I ran across Eric Fishman, MD a few months back when I stumbled onto his EHR Scope, a compendium of information about physician system and speech recognition. Ambulatory systems continue to be very hot in the marketplace and it was interesting to find a practicing physician who was putting so much time and expertise into that market.
Since then, Eric has decided to put his full time and attention into his business, which also includes a free service to help physicians choose an EMR/EHR and a package of products and services related to speech recognition for physicians (based around Dragon NaturallySpeaking). Note: I’ll mention as a disclaimer that Eric’s company recently decided to sponsor HIStalk, although our plans for the interview had already been made by then.
Thanks to Eric for bringing me up to speed on the complex world of physician practice systems. Big changes are happening.
Give me some background on yourself, the company, and how you got interested in physician automation.
I’m an orthopedic surgeon. About 14 years ago, one of my secretaries came to my office and said, “I know you like computers. I just took my son to a pediatrician and he was talking to a computer.” He was using a voice recognition product from a company called Kurzweil, which had been started by Ray Kurzweil.
I decided to buy it. Ours was a three-physician office at the time. The $26,000 cost was hard to swallow, so I opened a company to sell voice recognition software 13 years ago. And so the rest is history, although I didn’t want to say that because it sounds overly grandiose. [laughs]
I always refuse to use the term EHR since vendors started using that name in talking about their old EMR products without changing anything. Am I being too much of a stickler?
Yes. I have a treadmill in my garage with a wireless mouse and keyboard and I do a lot of Internet surfing. I don’t call it by the time, but rather by the mile. When I surf, I can do five miles.
John Naisbitt is the author of Future Trends. He made the rational conclusion that what is important to the present and what will be important in the future can be measured by how often items come up in newspapers. I compared “electronic medical record” and “electronic health record” to see how often they showed up in Google. I wrote in an article that the term “electronic medical record” would have become less prevalent when the lines met. Right now, “electronic medical record” is 46 million in change in Google hits and “electronic health record” is 71 million. Three years ago, it was exactly the opposite.
There are subtle distinctions. An EMR is used by a physician in the office to take care of patients. An EHR is more connected and takes care of the community. Connectivity is the distinguisher.
The manufacturer calling it so doesn’t make it so. The terms are very frequently interchanged. I changed the name of my company from EMR Consultant to EHR Consultant in recognition of that change, although you’ll see Word changing EHR to HER. [laughs] In EHR Scope, we talk about how Microsoft Word versions can be corrected to stop doing that.
Notwithstanding all the above, I frequently use the terms interchangeably.
What’s holding back widespread adoption of practice automation?
It’s a few basic issues. Physicians are the ones who pay for it, both with cash and, more importantly, blood, sweat, and tears from the angst of changing how the office functions. Third parties are the ones that benefit, like government and patients. That disequilibrium is disconcerting to many physicians.
I’m a strong proponent of using voice recognition. It substantially minimizes the inconvenience of electronic recordkeeping. It allows physicians to alter the way they interact with patients to a lesser extent.
Despite the significant amount of time and cost, essentially every physician who has been involved with a successful implementation says they would never go back to a paper office, myself included.
I saw recently that a physician insurer is offering a discount for EMR users. Is that common and will that benefit be attractive to fence-sitters?
I believe it’s common. It’s probably not a sufficient amount of money to pay for the software, but it could be meaningful. I was pushing that idea in 1994 with insurance companies to use Kurzweil and structured reporting systems. Physicians who prove they can provide greater quality of care will not only have greater gross revenue due to pay-for-performance, but will also be offered more meaningful malpractice insurance discounts.
Can a one or two physician practice implement a good EMR with reasonable cost and effort?
You used the term EMR either intentionally or not, so I’ll speak to an EMR specifically. Yes. But, you can’t implement a state-of-the-art, easily interconnected EHR with all the bells and whistles and billing capabilities for $5,000. However, if you want to take a substantial step in the right direction and automate reports, absolutely. In fact, a number of those systems are CCHIT-certified, surprisingly.
