HIStalk Interviews Steve Hau, President and CEO, Shareable Ink

Stephen S. Hau is president and CEO of Shareable Ink of Nashville, TN.

Tell me about yourself and about the company.

I’ve had the privilege of starting two very provocative healthcare IT companies. At the age of 25, I dropped out of a PhD program at Harvard to start a company called PatientKeeper. I started that with a physician friend of mine, Dr. Joe Bonventre. We founded that company based on a very simple observation — doctors are highly mobile professionals because they walk about three or four miles a day, they cross different care settings, juggle numerous information systems, and rarely sit in front of a desktop computer.

From that starting point, many people worked together to build a very interesting and valuable company. I spent over 12 years at PatientKeeper. I collaborated with some wonderful people, learned a lot, and formed some strong opinions about the industry that ultimately lead to my next venture.

About two years ago, I left PatientKeeper to start another healthcare IT company called Shareable Ink with another physician friend of mine, Dr. Vernon Huang. This time, the simple observation was twofold. One, healthcare will become more electronic, and I think everyone agrees with that. And two, without a new approach to healthcare IT, that transition to being electronic will be very, very difficult.

During the formation phases of Shareable Ink, I got very excited about the potential of digital pen and paper technology. As you might know, digital pen and paper technology utilizes a special ballpoint pen with a small camera embedded in it that’s capable of recording and transmitting the user’s pen strokes. I felt that if this basic technology could be augmented with the right software, we could deliver a hugely valuable tool for clinicians and healthcare organizations. 

I put the band back together, bringing back some very talented friends, including some amazing engineers. I’m a firm believer that great software is a balance between technology and psychology, I say this a lot. It’s really only when clinicians truly embrace the tools when the tools aren’t cumbersome to them that we can deliver the full potential and the benefits of IT.

Companies either say “Doctor, you have to enter everything, so here’s your keyboard and this is where you’re going to live your life from this point forward,” or they say, “We don’t believe in that. You never have to type anything. Doctors should be consuming data and not creating it.” You’re giving them an alternative.

That’s right. We look at digital pen and paper as an input modality into electronic systems. It’s not really an “either-or”, but a “both.”

We initially set out to explore three clinical settings: emergency departments; operating room, specifically anesthesia; and physician practices. The factoids are that 80% of ED is documented on paper, 93% of anesthesiologists document on paper, and the vast majority of small doctors’ offices document on paper.

In the ED space, we’ve partnered and have had a great success with T-System. Sunny, the CEO you interviewed recently, is a real visionary. T-System has 1,700 emergency departments using its paper templates. That’s almost every other emergency department in the country. Our joint product, DigitalShare, helps those EDs become more electronic and thereby shortens revenue cycles, improves compliance, enhances access to clinical records. We accomplish all this without any change of the physician behavior. The clinician literally doesn’t have to do anything differently. 

We’ve seen similar benefits with anesthesiologists. We recently announced that NorthStar Anesthesia had huge success with our product and decided to expand it to 34 hospitals.

In the coming weeks, you’ll hear an announcement from a very large, well-known, publicly traded EMR vendor. Their customers will now be able to use their current paper documentation templates as an optional input mechanism into EMRs.

In a way, your company exists because EMR usability is at least perceived to not be very good. Do you see your product as a happy medium that lets vendors avoid rewriting their products with usability in mind?

Digital pen and paper can be an option for getting the clinician’s information into those systems. Their analogy is dictation. It’s a longstanding challenge where the entire industry wants the electronic data, but at the same time, we have to be mindful that physicians have very specific workflows that they’re comfortable with. For a period of time – and it looks like this will continue – dictation has been a way for physicians to input information. I think digital pen and paper is another example.

I’m also a fan of tablet computing. We’ll be introducing our take on tablets later this year. I think that might be another physician-friendly input mechanism into the electronic system.

Do you see digital pen and paper competing with tablet PC handwriting recognition or electronic forms completely contained in a tablet? Is that a direction you want to go?

Absolutely. Our business is really about helping healthcare organizations become more electronic. We do that by providing tools that physicians are comfortable with using as a way of capturing information from the physician. Pen and paper may be a way to go, dictation may be a way to go, and tablets might be a way to go as well. We’ll support whatever physicians are comfortable using.

We’ve had a very different take on tablets, at least, in terms of what I’ve seen out there. I’ve seen a lot of vendors take their desktop applications and try to convert it into a tablet application. We take an approach where, frankly, physicians are already comfortable with a way of inputting information, so we will use tablets as a way to mirror current physician workflows. Where they might have been scribbling on a piece of paper, they’ll have a choice to either scribble using a digital pen or scribble with a stylus on a tablet.

People underestimate the importance of the visual cues that you get when you write something in your own handwriting. There’s a whole psychology around how you place it and how bold you write and whether you draw an arrow to it or whether you scribble a drawing along with it. Is that something that physicians miss when they’re forced to type?

Yes. What we hear frequently is that the physician-patient interaction changes quite a bit when you introduce a computer keyboard. What we’ve found is that by utilizing digital pen and paper, physicians get to maintain a workflow they’re accustomed to.

