Dr. Michael Stearns, President of e-MDs, sits down with Dr. Eric Fishman to discuss a variety of issues. e-MDs has grown to over 19,000 users and expects continued growth due to its powerful functionality and the recent HITECH Act. Stearns addresses some of the features the e-MDs solutions offer, such as a patient portal, and the fact that it has won a variety of honors from various medical societies.
Category: EHR Press
Date: April 20, 2009
Dr. Eric Fishman: Dr. Eric Fishman for EHRtv. Today, we have a special guest, Dr. Michael Sterns, President and CEO of e-MDs. e-MDs is an electronic health record company founded by Dr. David Winn in the mid 1990s. And Dr. Sterns, would you be good enough to tell us a bit about how the company was founded originally?
Dr. Michael Stearns: Yes. David Winn, a primary care physician in Texas was trying to find an electronic medical record back in the mid 90s and he couldn’t find one to his satisfaction so he built his own kind of a primitive tool but it was effective enough for other physicians to be interested and they asked if they could get it in their offices. So we hired some developers and it started out very slowly and gradually gained momentum. Eventually, the program was being written by developers on the second floor of a clinic and on the first floor, they're practicing medicine. So it develops an opportunity to see really how medicine was practiced and the live input from several physicians to get the program started. So it really had its roots in clinical medicine where developers were involved almost at the point of care with designing the product.
Dr. Eric Fishman: So that was in 1996 and Dr. Winn was practicing medicine and having the software developed for his own office and he had, I imagine, one customer if you will and take us now over the next decade or so. I understand that you've got a substantially larger customer base.
Dr. Michael Stearns: Yes, we've steadily grown. We have physicians using our product in 49 states. We have about 19,000 total users. We're up to about 170, 180 employees right now and we anticipate some very dramatic growth in the next couple of years with the new incentives. We are doing very well and objective evaluations have been done by the groups such as the American Academy of Family Physicians and the American College of Physicians and the American Academy of Neurology are three very respected organizations which have taken an in-depth look or at least in a survey of electronic health records and we've been right at the top of that.
That has led to a lot of interest in our company and we've seen a very substantial growth over the last few years. We average about a 16 percent increase in revenue each year which has been well sustained. However, we're anticipating much greater growth in the next couple of years through the incentive package.
Dr. Eric Fishman: So this incentive package, the stimulus package, this is part of President Obama's $787 billion package and I understand that there are quite a few billion dollars that are available and I guess it's the HITECH act that is available to stimulate the adoption of electronic health records. I understand that you've had a lot of experience in politics. You've spoken with a number of congressional offices for instance. Tell us about your understanding of the stimulus package.
Dr. Michael Stearns: Well, our understanding of the stimulus package, and this was supported by HIMSS, is that the congressional budget office is estimating there's going to be about a $36 billion outlay of funds related to the incentive package for physicians. They're hoping there'll be a tremendous number of savings towards the end of the stimulus package outlay and the net benefit is going to be $19 billion.
Dr. Eric Fishman: So we hear $19 billion over and over and over again and as I understand it, that is the difference between the total amount of money that will be spent by the federal government in incentivizing physicians to acquire this technology, to put in some framework, to get the HIEs up and running and the savings that the government is anticipating getting from that $36 billion.
Dr. Michael Stearns: That's our understanding at this time and these are all estimates as what the outlay will be. It will depend on how many physicians partake, become meaningful users, et cetera, but yes, that's the rough estimates right now. That also requires there be very substantial savings of roughly $17 million dollars which I anticipate will not occur in the early phases of the incentive program however, this will start to kick in later.
Dr. Eric Fishman: Now, you've mentioned physicians a number of times. Let me go back to your company of physicians. Dr. Winn, a practicing physician for many, many years is the founder of the company. You are a physician and neurologist by trade, you probably have other physicians in the 170 employees as well certainly if you're developing software for physicians, it's helpful to have physicians developing it. Can you tell us about them?