Speaking of CCHIT, is it accomplishing what it was intended to accomplish?
I’m not positive that I know what it was supposed to do. I feel badly about specialty-specific programs that were not offered the opportunity to be CCHIT-certified. If you wrote a state-of-the-art, phenomenal program for OB-GYN or ophthalmology, you won’t be certified because you don’t have the features they require. Certainly that will change.
I’ve heard scuttlebutt about the $28,000 certification fee and the hundreds of thousands of dollars needed to bring products up to CCHIT specs and whether that has caused a material increase in the cost of software. It probably does weed out some of the mom and pop operations.
I spent a substantial about of time and money developing what I called an EMR that was more of a documentation product. I stopped developing it about three years ago, so I can feel the pain of someone who spent years to develop software that helps people accomplish what they need to in their specialty, but because of CCHIT certification, may be put out of business. Over time, under-funded companies will go out of business.
If its purpose was to give comfort to physicians buying software or to make it easier, I’m not sure it accomplished that. I’m not seeing it. One of the bits of data I maintain from people going to EHR Consultant and telling us what they’re looking for is whether they want a product that is CCHIT-certified. Maybe 20% of our clients say they won’t look at non-CCHIT certified programs. That means that 80% will. Many say it’s of no consequence to them. Smaller offices seem to care less and larger offices care more, but that’s a subtle trend.
You offer a free EMR evaluation service. How does that work and are other companies offering something similar?
I went to HIMSS 3½ years ago and rapidly realized that most mortal human beings would be incapable of learning about the wide variety of programs in order to support them, which is what is consultants do. I decided to do an evaluation. I devised a vendor questionnaire of 600 questions and then asked doctors 200 to 300 questions.
If you look up electronic medical records on Google, a surprisingly large number of responses are from companies that will gladly help you find the proper EMR. My experience is that many of them ask name, address, phone number, number of docs, when purchasing, and not much else. They’ll say, “Here are the top five products.”
Our methodology is that there are dozens of qualified products and not all are appropriate for an individual office. There are a number of cars, Mercedes and BMW, all of which have different styles in the marketplace.
By matching the 200 to 300 questions the physician has answered against the 660 the manufacturer has answered, we can make a qualified match of the appropriate technology. It’s a matter of judgment, but we give large positive grading for EMRs designed specifically for one specialty for somebody of that specialty. In that way, we’re best able to give a good number of very appropriate software program recommendations to each individual physician.
Is speech recognition software underrated in its ability to help physicians save time?
Absolutely. I’ve been doing it and selling it for 13 years. You’re not supposed to take returns of open software, but if someone returned it, I took it back. In 1994 to 1995, I had a 50% return rate. Nobody asks me to take it back any more. You get 99% accuracy. You can speak like a New Yorker. It’s like transcription with no fees.
The sweet spot is a rich EHR. I can click through the physician exam, click through the review of systems and family history, and social history. I dictate the history – how the accident happened, what restaurant they were at when they started choking. The specific factors that make each individual’s history unique are important. Speak those first two paragraphs. Minimize the transcription cost and let the EHR do what it’s supposed to do, which is get good data capture.
I have some confidential information as a distributor. It used to be a meaningful event when a medical group would buy five or 10 Dragon licenses. With increasing frequency, we’re quoting and selling 100- and 500-license opportunities. If somebody bought 10 licenses, then 50, by the time they’re buying 500, they know it works.
What’s the penetration of speech recognition in practices?
Tens of thousands of physicians use Dragon NaturallySpeaking. That’s probably still single-digit percentages, but it’s increasingly rapidly. I have no visibility into the market of companies not selling Dragon NaturallySpeaking. They’re clearly the market leader, but I don’t know the percentages of the others.
