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HIStalk Interviews Stephen Hau

December 2, 2009 Interviews 8 Comments

Stephen Hau is President and CEO of Shareable Ink.

Everyone on your management team comes from PatientKeeper, a company that created a niche in the mobile healthcare technology. What’s similar and not similar with Shareable Ink?

That’s a great question. Shareable Ink is a very different company than PatientKeeper. When you take a look at the management team, as you pointed out, there are a lot of people who crossed paths at PatientKeeper. That’s because I spent twelve years at PatientKeeper.

As you know, I started the company and just left that six months ago. As I looked to start another company, I went out and thought of the people that I worked with in the past that would be good in a launching a new venture. Of course, I went to a lot of people that I crossed paths with at PatientKeeper.

What’s similar and not similar between the two companies and products?

I would say Shareable Ink represents a very different approach to healthcare IT. Shareable Ink is also a software company, but we combine digital pen and paper technology and some sophisticated enterprise software, form automation capabilities, and actually, a huge dose of pragmatism to deliver a very meaningful solution in healthcare.

As I look at the marketplace, I think the reality is that more than 80% of healthcare is still driven by paper. Shareable Ink makes existing paper-based processes like documentation, orders, and billing electronic with no change to workflows or individual routines. In fact, with Shareable Ink, no software is installed on-site, so we’re not “another IT project.” Actually, no training is required and we receive almost no support calls.

The result is that we’ve demonstrated 100% physician adoption and the entire organization realizes the benefits of electronic information. This is a different approach and it’s something to get really excited about.

Think about this: every year at HIMSS, what you see is vendors put up signage proclaiming that their products will reduce costs and generate phenomenal ROIs, improve outcomes and more. I believe that. But I kind of feel like there’s fine print or at least an asterisk that says, “All these benefits are only possible if doctors actually use the software.”

The industry’s dirty little secret is that physician adoption of IT is abysmal. And surely there are a lot of bad software products out there and doctors refuse to use them, but there are also a lot of robust, well-designed software products out there. Sadly, generally, they’re not well adopted.

We considered all of this when we started this new company, Shareable Ink. It’s my opinion that the issue is really not that of technology, it’s actually really about psychology. I think there are a lot of well-intentioned software designers out there that are tackling some of healthcare’s big challenges, and that’s great. The problem is that historically, they ask the doctors to completely change their workflow. And as I said, we took a very different approach. We’ve created a platform that produces electronic information without changing physician’s routines at all.

So much of the benefit of moving from paper to computers is to avoid illegible handwriting and to get information in discrete form rather than as a picture. Isn’t digitizing handwriting a step backwards?

I don’t think so. I think we’re taking a very pragmatic approach here. I can give you an example of our first large customer, which is an outsourced anesthesia billing company located in Michigan. They’ve got over 8,000 anesthesiologists under contract. Before Shareable Ink, these anesthesiologists would record their cases on paper anesthesia records. Some of the anesthesiologists would wait until the end of the month to FedEx these records to the billing service, where the envelope would be opened and the anesthesia records would come out. A human being, a biller or a data entry person, would actually key-enter all that information.

Other anesthesiologists would deliver the anesthesia records to someone in the back office that would essentially put the anesthesia record in a queue to keyed in. When the records finally reached the folks in Michigan or over to their overseas FTEs, often it would be too late to update incomplete forms or incorrect records because basically you have to chase down the anesthesiologist and say, “Hey, remember that case you did three weeks ago? Well, when was the anesthesia end time?”

With our system, the record is made available to the back office, literally, a few seconds after you complete the record. The paper form looks exactly like the forms the doctors used before we introduced our system. There’s literally no training whatsoever. But now, the records are processed immediately by the back office because information is available on our secure Web site — our Web portal — and the doctors are notified of any sort of errors they made in the anesthesia record within seconds after the form completion.

We did a study at a surgery center in Delaware. We were able to show they were able to improve form completion rates from 78% to 99%. Is this a step backwards? I would say no. I mean, what we were able to do, we were able to reduce a tremendous amount of re-work. We were able to, for this particular example, shorten AR days and vastly, vastly improve physician satisfaction.

What’s the benefit of offering a handwriting application as a software as a service instead of running it on a consumer-grade Windows application like Microsoft and others offer?

In my personal opinion, software as a service is hugely applicable to healthcare IT, so there are a few notable benefits. First of all, because we don’t have to install any software on-site, we’re not another healthcare IT project. This allows us to move very, very quickly. That’s definitely because our technology is off-site. We’re able to bring a lot of fire power, a lot of computationally-intensive functions to our technology.

As an example, rules and alerts, as I mentioned before, physicians, when they fill out a form and it lacks a key piece of information, perhaps related to some sort of PQRI initiative, we can send them an SMS message to their pager and e-mail, what have you, instantaneously, because all our capability is on the Internet.

