care provider to them and their employees, a guarantee for a certain per-member, per-month fee that would be paid to us, guaranteeing to the extent that we can help the employees. And so we are beginning to work on various models today for implementing health and wellness services with employers so that their employees can have the greatest attendance and be most productive at work. So we have a wide array of different projects underway at any one point in time, about 150 different major projects being undertaken by the CHRISTUS IT organization. If we could move on to the next slide.

So why is application performance important? Application performance is important for the reasons that Larry stated before. But as some of you that are on the call that know me, know I'm a clinician by background, a psychologist, not a physician. But for me, all of my time in health care IT has been about providing the right information at the right time to the point of service. And that information includes information, if I'm the patient, that's known about me. It's also information that's known in the medical literature about what best clinical practices are. And it's also the ability to be able to communicate with other clinicians who could be -- or more expert, might be able to provide consultative services. So the application performance, it's increasingly important as we begin to move more and more of that paper that you saw on Larry's chart and that you see here, onto the computer. And in fact, where, in some cases in our markets, it's the only place that that information resides is in the computer, that information is readily available. So it's available as the -- where for our service level expectations, we're trying to set it to at least as available as the paper chart, probably even more available than that because the paper charts are frequently somewhere else when somebody on the floor needs them. So we are looking very carefully at how do we make that information as available as possible, how do we make our technologies and systems and all the networks that you saw on the previous slide as available as possible. When systems are unavailable, cost and quality are going to be impacted, specifically because the paper record itself will be going away. Slow or no systems availability raises the possibility of adverse events as Larry mentioned before. The $2 trillion figure that Larry mentioned is a sad testimonial, it would be a much better number if our health care quality was better. As of one of the recent World Health Organization studies, the U.S. ranks 37th in the top 50 nations in the world in health care quality. On that study, we were one step below Croatia. So if we spent $2 trillion and we're getting supreme quality in every health care interaction, probably people would still be concerned about the amount of money being spent, but at least there'll be comfort given that the best care was being delivered. With us being 37th and with 100,000 deaths per year, as Larry talked about before, coming out of the IOM study back in 1998, that is a sad testimonial to the way things are. So if applications don't perform, we can slow down clinical care, which will have direct operational cost implications, and we can impact the quality of care. Those are the reasons why applications performance is so important.

Go onto the next slide, please. The performance impacts affect us across the organizations. You're probably familiar with the concept of value-based purchasing. That is a new initiative on the part of CMS and the federal government to rank organizations based upon their performance on various cost and quality indicators. And if we are chronically slow, show a lot of adverse events, support poor patient outcomes, have low patient satisfaction, we will not score high and in essence, what value-based purchasing is going to do for both insurers and employers, is create a food chain. And what it will say is that the top people, the top performers on this value-based purchasing list will be the ones who'll get the most contracts because they provide the best value for the lowest cost, and ones towards the bottom will likely wither and die eventually. So value-based purchasing is going to be a tool that the federal government will be using to purge the system of ineffective providers.

Prolonged log-on times create huge physician dissatisfaction that affects their ability to be able to manage patient care in a timely fashion. It affects their ability to be as productive as they need to be in the present health care environment in order to be able to optimize both the quality of the services that they provide as well as their own incomes. Rapid decisions that affect the well-being and even the very lives of patients need to have systems that support them that are working all the time.

In addition, one of the things that we're implementing here at CHRISTUS Health through some work of a team of people led by our Chief Medical Information Officer, Dr. Luke Webster, are order sets. These orders sets, in effect, establish a workflow based on best practice data that we've collected and that we've worked through our facilities to determine what were the best ways to treat patients. We now have several hundred of these order sets in the process of being implemented across our organizations. And what we see, according to our organizational balance scorecard, is as long as we continue to take on these order sets that are based upon, again, medical evidence, that we see a constant progression towards good care, consistent outcomes and predictability across our healthier environments.

The last thing I want to mention about is the wear of care. We -- this is a term that I adopted a little while ago, particularly as we begin to talk about the clinical integrated networks as I mentioned before. In these clinically integrated networks, care of service can be delivered to me anywhere within the community in which I live. So today I live in Houston, we have a number of hospitals and physician services and other partnerships in this community, a growing number of those as well, and I can appear at any one of those. Any place that I appear, the clinicians, they ought to have access to all of the information that's known about me. If not, simply to make the care more customized and better for me, but probably more importantly to make sure that they don't make an error and order for some -- order something for me that I have an allergy to. So as we move more and more into these clinically-integrated networks, not only is it a good clinical rationale for tying all this information together and presenting it quickly, there is also now a significant risk component associated with that. So next slide please.

