DrChrono (YC W11) Makes The iPad A Doctor’s Best Friend In The Exam Room
techcrunch.com
techcrunch.com
1) A majority of doctors are in small private practices
that reinvent the wheel of how they run their practice.
2) All of these doctors are extremely pressed for time
and are practically _always_ behind schedule.
Record keeping is to doctors like text editors is to us hackers. Imagine if a doctor had built your text editor; They're probably very smart and energetic, but they don't really understand your problem and how much you personally need specific things just so.
CR-48 will not be able to detach from keyboard. Everything will be designed to support a touch screen interface; input devices will be external.
But I'll admit that speech-to-text has good potential for information recording, as long as it is reasonably accurate and provides an easy way to correct errors & omissions.
I have before me a ~1 kg laptop with an actual keyboard on which I can type notes almost as fast as I can speak, hold in one hand as I see a patient, with speech recognition already installed, local secure printing, sensitive data that lives in my office and not on your remote server farms, a hard drive that I own, can copy and share as needed, and can keep as secure as I like, and applications which do not require constant secured access to server(s) whose reliability and security I have no control over.
I love the iPad for a bunch of stuff. I own two. I'm an early adopter of all kinds of this type technology. I love toys.
But I'm not getting the "revolution" part of this beyond, forgive me, somewhat breathless and vague marketing hype. Tablets have been around a while and not caught on with physicians for a whole variety of reasons that you folks seem oddly unaware of.
Sincerely good luck with this, but you're not solving any problems for me or any physicians I've talked to about it.
The iPad was a revolution in exactly the same way the iPod was a revolution. It had a more accessible UI and made trade-offs to be a bit slicker than what was out there, but they were the right trade-offs which were needed to take it to mass appeal. It's a good product, and it will revolutionize tablet use, but not because it's a massive technical improvement.
Can you give us a citation of how you got that number?
The estimate is that there are less than 1 million doctors in the US. http://online.wsj.com/article/SB1000142405270230450690457518...
And before October 2010, about 8.25 million iPads were sold - that number is probably way outdated though. http://www.tuaw.com/2010/10/07/estimates-vary-on-number-of-i...
anecdotal evidence from the conference of 30,000 orthopods in San Diego last week, that seems very plausible.
This lets the doctor move from paper to an EMR with a very similar workflow, but still gives the benefits of having the data stored electronically and getting clinical benefits like having drug-drug interaction checks on the patient's medication list.
Frankly, with a full-size keyboard I can't type fast enough or click fast enough to keep up with my mouth and ears and fingers and eyes, so dictation would be awesome, but I don't see how to get that started in the iPad app.
I still haven't figured out the forms...
As I did my research, I reasoned that a Dragon Dictation-esque solution may be best. However, such a solution already exists. And built by Dragon Dictation too, coincidentally.
It's a very efficient solution for doctors in case #2. They can just dictate their patient notes to an audio recorder, and the software is intelligent enough to sort it out appropriately, with perhaps 80-90% accuracy. However, for patient records, you need to have it at 100% accuracy, otherwise you could face medical malpractice. So the current products require doctors to review their notes on a confirmation screen on their handheld tablet devices (yup, it's on a tablet device much like an iPad). The result? Most busy doctors just hit SUBMIT without reviewing their notes, and their 80-90% accurate patient notes get recorded. Medical groups saw this behavior and have been moving away from these types of products.
I'm gleaming over a lot of details, but this is the gist of what I found. This is definitely a problem begging for a solution, so I wish DrChrono a ton of luck in solving it.
Hospitals and doctor offices are two completely different markets with very different needs and scales. Speech to text doesn't address managing a doctors appointment book, communicating with patients, giving drug-drug interaction checking, etc.
Good luck with the speech-to-text feature! I agree with niels_olson that text entry on a touchscreen is painful. I'm glad to hear you've already got a solution in the works. Best wishes!
I know that for an app like this doctors are probably looking at functionality first, but it'd be nice if one of the first iPad apps in this niche actually looked decent. Right now it looks like Interface Builder exploded.
We are releasing a new version of our iPad application roughly once a month and we are always working on making it better. I think we have a better UI than any other medical company out there, but that isn't hard! It is like playing basketball against Junior High School kids.
If you know a designer who could help us email me and put me in touch with them as we are rapidly expanding the company!
1. Doctors can be extremely cheap. I had to port over a legacy dial up system because the doctors would refuse to upgrade to high-speed.
2. The entire industry, at least here in Canada is ass backwards. It takes ten people to do a single task. You will run into having painstaking long conference calls
3. Multiple standards. Every provider has there own standard that sometimes overlap.
4. Older doctors barely know how to use a cell phone, let alone an iPad. Luckily these doctors are fading out fast.
5. Market to the secretaries. They will pitch to the doctors anything to make their life easier.
Good luck guys....hit me up if you have anymore questions.