We’re a distributor, so we sell to 100 Nuance-certified solutions providers. At the present time, I’m doing an ambitious project, which is finding out from each reseller which EMR packages they’ve installed Dragon with. I’m putting together a series of Google Maps. I can point them to a page on the Web that will have a map point for each qualified, certified Dragon reseller that has experience with their particular EMR program.
I just sent an Excel worksheet to 160 resellers with 362 EMRs listed down the left hand side and a dozen different qualifications across the top: have they used it, have they developed macros, do they help install it, etc. We’ll tabulate that onto Web pages to display that data.
What do you think about AcerMed’s situation?
As I understand it, there was an intellectual property infringement lawsuit that led to substantial legal fees. That was the immediate cause of the demise of AcerMed, not the fact that the program didn’t work. I’ve spoken to people who liked it and people who didn’t.
Functionality didn’t lead to AcerMed’s demise. I don’t believe that CCHIT is in the business of looking at the financial aspects of companies.
Will that event change how doctors look at software?
If you’re a single doctor spending $10,000 or $15,000 on software, I don’t think you need to pull out all the stops. Larger installations spending hundreds of thousands should get financial information and do a Dun and Bradstreet or Hoover’s check.
What changes would you predict in the physician office system market over the next 3-5 years?
There will come a time where a specialist is no longer getting referrals from their general MD because that doctor has an interoperable software program with the specialist across town. When that happens, you’ll see rapid adoption because they’ll need to stay competitive.
You’ll see greater use of non-MDs putting medical information into the history, either the patient or less highly paid people to enter the data, whether a physician assistant or nurse practitioner or medical assistant. I think that’s an inappropriate use of an MD’s time. They should be spending their time diagnosing people. It can be a substantial change of physician time to document an encounter and I think it will be attacked in different waysE
The EMR industry seems to be polarizing, with legacy, expensive vendors on one end and modern, inexpensive products on the other. How will that shake out?
That’s absolutely an accurate depiction. I am somewhat surprised, and I’m not politician, but hospitals are permitted to pay 85% of software costs that are compatible with hospital legacy systems. I was expecting to see a sea of change where legacy systems would run over these new companies. I haven’t seen the new companies being quashed like I expected.
What does that mean?
New companies that are selling 10, 20, 50 million dollars of software a year in to medium and increasingly larger practices have a very bright and rosy future. As I think should be self-evident, I do analysis for physicians for free, but I have some referral agreements with a very few vendors. I’ve been doing this for 3½ years and I used to get an intermittent check from these companies for sales to a one -or two-physician practice. Now I’m seeing small companies selling to 10-, 20-, or 100-physician practices.
Are they taking away business from the legacy vendors or selling to first-time customers?
In 2010, they’ll be taking their business away. I don’t think that the current sales being made in physician offices for a few thousand dollars would have been made for $75,000 if the smaller companies weren’t there. Those sales would not have been made.
If I were a large public company with product installed in hospitals, I’d rapidly provide an inexpensive offering to the local physicians to stay competitive.
So you like the Misys-iMedica deal, where Misys will resell the small vendor’s product instead of developing their own so they can get to market faster?
From Misys’s perspective, it was the proper thing to do. I have the pleasure of having thousands of offices telling me what they like or don’t like. Misys will likely benefit from having a new, up and coming, recently written, capable software program. They’re a billion-dollar company with long marketing reach and having a product that physicians are happy to use will be a welcome opportunity for them.
Will the smaller vendors be bought by the larger ones who worry about the competition?
I don’t think big companies will buy them because they’re a threat. They will buy them because they provide an opportunity.
I live in the same county that Dr. Notes was headquartered in. I was appointed by the bankruptcy court to sell the company’s source code to its .NET version. They had a Windows-based program and were allegedly 90 days away from shipping a .NET program. They went into bankruptcy and I’m helping sell the 400,000 lines of code.
I sent 360 e-mails at 9:00. By 9:01, I started getting responses. People from the up-and-coming companies wanted to buy the code. They wanted a billing module, which Dr. Notes didn’t have, or wanted their customers, or wanted their code.