I’ve observed that the documentation process is often interactive. Physicians aren’t court stenographers, where they’re literally just transcribing a predictable stream of words. The documentation process can often be non-linear, where there are surprises and they jump around and make changes during the documentation process.

I can see where patients would perceive a physician writing as they speak to be paying extra close attention and being extra careful, whereas typing almost seems like you’re being ignored.

Right. We’ve heard that before. As a consumer of healthcare, I can appreciate that as well.

Where do you see the role of the digital pen and paper for providers trying to meet Meaningful Use requirements?

Shareable Ink currently supports Meaningful Use in several ways, including the capturing or recording of clinical quality measures required under Meaningful Use. As an example, in the ED setting, we help capture emergency department throughput. In the anesthesia setting, we help capture antibiotic administration prior to surgery, which is just a quality measure.

In broader terms, we support the move to Meaningful Use, because what we’ve observed is the more the hospital becomes electronic, the harder it is to deal with existing paper processes. Shareable Ink takes those paper processes that are difficult to automate and we make them electronic with hardly any impact on the otherwise busy IT department.

If the IT department is the gatekeeper as they sometimes are, what would be your pitch to them about the cost and the technology and the manpower required to implement digital pen and paper?

Shareable Ink has taken a unique approach in terms of how we deploy our technology. All our software is hosted off site. There isn’t software to install on PCs. That obviously shortens the initial installation process, but also the go-forward support. We offer our product as Software as a Service, so it’s very, very easy to get started and also quite reasonable to manage going forward.

The advantage of interacting directly with a computing device is that the programmer can provide edits and completion messages and warning messages as the form is being completed. Do you have those tools available?

Yes. Our software can provide immediate feedback, including decision support, through our companion Web application. In this particular configuration, a USB cradle is connected to a Web-capable computer, and within a few seconds of docking the digital pen into the cradle, the pen strokes are delivered to our remote servers where they’re processed. That feedback is provided to the clinician in a browser window.

You’ve identified anesthesia as a key market. How are they using digital pen and paper?

The anesthesia market is a great example. For decades, there have been these so-called AIMSs – anesthesia information management systems – that have been marketed to anesthesiologists. They have, for the most part, not been very successful. In fact, as I mentioned today, 93% of anesthesiologists document on something called an anesthesia record, which is for the most part a two-page piece of paper.

But with that said, there is a need to go electronic, especially these large anesthesia groups. They’re essentially service organizations that compete with each other on the basis of the quality of their work. But that data is hard to come by. A lot of provider groups hire FTEs to spot-check individual records to make sure they’re being compliant with best practices.

With the Shareable Ink approach, the anesthesiologist continues to do what he or she has done for years, which is documenting on a paper anesthesia record, but that document is converted electronically to data. That data is available to medical records, but that discrete data is also available for compliance checking, for providing anesthesiologists immediate feedback if records aren’t complete or if they’re not being compliant with certain measures, and when the data is aggregated, to provide the provider group an ability to evaluate all of their providers on an objective basis.

It occurred to me as you were saying that in a hospital, the higher the level of acuity or specialty, the more the physicians’ practice becomes less free-form and more form-driven. The ED, ICU, surgery, anesthesia — all of those are more form-driven than general medicine or some of the other broader specialties. Are there others you’ve thought of that are form-centric that would find an easier transition to digital pen and paper than to just say, “Here, start typing.”

That’s a great observation. I would say that so much of healthcare is form-based. I didn’t fully appreciate that until we started Shareable Ink. I’ve been in environments where physicians will bring out their highly customized form … I’ve got a couple of MIT degrees, so when I observed this, I thought, “Well, gosh, that’s not really intellectual property, that’s just lines on a piece of paper.”

With reflection and maybe some maturity in my thought process, what I discovered was that what these physicians are showing us is their most highly customized, specialized tools that they’ve built that simply work for them. Shareable Ink, to some extent, is about taking what works for physicians and turning it into electronic data that the industry and the market requires.

What did you learn from PatientKeeper that you’ve taken to Shareable Ink?

I learned a lot from PatientKeeper, but I think what I appreciate most is the psychology of software design. The reality is, at the end of the day, it’s not about necessarily the robustness of the technology, not necessarily about the level of sophistication of the code or algorithms behind the scenes. Where the rubber meets the road really is, is the tool ultimately physician-friendly? Is the tool something physicians can be very comfortable with and can begin using right out of the box without an instruction manual?

Where do you see the company and the product going out in the next few years?

The great news is that, in a short amount of time, we’ve won a lot of customers. Our focus right now is taking great care of our customers. As an additional benefit, is we’re learning a ton from our customers. Every day I’m being educated about the next generation of applications they would like us develop. Not only is our customer pipeline very strong, our product pipeline is also very, very robust.

Any concluding thoughts?

I appreciate the opportunity to be included in your blog. As I mentioned, everything we’ve learned about healthcare IT has come from candid conversations with customers and other leaders in the industry. The Shareable Ink suggestion box is always open and we’re eager to get candid feedback from the industry.