So performance does matter to the end users. Our focus with the work that we've been doing with Compuware is to ensure that problems are identified and isolated proactively. And I emphasize that last word in this bullet because that is probably the most important part about this. In as of [ph]today, in many of our locations, we hear about a system outage when somebody calls us and tells us about it. We want to be in a position to be able to identify a system outage before people even realize that. Compuware products are putting us in a position where we're going to be able to do that and to then be able to jump on those problems as quickly as possible. This will help us to ensure that our clinicians have the maximum amount of information that they need to be able to make decisions and so are able to provide the best in quality care. When we're able to trend data over time, we can also begin to notice where there are gaps or weaknesses in our network, begin to focus on those gaps and weaknesses in the networks, and so enhance the quality of the service that we're providing, again proactively, by working to identify where there are issues and where problems are going to be occurring potentially in the future.

The tools also provide us with the capability to do very deep analyses of end-to-end productivity. We have very high-level analyses dashboards and things like that that I can take a look at. From those dashboards, I can double click and go into greater and greater levels of details down to levels of things that, frankly, as a psychologist, I don't even know about. But all that technology, the doctor will begin to isolate where specific problems are. We did a pilot test, a point test of the APM product last year. Installed it in our data center, almost immediately after we installed it, we saw some problems beginning to occur with our big MEDITECH systems or at least, apparently, with the MEDITECH systems. We thought initially that it was the Compuware products that caused the problem, so we took those down immediately. However, when we began to evaluate the data that was stored in the Compuware applications, what we saw was it wasn't the Compuware applications, it wasn't MEDITECH, but instead, it was a switch that was beginning to fail and needed to be replaced. So rather than focusing our time on MEDITECH, we're focusing our time trying to assess why we had a seeming problem with Compuware, we were able to get right to the device that had a problem. We cut hours off of the system's slowness that we were seeing able to recycle and replace the device in a relatively short period of time. For that, to me and to many of my staff, persuaded us that this was an extraordinarily powerful product, and it was going to give us the capability to be able to hone on into the lowest level of where issues were occurring so that we focused our times on the issues were occurring rather than on trying to figure out where the issues were occurring. So this has been an extremely important component of the work for us with Compuware has been getting us to move into that kind of a direction. Next slide, please.

Now, what you see listed on this slide, and this deck is going to be available afterward if you want to download it, are the best practices that we have been developing. And I'm going to go through each of the major colored bars on this. I'm not going to go through each of the detail bullets except to call out some specific examples. But these are important best practices. The first and foremost is defining what acceptable performance is. One of the things that we have been able to do is to develop tools that let us evaluate different levels of performance against the cost of getting to a higher-level performance. And then we're able to bring that to the governance body, that we call our Information Management Executive Committee for CHRISTUS Health, to define then what acceptable service levels are going to be relative to the cost to reach higher and higher levels of service. Frankly, it's impossible for us to reach 99.9999% level of availability of our system, so that is something we're going to strive to do because today, the cost of reaching 99.9999% levels of availability would be monstrous. And so what we're doing is balancing the cost in the need of the organization to be able to define those acceptable performance levels. We engage end users in that. We ask clinicians to speak to us realistically about what they expect for performance in the computer systems. And then we set some baselines based upon where we are today so that we can then, as the measurements start to get collected through APM, begin to then show our steady progress towards reaching those goals that we've defined through those other analyses that I just talked about.

First, probably, one of the first things for me has been having worked for nearly 40 years now in health care services both in the New York area, at Presbyterian Hospital, Mount Sinai Hospital for the State of New York, and in Oklahoma at Integris Health and now here for CHRISTUS Health, has been the belief that the only important thing is the end-user experience. The fact that we can say that we have 99.999% reliability on our MEDITECH systems and the data center and 90% reliability on our network means that from an end-user expense perspective, it's a 90% user experience. And that's not the experience that we want our users to have. That's not, by the way, what we're having, I'm just using that as an example. So we monitor every user on our electronic medical record or MEDITECH application in order to determine that we are maintaining those systems within acceptable response time levels as defined as I mentioned before. And then we begin to develop action plans to address chronic issues that we see with either users or classes of users.

