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HIStalk Interviews Laurent Rotival, SVP/GM of Enterprise Solutions, GE Healthcare

December 17, 2007 Interviews 6 Comments

Regardless of how you feel about how multi-national conglomerates have changed healthcare IT, you must at least acknowledge GE Healthcare’s size and influence. GE Healthcare, formed in 2000 and headquartered in the United Kingdom, replaced the old GE Medical Systems Information Technology (GEMS-IT) and brought medical imaging, patient monitoring, and drug research into the fold to form a $17 billion business unit (over ten times Cerner’s size, to put that into perspective). The company’s IT profile was raised with its 2005 acquisition of IDX for $1.2 billion.

I don’t hear all that much about the company’s plans, so I was pleased to have Laurent Rotival volunteer to be interviewed (or, more precisely, to have one of his executives suggest it with his subsequent approval). To have a top leader of the industry’s largest vendor agree to be interviewed by an anonymous blogger … well, I was surprised and delighted to take him up on the opportunity. Thanks to the folks at GE Healthcare who made the arrangements.

Tell me a little bit about your background and your responsibilities at GE.

I’ve been with GE for about twelve years. I’ve just joined this role. I’m senior vice president and general manager of what we call the Enterprise Solutions business that includes five product lines. The most notable one is Centricity Enterprise, with the Carecast line or LastWord. We have Centricity Perinatal, Centricity Perioperative, Centricity Anesthesia, Centricity Laboratory, and Centricity Pharmacy. So, it’s basically the clinicals.

Vishal Wanchoo, who’s the CEO of GE Healthcare IT, has two other business units. One of them is called Imaging Solutions, which is run by Don Woodlock. That’s our RIS/PACS solutions, and with the recent acquisition of Dynamic Imaging, it includes that product as well. And then the third business is called the Clinical Business Solutions. Actually, that’s the integration of two businesses. They were separated before. One is called Practice Solutions that was focused on selling EMR solutions for physician practices, smaller physician practices and distributive physician practices. And then the business side is what used to be Flowcast or the revenue cycle management solution, again for physician practices and standalone hospitals. That’s run by Jim Corrigan. That’s the total entity, so I’m one of three business leaders under the GE Healthcare IT umbrella.

I’ve been here one year. Before that, I was the CIO of GE Energy Services, which is the service arm of the GE Energy business, which is based out of Atlanta. It’s about a $9 billion service business that basically takes care of all the support services that follow the sale of the turbine from installation all the way to its life cycle management.

Prior to that, I was the CIO of NBC in New York. And prior to that, I was the CIO of GE Oil and Gas based out of Florence, Italy, which was also an acquisition, a state-owned Italian business that GE had bought that went through tremendous growth. From what I recall, from a $900 million business to a $5 billion business while I was there. I think they’re reaching to $10 billion now, so that’s quite a neat story.

What about your personal background?

I went to Brown University. I have a bachelor’s and a master’s degree in Material Science and Solid Mechanics. Loved that. Prior to that, I’m what you might call a United Nations brat. I was born in Kinshasa, Zaire, now called the Democratic Republic of the Congo. I spent thirteen years in Africa and lived in Chad, Malawi, Niger, Ivory Coast, and Congo of course. I also lived in France, Switzerland, Italy, and Romania prior to graduating from high school.

I used to have lots of hobbies. [laughs] Not too sure anymore what my hobbies are, but I do have three young kids, married, living in Seattle and absolutely thrilled to be in the Pacific Northwest. I sort of accepted this job sight unseen, but I was not disappointed by this region. It’s a very beautiful place and I’m getting into all kinds of outdoor sports kind of things, like hiking and skiing and those types of things, which seems quite natural around here.

GE moves executives around a lot around their vertical markets. You’re a healthcare outsider. What’s your assessment, being fairly new to it and seeing it as a CIO who’s been in other industries?

You know, its fascinating and daunting at the same time. What’s fascinating from a technology standpoint is that healthcare is going through a lot of the same struggles and transformations that other industries have been part of.

What is not the same is the extraordinary impact technology can have in a positive and a negative way on the processes and workflows that we impact. And I think that’s quite a thrill, but also very intimidating in my position, because clearly not having the clinical background, ramping up as quickly as I can, of course, with the help of our clinical leaders here at GE Healthcare IT, not to mention the CMOs and our customers.