A home run offering for our environment would include a migration path for data from years (and many thousands of patient's data) currently in a patched-together system with 40 years of duct tape holding it all together. Top it off with a massive dose of free text data fields (so no easy field extraction) and you're looking at a huge custom effort to pull it off.
But . . . I think there is room here for something that does something nice with machine learning and NLP. Some folks looking into this have found that even free text in path reports contains a significant amount of exploitable structure from a data mining perspective.
And once you solve the migration, you'll have to go around the heavily entrenched IT groups holding the duct tape. But, it would be a big win for patients and most physicians are looking for a better solution . . .
The fattest IT guy I ever saw worked database administration for a university hospital. He had his own elevator to his own floor of the building, and you needed a key to get on the elevator! In 2009 that hospital was still using meditech, and still using it on dedicated terminals with orange monochrome CRTs.
The Gov't will be the first one to bear culpability if they push too hard on this.
Riiight.
Meanwhile, I have seen IT departments sell physicians on obviously flawed security products, mainly because few physicians have any idea of what crypto is, let alone could they explain the most basic ideas. And frankly, they are not competent to even hire competent IT people. Whole university systems seem have this problem.
I'm mostly curious about the web stack and technical implementation:
* Encryption in transit (SSL) and at rest (whole-database encryption versus field-specific encryption)
* Select auditing (and performance thereof)
* Open-source stack?
I'm a pathologist so I'm primarily interested in interfacing with existing LIS (lab info systems). I'd like to pursue efficiency solutions for the laboratory (like dashboards, specimen tracking, lab ordering, intra-lab communication).
Of course, it's all moot with respect to my day-job because I work for the military and they mostly piss on open-source (MS all the way!) with no real path for putting applications on NIPRnet (yes even at the hospitals) without enterprise-level support and multi-level security audit/approval. Which explains why in the age of digital pathology, we are stuck entering pathology information over ssh (terminal emulation) into a MUMPS system.
http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyr...
>they mostly piss on open source
At the top, they guys with stars who sign off the contracts, yes. On the other hand, I was just on the phone yesterday with a Navy cryptographer who is working with Google on NIST certification of Mozilla's Network Security System (NSS) for FIPS 140-2 compliance. I think getting the network changed will ultimately come down to smart people like yourself continuing to beat the drum.
BTW, I'm military too! I know CHCS and AHLTA all too well. email me: niels.olson at gmail
drchrono takes security really seriously! The Doctor is our only customer and we always use encryption and security standards to make sure no data is ever compromised and never shared with any 3rd party.
Healthcare information is even more important to keep private than financial information. If you were bankrupt 5 years ago, nobody cares (you could be a millionaire today.) But if you had a serious medical condition 5 years ago, that still affects you for the rest of your life and could be used to unfairly discriminate against a patient.)
In addition to following HIPAA standards, we are in the process of getting certified for Meaningful Use criteria by a 3rd party government certified laboratory for security and encryption standards.
Bring on the tech! I'm tired of having doctor visits where I have to re-state my history when they can read it in a second, and they're tired of lengthy reviewing of my data before the visit (if they do so at all). The only complaint I've heard from the doctors / nurses (and I've asked every single one I've encountered with them) is that they hate using a pen and hate the interface (missing the maximize button and closing the application, for instance).
The nurses in particular loved that the doctors typed. Universally, they've said they had fewer medication errors, fewer "what is that?" questions for the doctors, and they get a bit of history and can see abnormal changes and question them in case of a mis-type. Which happens, but usually goes unnoticed if it's not on a computer.
YMMV, of course. And theirs.
Billing and medical: why do they belong together? I doubt the doctor is also the accountant in even the smallest clinic, and they have no need to see the information. It's more noise, doesn't help them, and can influence their perception of the patient in front of them.
In the office, tablets should be used to review patient data, but the physician should probably not be entering any data - such as writing up the progress note or billing - while in the exam room. This takes away from the physician patient relationship. So to review data, tablets can be helpful, but are not exactly revolutionary. Real changes in how healthcare is delivered will be determined by how data is collected and how it is interpreted (like the Crimson Initiative).
Still, considering that EMR systems like AllScripts are charging over $600 a month PER physician (and that's at a "special" discounted rate for a few years), it's nice to see companies like DrChrono taking a stab at it, to see if they can offer something better, or equally compelling, for a cheaper price. A lot of existing EMR systems are bloated with features that most physicians will never use, and don't even really fully understand.
I personally think DrChrono is going for a diminishing slice of the healthcare pie. The current trend in healthcare is that a decreasing proportion of physicians are working in small private practices - the cost of healthcare infrastructure, logistics, and billings means large practices and hospital based have significant savings on scale and tremendous bargaining power with insurance and etc. This kind of app, with the appointment scheduler and prescription system, seems very much geared to small private practices.