Now this next bullet below here, synthetic control measurement, is an important concept. It is a not-so transparent technical term. But basically, what we attempt to do is recognize -- well, first what we do is we recognize that we cannot present to a user of our systems or even our governance, the full complexity of the underlying networks. So what we are developing, we haven't completely done that at this point, but what we're developing at this point are series of what we're calling synthetic control measurements that are temperature probes that, in essence, they give us a sense of how the overall network is performing based upon these specific synthetic control measurements that we're taking. So we have -- the best example of that and the simplest is the end-user experience. So end-to-end, what is a particular end user, what am I experiencing on our computer systems? What is a physician experiencing on his mobile device in one of our hospitals? And we measure those end-to-end experiences. We look at specific measurements between that device and the processors back in the data center and then back again in order to be able to determine where there are potential weaknesses, and the we can dive deeply from those control measurements when any of those indicate that they're going to yellow or red, and dive deeply into those to be able find out what the specific issues are and hone in on particular devices or applications or vendors or products or whatever that are creating the problem.

We monitor the entire application delivery chain. As you can imagine, that is a very complicated delivery chain. I mentioned some of the partners that operate in our clinically integrated networks. We, within CHRISTUS today, have close to 1,200 different applications that we run within the organization. Some of those are financial applications and business-related, but many of those are clinical applications. And so you can imagine like Lego blocks, those are going to be assembled differently for each patient that comes into the system. And so monitoring that entire application delivery chain process is an extraordinarily difficult and complicated thing to do. That said, we do it, we look at actual versus baseline performance that we've set, and we try to isolate, as I mentioned before, through deep dives down to where we're seeing specific issues. Again, the synthetic control measures are extremely important in doing this because they keep us away from having to reassemble the network on a second-to-second basis as a physician resets the Legos that he's working with for any particular patient. We're using all of the relevant data. We're collecting data from every potential area that we can collect it from. So from the EMR itself, from database and network device tools and in integrating other performance data from other applications, particularly beginning now to integrate data in from some of our cloud providers as well.

So in the last part of this is to then communicate back to clinicians and management organization-wide. The tools that we're providing are going to be able to -- or be accessible to people to look at, at least at the dashboard level. And we stress complete transparency relative to performance issues or the performance of our applications. I find that, that I've been here for 13 years, I've been everywhere that I've been for longer than the survival rates of most CIOs, and I think in part of that is because I am transparent. When we suffer problems or we're having issues, I broadly communicate those issues and I make sure that people understand that we're working carefully to get those issues completely dealt [ph], an immense amount of trust with people as you begin to do that. So that ends my portion of the presentation. Larry, I'll turn things back over to you.

Larry Angeli

Thank you, George. I wanted to close on a couple of points. The first is to talk about our health care customers. We learn a tremendous amount from the association with organizations like this, both in terms of how to effectively apply this technology to the improvement of end-user experience and then also taking those best practices that we talked about today and how to apply them for health care in the unique environments that exist. And practically, what this means for those of you in the health care arena is that whether you're running Epic or Cerner or MEDITECH or McKesson or any of the other hundreds of clinical applications in the industry today, it's highly likely that we've seen it, that we're currently managing it, it's performance at another health care organization, and that we can bring those best practices to the table, and when we talk to you on how to get the most out of that particular application and how to improve its performance in production.

Obviously, we're not going to spend a lot of time today diving into the solution. Certainly, if there's any interest, please feel free to follow up with me and we can provide you more details. But I did want to share, at least at a high level, the visualization of this technology in production, what it looks like. The idea here is that, simply, we're instrumenting your environment to be able to understand end-user experience and the performance of the applications in production. We do that through a series of technologies, primarily agent-listing fashions [ph] or not introducing any individual overhead into the environment, but to be able to truly understand the performance, as we said earlier, end-to-end. So understanding how those applications are performing in production for individual end users. And then if there are issues anywhere on that value chain, understanding how many users are impacted at that time and then providing organizations an ability to quickly isolate the fault domain and address the problem prior to significant impact in the environment.

And that can be, again, realized in terms of dashboards like this one where you're seeing the core applications of the organization, in this case, the Cerner example with their core facilities or key facilities at the top, and simple, green, yellow and red light representation of how performance is at the facilities. Of course, through a dashboard like this, you can drill down into successive layers of detail to get all the way to the understanding of the true fault domain. But again, all of that starts with our ability to truly understand performance at a very granular level inside the data center, actually how individual end users' performance is at every point in the network.

For those of you who are Gartner clients, you would see a report like this related to their most recent assessment of the application performance market. This was their report in September 2011. It's our intention to be and to continue to be the leader in the application performance market, and Gartner has recognized that. In their most recent report here, you'll see that, again on the chart in front of you, that for the most recent Magic Quadrant, we were the furthest along relative to the competition in the completeness of our overall vision in application performance and certainly within the top 2 or 3 in terms of ability to execute relative to the over 50-plus vendors that they analyze in this particular market space.