But I have to say, I guess it’s a bit of a dichotomy. You have this tremendous opportunity to upgrade the technology, to bring in new solutions that have the potential of significantly improving the quality and cost of the operation. The flip side is the risk associated to those conversions are probably greater that I’ve seen in any industry I’ve been part of, and so it’s something to be taken very seriously. That’s probably what makes this job one of the most exciting jobs I’ve had in my career — because of the impact you can have.

Also, when you work in gas turbines or in broadcasting or oil and gas pipelines or automotive plastics – you know you’re part of something important, but its all about money and cycle time and inventory turns and things of that sort. Where here, it’s neat to be able to go home and know that you have a real personal impact in everything you do every day. It adds a personal and maybe even an emotional dimension that is probably wasn’t as strong in other roles that I’ve had. I find that’s actually an extremely positive thing.

GE buys most of its applications instead of building them. Do you think that’s a good strategy as far as the customer is concerned?

That’s a good question. Actually, what’s interesting is what we’re doing with this business is a bit of a shift on what you’ve just stated.

There’s no doubt that the GE Healthcare business has been built by acquisitions. So, the GE was not in the space. I mean, they had some nominal departmental applications that were extensions of the diagnostic equipment that is the bread and butter of GE Healthcare, but very small activities in software. You could argue even that GE, especially under Jack Welch, never thought of software as necessarily a core competency.

What has changed over the last fifteen years, however, is that there is practically no technology that we have in our portfolio, whether it’s in healthcare or outside of healthcare, which is not differentiated by the software products and the software technology that we associate to those products. So I think in the healthcare space, we’ve made a number of acquisitions.

We’ve created a business that in 2000 was just under $400 million and we’re closing in on $1.7 billion this year. A lot of this was through acquisition, but a great deal of it actually was organic growth and, of course, on almost all the platforms that we’ve acquired or inherited, we’ve followed an evolutionary path to enhancing them, rather than re-writing them from scratch.

What we’re doing in the Centricity Enterprise space is actually taking Carecast to that next generation, which we call Centricity Enterprise 6, which we just launched a few months ago. Actually, it was one of the first major releases of the new product in this business in at least three years as far as I can tell. What we’re doing is grounding ourselves and reinforcing the very strong position that this business has been able to build over at least 25 years. And then what we’re doing in parallel to that is starting to build a state-of-art tech stack for the Intermountain partnership. A set of applications that will extend the Centricity Enterprise 6 platform, and then ultimately over a long period of time, overtake it.

We’re very sensitive to the risk our customers are facing as we re-write a platform. I think it’s dangerous, sometimes. On the one hand, you’d love to write from a clean sheet of paper because you have no constraints and you can usually develop a new application faster. But then when you look at the risks associated for one of your existing customers to actually convert from what becomes a legacy platform to the new platform, you find yourselves getting into some significant risks.

So the approach we’re taking, that might take a little bit longer, is to reinforce the foundation that our customers depend on every day for the same values and benefits and risks that I mentioned earlier. Then, incrementally add on some cutting-edge components, which ultimately will add up to a completely new footprint. We believe that that’s a path that presents less risk for our customers, protects their total costs of ownership, and ultimately takes them from a legacy architecture to a state-of-the-art architecture.

GE’s healthcare IT acquisitions were mostly middle of the pack, not the best or those with the biggest market share. Is that contrary to the overall GE strategy?

I think GE has multiple strategies. I’m not sure there is a single strategy for acquisitions, but then again, I won’t speak on behalf of all my colleagues across the company.

You know, the #1 and #2 thing was very much something we were aligned to in the Jack Welch days. But as you want to grow as a business, you can’t afford to just go for #1 and #2 because then, by definition, you don’t have that much growth left.

So the approach we’re taking now is to try to position yourself, not always necessarily with the absolute best technology, with the absolute best customers and partners. And one of the things we found that was extremely valuable, and is proving itself out every day and every week that we work here, is the customers that we have in the Carecast installed base, organizations like UCSF and Wake Forest and University of Virginia and so on, are really exceptional. And as you look at developing that next generation platform, what’s more important is not to have the best technology today, but to have the organizations that are the most distinguished in practicing care so that they can influence us as we build this next generation software.