I imagine this kind of system will make limited leeway in large healthcare practices and large academic institutions - this is the difference between enterprise software and web applications. Epic and the like, despite being aesthetically unpleasing and rather cumbersome, is dominating this segment of the market. It's not even a question of cost - these solutions cost much more than competitors, but there is a perceived level of stability and a proven track-record. In both culture and priorities, I think YC companies are not as well prepared to offer enterprise solutions. Large institutions are fickle, full of politics, and without a dedicated sales team, difficult to sell to.
They are definitely going for the "meaningful use" incentives as part of healthcare reform - the healthcare reform gives physicians incentives to adopt an EHR (electronic health record) system and going for the sex appeal of using ipads - but I am wondering if that is enough incentive to adopt an electronic health system. Personally, I type 1000x faster on a keyboard than with an iPad, and speed would be an consideration - ie. even as a physician-in-training (hypothetically with comfort in technology), I would have to look hard to decide whether to use such a system.
As a medical student, don't think there is enough of an market for general primary care physicians and not enough specificity (currently) to most subspecialities. There are a lot of older physicians that have limited comfort in medicine. I would imagine there is a good market for concierge medicine practices - the kind of places that already have iPads and are interested in distinguishing themselves from the market.
There is a multi-billion dollar per year market in selling EHR services to the private practice doctors we all see everyday.
Large hospital level systems are designed for hospital admins 1st, doctors 2nd; they are widely hated even in hospitals and unusable in a small practice.
We are launching a speech to text integrated product in the coming few weeks that will remove the need for most typing on the iPad.
http://www.nejm.org/doi/full/10.1056/NEJMp0808076
Most numbers I have see range from 50-60% in small to solo practice, while I would argue that this is a lagging indicator - a lot of older physicians are in solo practice and seeking to pass on their patient panel. It might be more interesting to see where current residents are going after graduation. That said, there is still a large market and I think it's definitely something that should be pursued. Good luck!
Have you ever heard of live scribe?
http://www.livescribe.com/en-us/
It's this cool pad thing where the paper is timecoded. You write on the paper, and draw, with a special pen, and it records sound along with the time code. If you're familiar with Serato Scratch Live it's a similar concept to that - basically taking a "real world" interface and semi-digitising it using some form of time encoding.
Speech to text is HARD and what's worse is inaccuracies in a medical field could result in some really serious consequences (misdiagnosis, improper dosage, incorrect medication being prescribed etc.)
Doctors are pretty used to shorthand, and also my understanding is they quite often have a typist for dictations - perhaps an alternative to speech to text is to record speech by proximity in time to what has been typed. That way they could be saying something, take minimal notes but have a sound file linked to those notes. That way they can elaborate on the notes later if required, but also if they go back to their notes and can't remember what the hell they meant when they wrote "PKR instead", they can touch "PKR instead" to hear what they were saying at that time in the conversation, and fastfoward, rewind to get the context.
We have a really good relationship with Apple, and we are one of the killer apps that make doctors go out and buy iPads. We launched on the iPad initially within a month of its release and work closely with Apple to make sure we comply with security and Apple standards.
So it is unlikely Apple will yank our app. We do have an Android phone application frontend and we can invest more in Android tablets as they evolve in the future.
The market has been BEGGING for this, and this looks like it might be the right answer. Good luck!
An example of a huge electronic benefit you can't get on paper charts is drug interactions. drchrono can automatically check drug interactions and warn the Doctor in realtime based on latest available clinical information and drug warnings. My parents take 20+ prescription and non-prescription drugs each, there is no way even a genius Physician would be able to process that number of associations at first glance of a paper chart.
The risk of misentered information being accepted as factual because the computer presents all information in the same way is a very real risk that has to be addressed and have safety nets put in place to scrub and check for these errors. One cool way we are tackling this problem is launching an industry leading speech to text processing system in the coming weeks. Letting Doctors record their notes and have an automated transcription can give a safety net for errors.
So, maybe you should design the interface good enough that docs want to use it but not too good that they use it all the time. Or you can put some alerts in there so that when the doc has been watching too many videos, it reminds them to look at the patient..... just kidding....
Even if there are other benefits associated with it such as being SaaS-based and cheaper/more secure, the conversion rates I would think would be low when there already exists free cloud based solutions and open-source solutions which they haven't already converted to already.
Thus, this makes me think the target market would be the pen & paper crowd. I'm curious to see what the conversion rate is for this crowd since this seems like a tough crowd to convince.
Even in scenarios where the EMR/EHR system is completely free (either through pricing plans or government grants) you don't see many of them moving away from the pen & paper which signals price might not be the most important factor here either.