So with that, again, we'll move to the Q&A portion. By the way, let me say that if any of you would like that Gartner Magic Quadrant report, please feel free to send me an email, I'd be happy to provide you a link to that report. So again, why don't we move to the Q&A portion and I'll turn it back over to Kristen [ph].

Question-and-Answer Session

Unknown Executive

Wonderful. Thank you, Larry and George. We do have a few questions from our audience. And we'll start with George. George, are you using any cloud-based services today? Clearly, there are security concerns, but as these get addressed, what other adoption inhibitors from a health care provider point of view? Can you share that with the audience?

George Conklin

Yes, certainly. As I mentioned, we are using about 40 cloud providers today. Security is a significant component of the evaluation that we do with each of those vendors. Particularly, if you know how cloud services have evolved, particularly given the significant growth in virtualization technologies, it's quite possible that some of our data could even be in a cloud in China or somewhere else outside of the U.S. that doesn't have the same kinds of coverage relative to our concerns, relative to the security around health care information. So part of what we do in our evaluation is to look at the current technology framework that is implemented by the cloud provider, ensure that it doesn't place any of our data at risk. We do test the vendor or we look to see what results of testing that they might have had, for the Persocks [ph] or Cybertrust or any of the other certifying agents that are out there. We do look for their SAS 70s and make sure that there aren't any obvious weaknesses through those. Then what we do is, as part of our contracts with those vendors for cloud services, we stipulate very carefully what our expectations are going to be relative to both the ongoing storage of our information and our ability to be able to extract it later on, in the event that our relationship dissolves.

So we spend a lot of time focusing on security and a lot of time focusing on the potential issues for data stored remotely from us and not in our immediate span of control. That's one of the reasons why with the VNA project that I mentioned before, we are proceeding carefully. With that, our first cloud applications are actually going to be internal to CHRISTUS and will operate on our data center floor. And then after that, we'll -- depending on how successfully that works, we'll then consider moving those medical images off our data center floor to another site.

Unknown Executive

The next question is for Larry. Outsourcing infrastructure or leveraging service providers to offset cost seems to be top-of-mind for many IT organizations. What are the -- what's the best practice approach for IT managers to ensure the quality of services being delivered?

Larry Angeli

Yes, it's a great question. In fact, those of you who are in health care on the phone, it's highly likely that you're using a service provider for some element of your business. It's fairly pervasive in health care. What we tell organizations is that these best practices apply the same, if not more, in a managed service provider environment. And the organizations that I think are best in class in this area treat their service providers as an extension of their own organizations. And what they do is work with them and collaborate on the definition of service levels based on the expectation of their end users. So it becomes about servicing the end users. And most successful service providers today, it's been my experience, believe very strongly in the notion of transparency. And therefore, the idea of communicating how they're servicing the end user to the organizations that they're contracted with becomes an important part of their overall approach to the market. And again, when you have that level of transparency and clarity, it becomes very obvious to understand, if we're delivering the service at the end users per the expectations that have been set up with the service provider, and if not, if there are issues, as opposed to finger-pointing, take a very collaborative approach. Let's quickly identify the fault domain and let's work together with the service provider on how to fix it. All of that becomes very difficult unless you have capabilities like we talked about today. Because again, you open up a whole environment where we're not really sure what the issue is, that tends to lead to finger-pointing and, again, arguments as to exactly where the problem is occurring. But when you have fact-based information, you can work very collaboratively with that service provided to fix the problem and reestablish the service to the end user.

Unknown Executive

Another question is to George. Because delivering the right information to the point of service, how do you justify the information?

George Conklin

I read that question, I'm not entirely sure how to read it, so I'll take a shot at it. And if it's not the right answer, please re-ask the question. When -- and the way I read the word justify in this is, and it's maybe just because it's my particular predisposition, is about how do we normalize the information, how do we ensure that information collected in various locations means the same thing. If that's the question, that is a great question and one that the industry at large is still struggling with how to address. Part of that comes through some of the standardization efforts that are occurring right now with ICD 10 and the adoption of Snowmag [ph] codes and other structures that will create significant degrees of standardization of data across information systems, so that if George Conklin's information is brought together from 2 different systems and it's a numerical information, you want to do a graph that you can be sure that the difference between those 2 numbers is clinically meaningful versus simply an artifact of the different ways that people collect information. So that's one of the struggles that's going on right now in the industry is how do we make that information across all these different entities more comparable. We would in CHRISTUS undertook that effort a number of years ago, and are continuing with that effort today, to create significant standardization of the data that we collect. So that when it is represented to people, it is clinically meaningful and so can be utilized at the point of service. As we integrate new service providers, and one of the things that we're starting to do now is to look at their information systems very carefully, not just to look at the technology for the information systems, but also to look at the way that the information systems, the meaning of the information that's stored out there. So we spent a lot of time looking at those critical pieces of information for clinical care and ensuring that as we bring those pieces of information together, that it is clinically meaningful. The long, laborious process, one that's fraught with all kinds of politics, as you might imagine, but it is one that's extremely important for the success of these information systems.