So we actually think that we have a ton of room to grow and, because to some degree, you could argue this is the silver lining in not having the absolute best dominant technology, is that we’re not quite as anxious about leaving some of it behind.

Someone once said, “No company has ever benefited from being acquired by GE.” Your reaction to that?

Well, in my personal experience, I mentioned the oil and gas business. So this is a state-owned organization, somewhere around the $900 million range; a strong supplier of a certain type of technology but without a dominant position. Today, they’re probably a $6 billion or $7 billion business. Not only the company and the employees have benefited. The city of Florence, Italy has benefited because it has only depended on tourism and now they’ve got a global giant right there in their back door. Which, by the way, is not a pure American brainwashed entity, it’s actually a very Tuscan Italian company that’s part of the GE company. I think that was a fantastic story.

Now you know sometimes, if companies are too small, they can kind of get steamrolled. That happens. I won’t say we haven’t had our fits and starts. But in my experience, companies have done pretty well. I mean, NBC, the RCA acquisition in the eighties — NBC Universal is certainly an impressive outfit today.

There’s no doubt there’s complexities. When you look at GE Healthcare IT, there are a number of entities. It’s well published and reported that we have become part of this business. Sometimes change takes time. Coming up with technical solutions to integrate everything in a seamless fashion is not easy when most of the products weren’t meant to work together to start with. But, we’re making good progress there. You start with the culture; you line it up with the financial and the common set of metrics, and then you start attacking the more complex parts, which is bringing all the products together and delivering on the promise of the very rich portfolio of technologies and products we have.

Healthcare IT has two camps, the conglomerates like Siemens and GE and McKesson on one side and the “we built everything” group on the other side like Cerner and Epic. How do you think that will play out?

I won’t comment on our peers’ strategies, but what I can certainly say about ourselves is that we feel very confident that there is not only value in the individual components of our organization, whether it’s Centricity EMR or the Centricity Enterprise business from the Carecast side, but we truly believe that these solutions have got to work together.

I think there are two dimensions. There are solutions that should be fully integrated, ideally intrinsically,like the clinicals. We believe there are tremendous benefits from a patient safety standpoint, from a workflow efficiency standpoint, to have the clinicals integrated. But then at the same time, for solutions like imaging integrated with Centricity Enterprise, we believe that it is our responsibility to provide a seamless integration of those solutions, but they don’t need to be intrinsically sharing the same database or the same back-end data storage or data management solutions. It become more of a connectivity play. We have not made these acquisitions or invested in these programs to pretend that they are integrated or to put some lipstick on them and hope that nobody notices.

I think GE culturally has a tradition of being very transparent, which of course a lot of people can use against us because we’ll tell you pretty much what it is, and whether it works or doesn’t work. But we are committed, and if you look at the resources we’re dedicating to integrating the portfolio, we believe that integration is critical. Now compared to some of our colleagues who have built their own applications, I think they’re doing a fabulous jobs and it’s simpler to integrate. By definition, they’re built to be integrated.

The flip-side is that I don’t think its going to be as easy for them to integrate the complete continuum of care from not only the software standpoint, the data management standpoint, the clinical decision support standpoint, but especially all the device connectivity and the integration from a total workflow standpoint in the space and the environment the physician or the clinician themselves is surrounded by. Not just a software company, not just a hardware company, but actually working through the total space in which the clinicians are working. That’s where GE Healthcare is trying to position itself.

How close do you think we are to that picture where the traditional lines of demarcation like being FDA approved or having sensors that actually touch patients, or whatever it is, separate IT companies from bio-medical equipment companies?

I don’t have the answer to that. But I can tell you that is a big question. It has very significant implications for all of us, especially in the IT industry.

The key to success, and this is certainly what we’re pursuing, is rather than trying to demonstrated absolute integration on a seamless basis across all these technologies and all these disciplines, we want to create an environment where we have a technology stack and a technology framework that makes it easy to integrate all the things that you know today, and also to integrate all those things that you don’t know you require in the future, but you will acquire and that it will make it significantly easier than it is today.

So all the investments we’re making today are based on open architecture and open tech stacks, so that as you invest in our products, whether you start at the departmental end or you come to the enterprise end, as you continue investing in them, it will not only be easier to integrate GE technologies, but it will be easier to integrate any technology. Where the regulatory impact to all this is — I unfortunately don’t have the answer to that, but I’m sure we’ll all experience that over the next 10 or 15 years.