Then, I noticed that the people calling me were saying things like, “Well, Dr. Fishman, since you seem to be in the business of buying companies, can you find someone to buy mine?” That happened dozens of times. Others said it wasn’t exactly what they wanted, but wanted to hire me to find them an ASP CCHIT product within 30 days.
There will be a lot of churning of these 1, 2, and 5 million dollar companies in the near future. That’s a particular interest of mine. In next EHR Scope, we have half a dozen pages about recent transactions written by an investment banking firm.
Was it a surprise that McKesson bought Practice Partner?
Andy Ury did a great job having a company of McKesson’s stature helping them do the marketing. I don’t have any insights into McKesson. The phenomenon of having billion-dollar companies snapping up EMR companies with eight-figure revenue will continue.
Do doctors like the idea of personal health records?
I don’t think it’s happening in doctors’ offices. Companies are interested.
I’m potentially involved with a PHR company and a clinical practice guidelines company interested in getting more entrenched into the personal health records. I think it’s something that will be very important and I’m surprised it hasn’t taken off more quickly. I stopped practicing 3 1/2 months ago and had zero patients express interest in interacting with me in that way. It’s not happening yet.
What about Google Health’s rumored PHR project?
It amazes me what Google knows. I think if they set their mind to it, they will do it. I understand they had some change in staffing at that level. I’m not qualified to offer an opinion as to whether they will or won’t do it, but I spend money advertising on Google and thinking about their algorithms and how much they know about people.
They certainly have the computing power to enter this space and pharmaceutical companies spend tens of billions of dollars in advertising their products. Google would certainly be willing to accept some of that.
A magazine just released its 100 Most Powerful healthcare people. If someone asked you, “Who are the most powerful and influential people when it comes to physician use of software,” who would you say?
The CEOs of those dozen up-and-coming EMR companies that I refuse to name. [laughs] They are involved in determining what the software that they’re producing will look like. They are profitable companies with millions or tens of millions of dollars of free cash flows without the shackles of having it burdened to something from their past.
They will decide whether to encourage or discourage interaction with patients, like personal health records or smart cards or thumb drives. They have the resources and knowledge and motivation to be in the doctors’ examining rooms around the country showing how healthcare will be delivered. They have the wherewithal to acquire technology, like clinical practice guideline technology, and integrate it in their software.
I know a little about nanotechnology. A friend asked me where to buy a portfolio of nanotechnology stocks, but they’re mostly privately held. If I could invest in a portfolio of smaller EMR companies, I’d do it in a heartbeat. You could reasonably choose a handful that will be successful, though I can’t pick them all, but the small ambulatory EMR industry will do very well financially.
My specialty is the smaller office, but two weeks ago, I got call from hospital CIO with 525 physicians on staff. He mentioned two legacy EMR systems they were interested in. I mentioned a couple of smaller systems and there appears to be some interest. Some of these up-and-coming players may play a role in hospitals
What about retail medicine?
I don’t want to grow old and decrepit in this country because healthcare won’t be as good as it is today. Retail healthcare is here to stay. Healthcare should be touching and care, but it’s clear that retail clinics aren’t going away any time soon. I don’t get my care at one.
Will retailers develop their own software or buy from those sexy companies?
I have made successful introductions between retail pilots and one or more of those dozen hot, sexy companies I won’t name. I don’t mean to be evasive, but I have relationship with those companies.
If an HIStalk reader is interested in ambulatory EMRs, what information do you provide?
EHR Scope is a free publication, over 150 pages, and the next issue is in October. It has a meaningful amount of information on over 200 ambulatory products. It comes out in a PDF and if somebody’s a cardiologist, they can search cardiology and find systems appropriate for them. They can quickly get their Web sites and contact information. I think it’s a very valuable resource. The electronic version is free.
Any final thoughts?
I love what I’m doing.
I think if you'd look at the recent hearings, VA was saying Cerner would require a 10% increase in staff…