Unknown Executive

The next question is for Larry. Mobility seems to be top-of-mind for most businesses, looking to enable teams to have remote access to data. How do you see Compuware APM playing a key role?

Larry Angeli

Yes, it's a great question. Clearly, there's been a tremendous explosion in mobility in every industry and, obviously, with consumers as well. And I think one thing that's perhaps obvious but bears mentioning is that the user expectation, whether they're on computer inside the organization or on a mobile device in the field doesn't change. So as IT organizations, it's incumbent on us to not only support that service and be able to allow those devices in the field. And I believe George mentioned that, again, they want a clinician to have any device that would like to have but also, to be able to manage the user experience with those devices. And in fact, from Compuware's perspective, we believe that those end devices, whatever they are, are an integral part of the delivery chain. And therefore, we need to fully embrace those in terms of being able to understand performance and end-user experience out to those end-user devices. So without going into technical details and we certainly could do that with anyone who's interested, who asked the question, but it's within our capabilities to completely support the understanding of end-user experience out to those devices. Kristen?

Operator

I think Kristen dropped off the call, so if we want to wrap up. Are there any other questions? If so, please put them in the chat box now.

Unknown Executive

I'm back, Jas [ph], I'm sorry. One last question for George. The presentation was the communication to the clinician community. As an important best practice, can you explain your approach to relationships with others in the C-Suite and how you manage with them to make sure they are staying on top of the needs of the clinician community?

George Conklin

Sure, that's a great question as well. The other members of the C-Suite, my peers in -- the way CHRISTUS is organized is that there is what's called the Executive Council, which is the CEO and all of his direct reports, of which I am one. And then there are regional CEOs and C-Suites for each of our regions that you saw on that earlier slide. So there are 9 CEOs and then 9 associated C-Suites. We, and together, they meet monthly with our Chief Operating Officer, Gene Woods, in what's called the operations leadership group. One of the CEOs from that group and several of the members of the Executive Committee sit with me as chair on what we call, as I mentioned before, our Information Management Executive Committee. This is our governance body. This is the body to whom I report for guidance and input on IT activities. So we have a list of KPIs, key performance indicators, that we manage that as an evolving list of KPIs. And a part of that are going to be several of the synthetic measures that I had mentioned before relative to system performance. And that overall KPI dashboard will -- serves as the communication vehicle to our leaders. So that's one way that we communicate to them. The second way, as I mentioned before, is that when we have issues with our systems, I proactively communicate. I don't want any of those leaders on the EC or in the OLG to be blindsided by a physician coming into their office and complaining. So I make sure that we're proactively communicating to the entire C-suites in every one of our locations, including at the corporate office. And that has proven to be very positive. People appreciate those contacts when I have to make them. But thankfully, it's not very often. So that is the way that we keep those communications going. Now, relative to the physicians and how we communicate to them, there are 2 different ways that we communicate to physicians. The first way that we communicate to physicians is to the management of our employed group practice. We have service level expectations that have been set by that group in concert with us, and we report back on a regular basis as to whether we've met those service-level expectations or not. Now, to the physicians at large, we communicate to one of the members of the C-Suites in every one of our hospitals, what's called the Vice President of Medical Affairs. The VPMA sits on the Medical Executive Community of every one of our regions. He or she is responsible for, among other things, collecting any information about any feedback on any of the IT initiatives that we've got and communicating that back through our Chief Medical Information Officer. In addition, our CMI, Dr. Webster and I and other members of my staff, will frequently go out and sit in on Medical Executive Committee meetings to be available to answer any questions. So those are the ways that we're communicating. The Medical Executive Communities in each of the facilities in across CHRISTUS have communication vehicles out to their physicians that are bidirectional, and so that's the typical venue that we use for getting to the docs.

Unknown Executive

Wonderful. Well, that concludes our presentation. I wanted to thank our speakers, George Conklin and Larry Angeli. Thank you both so very much, and thank you, all.

George Conklin

Thank you.

Larry Angeli

Thank you.

Operator

This concludes today's conference call. You may now disconnect.

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