To me this leaves overall usability and learning curve which I'm not sure if DrChrono necessarily promotes as their pitch seems to be portability.
I'd like to see how their product matures to tackle that issue since in my opinion their competitors really aren't other EHR vendors as much as the huge pen & paper market that's a much larger share of the pie.
Just wondering if you have thought about integrating into the big bulky industry standard type software? (of course I could be off on what most hospitals use, sample size of 1)
Centralized planning never has and never will work as well as a decentralized market driven system where the best ideas can rise to the top.
Dr Chrono may have its drawbacks, but I'd rather see my physician make that call instead of some over-age government bureaucrat.
Maybe a dr would pay $99, but the first HIPAA lawsuit they are going to spend $99,000+ defending all due to software.
I also have to admit that DrChrono reminds me of Dr Mario Nintendo game..
Fucking programmers.
Somehow I doubt an iPad being clutched in the doctor's bosom as they read it is anymore a violation than that.
Our price point for advanced features and integrated billing is also better than any competitor, $199/month to do all of a Doctors medical billing will save a Doctor thousands of dollars a year (in addition to EMR incentives!)
Works pretty well for doctors surgeries anyway.
But I have no idea how things work in the US so maybe it's completely different.
Computers are always an afterthought in most Doctor office setups, that is why they seem to be universally built into walls or tucked away into corners.
And if you'll forgive me, I have a hard time believing an app like this will drive pad adoption by physicians. Most docs have pads because, well, they just like toys.
Some docs have used laptops, which are a lot easier for data entry than these pads, and these don't require turning away from the patient either. In my experience, it's not common for physicians to write their progress notes in the room with the patient. Certainly writing a prescription and sending that to a pharmacy directly makes sense in the room, but there are classes of prescriptions where that cannot be done. Looking up drug interactions may be useful, but dedicated applications like eProcrates and other dedicated apps probably have become standard for that and I'm not sure I'd trust an "everything and the kitchen sink" app like this more than dedicated solutions (eg, these drug interaction databases require constant updating and care).
Billing info and medical data combined on a view is a no-go, if that's there. They don't belong together. Period.
Probably most importantly, most of us would need details about security of the transmission and storage of medical records before considering this at all. Someone said below this app is "HIPAA compliant", but I'm leery of that overused phrase because the HIPAA requirements are quite vague, and as far as I know there is no actual certification for something like HIPAA compliance. Vague claims of "HIPAA compliance" are likely NOT going to impress or satisfy juries and medical licensing boards. In addition, some information (depending on the state) requires more stringent care; for example, mental health records, record of drug abuse/dependence, etc. Hospitals and clinics typically have dedicated IT departments who put into place much more security than HIPAA requires. If someone hacks a system like this, the fact that you require passwords and do some encryption is not going to cut it if you can't demonstrate you are using standard of practice medical record security measures.
Specifically, many physicians would want to know, at a minimum, complete details for:
- backup, recovery, and retention policies for all data.
- logging mechanisms in place to track access and change of data. By "access" tracking, I mean a record of every last living creature who views the data, at any time, for any reason, and that includes everyone at "DrChrono", the employees of any firms that manage their servers, etc.
- audit mechanisms and schedules.
- policies Yet Another Third Party ("DrChrono") would have in response to subpoenas, direct request from patients for their medical records, requests from insurance companies, etc.
However (and I'm waxing philosophical here) people don't come in to hear information from their docs as much as they come in to be heard by another human.
Good docs ain't in that room with you to check off whether you had your oil changed and tires rotated, which tasks do seem like something a pad or laptop can be helpful in noting (paper does it just as well, however, and doesn't end up on the web).
Data capture just isn't the big problem in all this. A major problem is developing novel, innovative and SECURE ways to track and make USE of that data for the benefit of patients.
This brings up the very real issue that this is not just a fancy secure email app like hushmail where the data is stored and transported encrypted: here the data will live on the server decrypted at least transiently to build those novel ways to "track and make use of".
drchrono takes security really seriously! The Doctor is our only customer and we always use encryption and security standards to make sure no data is ever compromised and never shared with any 3rd party. Healthcare information is even more important to keep private than financial information.
In addition to following HIPAA standards, we are in the process of getting certified for Meaningful Use criteria by a 3rd party government certified laboratory for security and encryption standards.
All of the data put into drchrono belongs 100% to the physician! We host and secure the data for the doctor and can provide encrypted backup files with all of the doctors information for their own use and backups.
We are licensing our clinical data (like the list of drug-drug interactions) from industry leading data companies (the same ones that all vendors in the healthcare space are using.) There is very little difference across vendors in this regard (the challenge lies in presenting this information to doctors conveniently and providing an integrated solution so the tools are with the doctor when they need them.)