Also, it makes it very easy for us to automate forms. One of the challenges out there, or course, is there’s a lot of paper. That’s both the opportunity and the challenge. Part of our philosophy here is that we don’t want to change anything a physician does, so we make it very easy to customize or utilize numerous different types of existing forms that an organization normally might have.

Separately, we provide the ability for so-called ‘third-party validators.’ I can give you a few examples. We talked about the outsourced anesthesia billing company, where they’ve got billers and clinical folks both here, stateside in the United States as well as overseas in India, in that example. The fact that anyone on the planet can help get involved in processing the data is a huge benefit to our customers because it allows them to keep costs low and also to operate on a 24×7 basis.

We are working with a very prestigious cancer center and they are doing drug orders using our system. The interesting background there is that those physicians, about a year ago, tried to bring in an electronic system to handle the orders of their oncology drugs. It’s a great idea, but in practice, it was such a change in workflow that the physician productivity just plummeted. It turned out that in practice, it just wasn’t a system that worked well for them.

What we’re doing with them now is we’re essentially taking the paper ordering forms that they’re using today and we’re making them electronic. The physician, essentially, does nothing different. They’re still ordering drugs through their existing processes, but because of the ability to support a third-party validator, the person in the pharmacy department is now validates the data and then takes the next step, which is to electronically submit the physician’s information into the electronic ordering system where all the rules fire and all the good things about having electronic information occur. These are some of the benefits of being able to have a software as a service model.

How does Shareable Ink work with existing applications like an EMR?

We have, behind the scenes, a tremendous amount of integration capability. Some of our customers can actually start before using the integration capability because at the end of the day, we know that by automating paper-based processes, we can co-exist with existing processes. There are other customers where it makes sense to have the integration capability in place before getting started.

I can give you some examples where, in fact, we are working with EMR companies to provide their customers a paper-based modality to get information into their EMR. I think when you sit across the table from a CEO of an EMR company, he or she will tell you that of course there’s a huge value proposition for going electronic.

But the challenge is still trying to get physicians to put fingers on keyboards. There’s a longstanding paradox in healthcare, which is — institutions want digital data, but physicians, who are the highest-paid workers in the organization, don’t want to compromise their productivity by having to key-enter data into computer systems. What we’re offering customers on a direct basis, as well as with some EMR channel partners, is essentially the ability to bridge existing processes into electronic EMRs or EHRs.

Physicians who don’t want to type often look at speech recognition instead of a keyboard. Where does Shareable Ink fit then?

I think transcription is an interesting analogy. In some ways, there are physicians who have migrated to transcription. Dictation transcription’s a way of getting electronic data into back-end systems. Obviously, there are a lot of physicians who resist that, who essentially feel, “We’ll document on paper.” What we offer has both differences and similarities.

In terms of differences, because we’re utilizing often templated, form-based data entry, we have the ability of creating a better kind of structured information. Because, for example, we know that if a physician is entering, for example, allergies — in this particular area — our system is smart enough to say, OK, these are allergies. The system will now choose words from a more specific lexicon knowing that it’s going to be plugged in. Or perhaps drug names. Not only that, after we process the information, we’re able to then, in a structured basis, interface the electronic system saying that this is a list of allergies, or this is a list of drug names.

Some of the similarities … if you take a look at how the dictation/transcription business has evolved over the last few years, I think what we’ve observed is that that particular segment has brought more and more sophisticated computer-aided technologies to support or help the transcription process. eScription’s a great example, where they take the audio from the physician and then take advantage of voice-to-data technology to take advantage of sometimes semantic reasoning to improve the transcription process. I think the analogy is that we’re taking advantage of some very cool, cutting-edge technologies to assist us in the handwriting to electronic data conversion.

We also have the ability to take advantage of something called the Mechanical Turk approach. That’s a community model that allows us to essentially co-mingle computer-based computation with human beings. Not only that, we’re able to break down the problem by using multiple human beings to essentially support the handwriting-to-text conversion process.

One thing I forgot to mention about the SaaS model: one of the key benefits that we allow our customers is getting started with our software with very little cost to them up front. We charge for our product on a subscription basis, so this allows many customers to get started very quickly without any sort of up front capital purchase. That’s a key advantage of SaaS models, obviously.

So you’re selling a new concept as well as a new product. How do you get the message out?

Well, I hope this interview helps. [laughs)

It’s all about HIStalk.

Yes. Well, it’s interesting, because it’s a new concept and at the same time, it isn’t. I guess in some ways the new concept is: wouldn’t it be great to get all of this electronic information and actually realize all these value propositions that you’ve been hearing for quite some time without changing physician behavior? In that sense, it’s certainly a new concept. But at the same time, I think we’re addressing a lot of known healthcare issues and I think the timing couldn’t be better.