Do you strive to be #1 or #2 in the inpatient and the ambulatory EMR product segment?

That’s certainly what we strive for, but we want to do this correctly. We don’t look to growing at breakneck speed without having the quality and the support and the services. I had a business leader I admire who used to say, ‘You have to earn your right to grow’. And you can’t just grow because you have a lot of money or you have a lot of capacity or you have a lot of engineers.

We recognize that we have some work to do to improve the quality of our products and our services. We’re making very significant investments as we speak — to the service, the engineering, and the support side — to ensure that we are ready to grow. We’re GE and we have every intention to grow and we have every intention to be market leaders. That said, we don’t want to do it at the expense of delivering high quality products that serve our customers as we promised they should.

How is the $1.2 billion GE paid for IDX being realized?

The IDX portfolio was a very rich portfolio of products and customers. I described to you the three major business units we have. All those business units are doing very well and the business is growing. Certainly from a financial standpoint, the performance is very positive.

What’s particularly valuable about the realization of the IDX acquisition is that GE Healthcare needed a very strong information technology backbone to integrate all the various products and solutions that it offers. And what IDX had been able to bring was not only strong ambulatory products, but particularly the Centricity Enterprise side, is the platform we’re going to use to provide that core centerpiece of information management for the hospitals and the large IDNs. So we recognize we’ve got some gaps, but we’re making some significant investments jointly with Intermountain and a number of our other development partners.

The continuum of care is vital. There’s not a single healthcare organization that I meet with – certainly in our customer base, and even potential prospects – who doesn’t stress the essential importance of having a fully integrated IT backbone to run your operations, not only on a day-to-day workflow basis, but also on a retroactive advanced decision support capability, to be able to analyze how to improve care and how to tighten up the tolerances on how care is being delivered across different physicians, operations, hospitals, etc.

So I think that’s where the real return on investment is going to come, where we’re going to be able to not just deliver and implement a Centricity Enterprise inpatient or outpatient solution, but when that solution will actually allow our customers to fully integrate all their diagnostic equipment, all their labs, all their practices, and do it in a seamless way. So that’s the bed we’re in. When we reach that point, the $1 billion plus will be a small cost in the context of the rewards we’ll be able to get not only as a company, but for our customers.

When does the work at Intermountain come out from under the covers?

It started 18 or 19 months ago or so. There was a ramp-up of resources prior to the IDX acquisition in 2006. And as we acquired IDX and started integrating the business after the first quarter of 2006, we were at about 100 resources. We’ve been fully staffed for about three or four months. We’re a little over 310 or 320 resources, not only at Salt Lake City, but also in a couple of other GE sites.

We’re going to be releasing the first major parts soon. Not releasing to the market, but implementing them within Intermountain, the first major phase of the program, which will be focused on the emergency department. So we’re very excited about that. We’re targeting that for the end of the first quarter or beginning of the second quarter next year.

So the team is heads-down working on that, and we’re designing and developing the specs for the next two generations of the product and we’re very excited about it. So, it’s going very well. I think there was a little bit of silence for awhile because the team was really getting its sea legs. We had acquired IDX, and we bought in the Carecast business. As we were looking at the exceptional partnership we had with Intermountain, we also recognized that there were some luminary customers within the installed base that IDX brought in. We wanted to make sure they could participate and help enhance what is designed to become a transformational, next generation platform.

We talked about the acquisition integration, getting the cultures aligned, understanding what’s in conflict and what’s not in conflict. So that perhaps delayed us a little bit, but the result is that we’ve never been in a better place when it comes to our partnership. Our customers are excited about it. And, we’re having a pretty impressive set of collaboration across half a dozen large, very respected healthcare organizations, with Intermountain, of course, at the core. So it’s very exciting. We’ll have some cool things to show at the beginning of next year.

Do you think the end result will be targeted at large organizations like those ones you just referred to, or will it be something that the average community hospital can use?

It’s targeted for the average community hospital. We’re architecting it so it can be run completely on commodity hardware. So, it’ll be completely available to scale up to the Intermountains and the UCSFs of this world, but it also has the capability of running off Linux boxes and a fully open tech stack. Pretty much a state-of-art technology stack, which will provide not only a very low cost point and a low TCO, but also provide tremendous opportunity for integration, not only our products, but also third party products.