Look at the ARRA legislation. Look at the demands of organizations to go electronic. But at the same time, realize that they need to have a pragmatic approach that’s cost-effective, that they know the physicians will actually adopt and use. I think it’s a great time for the Shareable Ink idea, especially in this time with the government pressure to meaningfully use these EHRs. Well, clearly, I think our approach falls under that category.

What’s your elevator speech when you’re talking to the hospital CIO or CMIO or head of an anesthesia billing company?

I think the message is different. In some ways, we have a high-class problem here. I mean, reality is, as I said before, 80% of healthcare is written on paper. The high-class problem is that there are many, many different applications that we can provide. With some of the customers we’re working with, we are doing physician documentation projects. We are doing nursing documentation.

I mentioned that we’re doing orders and obviously, we’re doing these anesthesia records. There are many different applications. I think in some ways, the pitch is, often we share our capabilities as a seamless way to create electronic information with no change in workflow and with a very, very kind of easy way for an organization to get started. You start with that reality or if you start with that capability, and very quickly what happens is that the CEO of the organization says, “Oh gosh, you know, I’ve got a problem that you could solve with your approach.” This is something we can actually address and realize some success.

So the message is really one of, I think, very, very innovative technology. A lot of fire power that happens behind the scenes, but coupled with a very pragmatic approach to realize those benefits, there has to be virtually no change in workflow. It has to be something that addresses both not just the technology, but the psychology of the organization.

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Currently there are "8 comments" on this Article:

  1. “This is a different approach and it’s something to get really excited about…..So the message is really one of, I think, very, very innovative technology”

    Not to rain on anybody’s parade, but there is nothing new or innovative about inking technology in EMR’s. I’ve been working with this technology for years in healthcare IT and have ended up having to design user interfaces around it so that the clinicians would not have to ink at all.

    Inking just doesn’t work well. When a correction needs to be made because what was written was not recognized properly, it’s a pain to try and correct it which just leads to clinician frustration. They just end up typing. Another thing to mention, you really can’t write, you have to print very legibly, because inking does not recognize writing well at all.

    As a Nurse, I would never recommend this type of technology for clinician documentation.

  2. It’s very exciting to learn of a novel and yet common sense approach to healthcare IT. Mr. Hau’s comment about psychology resonates with me. The answer isn’t more wrestling matches with technology, and I do believe Shareable Ink understands that.

    I look forward to seeing the founder of PatientKeeper’s 2nd startup unfold and blossom. The timing is great. Godspeed!

  3. I have seen an earlier approach to digital pen and paper, and the capture is much more impressive than one might initially expect. Shareable Ink appears to have addressed a couple key obstacles to the technology: i. No software to install on desktop PCs and ii. Providing familiar forms.

    100% adoption sounds good to me.

  4. I keep getting a kick out of how vendors jump up and down saying a SaaS approach is better because there is no capital outlay.

    What’s the difference? if in a SaaS approach you have no capital costs, just montly transaction fees (that go on forever?) – against the ‘old’ turnkey approach where you do not sell the system – you lease the ‘system’ and amortize it over some transaction volume and/or time period. It’s all just financial machinations…

    …except on the time payment plan (whether turnkey or SaaS) the vendor has to wait to get his money, since there are minimum or no upfront charges. But this does mean as a buyer if you sign up with a SaaS vendor, particularly a small one, you better closely check his financial statements to make sure he has plenty of capitalization (cash from investors) to carry him through some cash flow struggles in his early years… if he doesn’t he won’t be around very long and you’ll be out buying a replacement system sooner than you planned.

  5. While I’m skeptical of the approach (implementation), I like the idea of taking folks who are still on paper — and reluctant to change — and going in this direction to start with. If feels like a useful transitional product, sitting between paper and full EHR.

    As Junkie points out, the payment models are different between SaaS and turkey, but SaaS requires more of a commitment on the vendor’s part to keep the provider happy and meet their needs. With turnkey systems that have a huge upfront installation/customization cost, the provider feels stuck with a multi-million $ investment which they have to just “deal with” when it does not meet expectations. And the vendor has less motivation to quickly resolve unmet expectations (and costs) because of the cost of jumping ship.

    Stephen, you should post some Youtube videos of your product in action. That could be a powerful demonstration of the benefit.

  6. “when they fill out a form and it lacks a key piece of information, perhaps related to some sort of PQRI initiative, we can send them an SMS message to their pager and e-mail”

    Yeah right, try to get this from me when I am in someone’s brain in the or. It is obvious that you do not know what doctors do and how they think. Get out of our house! You are tresspassing.

  7. Interesting approach but as always this really comes down to how well their application actually integrates with existing HIT products. I would imagine it varies a bit. Also, I would be curious to see what their pricing model is and if they are just targeting high-end specialists/hospitals or actually making this a pretty low-price to actually go after more of the downstream ambulatory market.

    Appreciate informative interviews like this even if some of the physician luddites just complain as normal about any form of technology regardless of its overall performance. Keep them coming!

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