As we all know, and I certainly know from my 10+ years as a CIO, there is no such thing as a homogenous portfolio of applications in any organization. So I think that’s the other element we’re trying to address here. You’ve got to have something that can work easily with other technologies. I think that will be a differentiator as well.

When do you think you’ll have the first fully commercial sale of the end result?

We’re not looking for a big bang, “Here’s the GE-Intermountain EMR, ready for sale with a nice ribbon.” We’re basing everything on the Centricity Enterprise 6 platform, which we released earlier this year. And the way we’re looking at it is to implement it on a modular basis. So what we’re recommending is that you implement Centricity Enterprise 6, and then we are building all the engineering integration requirements so that, as modules come out, whether it’s for ED, whether it’s for a flow sheet, whether it’s for a PDA, whether it’s for other types of services that we’ll be releasing over time.

Basically, every year we’ll be releasing different components. You’ll be able to enhance the Centricity Enterprise 6 platform with those components. And over time, and it all depends on the appetite and the rate at which an organization wants to consume these things, you will find yourself having the center of gravity of your application will be increasingly the new tech stack rather than the old tech stack. But it really will be up to the client organization to decide at what rate they want to absorb them. So we’ll start releasing some things next year.

You will be marketing it to new customers, correct?

Absolutely. But in 2008 and 2009, the output of the GE-Intermountain partnership is not going to be a full, complete, 360 EMR solution. I mean, we’re building this, we’re very focused on starting with ED. We’re going after ambulatory. We’re going after certain infrastructure components. We’re going to sequence it that way.

This is sort of the internal debates we’re having these days. What are we focused on first? What will we focus on afterwards? Where are we strong? And so, to a degree, we think we have the best of both worlds. We have a very strong orders and CPOE solution with Carecast. We recognize that there’s some areas of improvement, but we also have departmental products that compliment it well.

I thought one of the braver, more honest things I’ve seen a vendor do was when GE responded to the KLAS nursing adoption study and pretty much said, ‘Look, we admit it. We and our competitors haven’t really done a good job of giving nurses the systems they need.” What actions resulted from that?

It was a hard decision, but we certainly didn’t want be rewarded by trying to sugar-coat it. GE has a strong culture of transparency.

We’re trying to get our customers upgraded to the latest release of our product. There are a number of features in the latest release of our product that actually mitigate some of the issues that were identified in that report. But we’re also putting a very strong focus on nursing workflow. We’re taking advantage of a lot of the best practice methodologies and the operational rigor that GE can bring here to ensure that we not only interact with our nursing client communities in a productive way, but we also translate their requirements and their requests into actionable product requirements that will be built out and integrated into our future releases.

It’s a tough situation to be in, because clearly nurses are among the largest population of our users, probably without any competition. And at the same time, we would obviously prefer to have better solutions for them. But I feel good considering the resources we’ve invested in this business. Just to maybe give you a sense of the kind of resources we have in development today compared to the resources this business had in the IDX days, the Centricity Enterprise business or the Carecast had about 250 engineers when we acquired them. We’re now in the range of about 620 or 630 engineers dedicated to this one product.

So the exciting part is that if you combine the clinical expertise, the software expertise, the domain expertise that the IDX team has, and you combine that with the rigor and the operational excellence and the focus on execution that GE brings, and you add on top of that the significant resources to actually walk the talk, it’s not just a question of gathering the requirements, but its doing something with them. I think the prospects are very positive and optimistic.

What we’ve also done from an organizational standpoint is a CxO kind of client forum called the Physician Advisory Group, then the CIO group. We’ve added a Chief Nursing Officer Advisory Group. That was one of the things we did early last year. We have a chief nursing officer internally. We’ve been hiring more experienced professional nurses into our organization. So I think there’s a very strong culture so our nursing users have very strong advocates internally and we’re including them now in what was already a good communications process with the CIO and the CMOs or CMIOs. Now we also have the CNOs included in that. It’s making a huge difference in helping us understand how to continuously improve our products.

If you look at the broad spectrum of healthcare IT, which areas would you say are most popular right now?

One is a tremendous focus on clinical workflow. The software industry has had a tendency to always think in modules or components of modules and has always focused on the connectivity side and the automation side and the paperless aspect. Everybody has been talking about paperless and eliminating the paper artifact. I think a lot of organizations have taken care of that and are less focused on paperless and more focused on ‘How do I really optimize and maximize the efficiency and the quality of my workflows?’, which of course doesn’t always work naturally with the way IT solutions are architected.

I think the other aspect is driving evidence-based medicine; making sure the data is available, so it’s not just gathered after the fact through some kind of manual reporting, but that every transaction, every encounter with the patient captures data on a standardized basis. And as you look at the work we’re doing with Intermountain, literally leveraging knowledge terminology, management, setting up standard databases, and setting up clinical data models, ensuring that the data is captured at the moment of the transaction or the encounter with the patient, which then allows you obtain a very, very rich database that then can be mined for analysis and for discovery of how to improve care.

The other thing that we’re doing, of course, is including in the workflows best practice care. So I think that is something else that we’re hearing more and more about. How do we keep our physicians and our clinicians fully up to date on the latest developments in healthcare? How do we help them as individuals who have a tremendous amount of pressure both transitionally and from a responsibility standpoint to be aware of the latest developments, the latest adverse interactions, the latest discoveries on how to practice care and how to address certain types of concerns?

Through the software we’re developing, we believe we have a unique opportunity, not just as GE, but as a partnership with other organizations like Intermountain healthcare; organizations like UCSF and others, to take the best practices that they’ve developed and make them available, not only to large institutions, but particularly to community health hospitals and others. And so that’s what we’re targeting going forward.

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6 Responses to “HIStalk Interviews Laurent Rotival, SVP/GM of Enterprise Solutions, GE Healthcare”

  1. 1
    Wow... Horrible Interview Says:

    Well, whoever in the marketing dept suggested Laurent speak with HISTalk must secretly work for a competitor because all this interview did was empower GE’s competitors. I can see salespeople competing against GE printing and forwarding this article all night to prospects. I’ll summarize what I got out of the interview:

    - GE still can’t explain or keep track of all their new product names (“What is GE Centricity Enterprise? It’s CareCast, or LastWord. It’s our clinical system, except its not because we’re developing a new one with Intermountain, which will be called Centricity Enterprise 6… Got it?”)
    - GE is upgrading CareCast and the release will be hard to implement like a whole new release, but without all the new functionality of a new release — and it’s taking forever to finish
    - GE and Intermountain have 300+ (or 600+) people working on an EMR and after they get their sealegs they’re going to release a system (a complicated one) beyond the ER in a few years.
    - GE has trusted their next-generation clinical systems to a CIO, not an MD, or a visionary. I also don’t get the sense he’s thinking about GE Centricity whatever in ten years, because he’ll expect to move on in 2-3 years, if that long.

    I’m not really a Cerner, Eclipsys, or Epic fan, but if you buy from them you’re buying from executives that only ever think about healthcare software (and have learned a lot from healthcare software for years). Another thought… If IDX had never bought Phamis, those folks out in the Northwest would have made LastWord twice as good by now. Years have been lost in the mess of IDX and GE.

  2. 2
    Will Weider Says:

    I can’t believe that you did not ask him about his dealings with the Sheinhardt Wig Corporation.

  3. 3
    Tim Kirk Says:

    Mr. HIStalk:

    Great interview.

    Mr. Rotival gave me a much clearer view of GE Healthcare strategy and the challenges the healthcare industry faces.

    Thank you both.

  4. 4
    HISReader Says:

    Haven’t seen that kind of random rambling in quite a while. Not impressed. Still feels like a money play.

  5. 5
    CIOGuy Says:

    We run a lot of hospitals and GE is the worst vendor I deal with from a service and accountability standpoint. All of the people that he mentions in his interview we have met with and they have made big promises. Nothing ever comes of the promises. GE has no idea how to do large account management and their customers pay the price for their dysfunctional business units not working together.

  6. 6
    CPO4 Says:

    I have been on GE Centricity since 2005. Not once have they ever tried to improve on the PM software we purchased. The upgrades (few) come in a way you have to buy a whole new package. Now they say we have to purchase the EMR with the Phys system. This was a large investment made initially. GE is only interested in making money. There support is the worst. We had to hire a company that just does their support because they cant do their own. This is the worst software & support ever. They told us they cant make it do whatever we needed. Unfortunately, our administrator bought in to that one. Buyer beware.

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