Dr. Michael Stearns: We have the founder and chairman of the board, Dr. David Winn, who's a family physician and he still does some missionary work mostly in Mexico. Otherwise, he's primarily retired. We have myself, I'm a neurologist and I've been doing informatics and EHR's for about the past 10 years. I got started with the National Institute of Health working on a national medicine project helping the pubmed tools that do literature searches which a lot of physicians are familiar with. I also worked at the National Cancer Institute starting a research database for tracking how research dollars are being spent and also helping to identify new research opportunities and that's called the NCI ____Source.
Then I was recruited by the College of American Pathologists to work on a project called Snomed CT and I was instrumental at the center of bringing together a very large British medical terminology design for computer usage with an American version and that became Snowmed CT and the U.S. government purchased rights to that for about $35 million I think it was over five years ago and now that's evolving into the international standard of medicine.
Dr. Eric Fishman: Now you'd told me many years ago about your involvement in Snowmed and Snowmed CT. Can you elaborate a little bit more on why databases of that nature are of critical importance in improving the quality of medical care?
Dr. Michael Stearns: Absolutely. Well, ICD is the one that everyone uses right now, but one ICD code can mean many different concepts. So it's very difficult to use ICD codes to get realistic data from databases that are using HR's.
Dr. Eric Fishman: And so the ICD is the International Classification of Diseases and I think we're up to ICD 9 and people are talking about ICD 10?
Dr. Michael Stearns: Right.
Dr. Eric Fishman: And maybe you can give us an example of an ICD code that would lead to confusion but where Snomed or a database of that nature might be able to segregate them out to different conditions?
Dr. Michael Stearns: Yes, a good example is pelvic pain for gynecologists, a commonly used term. There is no code in ICD which matches pelvic pain so doctors are forced to choose either the non-specific code for I think it's female reproductive organ systems symptom which is very non-specific. It could mean a large number of different concepts. There's also left lower quadrant pain and right lower quadrant pain of the abdomen which doctors can use any three of those and it all really means pelvic pain for billing purposes. However, if you're trying to evaluate a database for research purposes, you really don't know what you're pulling if you use one of those codes.
Dr. Eric Fishman: And so if you're trying to figure out what type of treatment is appropriate for what type of condition, it's way too generic to just say pelvic pain or right lower quadrant pain and be able to determine whether they should have had an appendectomy or an ovarian condition was being treated.
Dr. Michael Stearns: Exactly. And there was an interesting article in the New York Times where they compared baseball managers to doctors. Baseball managers now have statistics. They have valuable data to use and they're able to, at a very relatively low cost, have much better performance - the ones that have chosen to go this path - because they have real data to use in the evaluation of the performance of their athletes. So they make decisions based on this clinical evidence you can almost call it where doctors are more shooting from the hip, basing their decisions upon what they learned in medical school without the data and evidence to back it up. And that was a significant part of the incentive package which was of great interest to me because there is funding now for efficacy studies.
Dr. Eric Fishman: So that brings up the entire subject of EBM or evidenced based medicine, quality improvement and I understand that not only do you personally know a lot about that but that e-MDs if you will, prides itself on being able provide better quality care to the patients when a physician is using that product. Maybe you can give us some specific examples of how a physician using e-MD's can provide better quality care than one without e-MDs.
Dr. Michael Stearns: That's a great question. The advantages of the technology primarily we've seen in medications where there is the "To Err is Human" was a report published by the Institute of Medicine about 10 years ago now, but they estimated about 100,000 lives are lost each year. Now, if you're going to take advantage of the technology, you have to get doctors to actually use it. So it has to be a very usable product and that’s where we think we excel.
We have very high ratings in usability, ease of use. Our goal is to get the physicians to use the product and then almost by secondary nature, the patient care is going to be improved. At the time you are writing a prescription, the tools will provide you with information that maybe there's a contraindication for the medication. Maybe the patient is allergic to a drug or there's a cross-reaction with another medication. Maybe there's another drug the patient's on which is a contraindication and maybe the patient has a disorder which is a contraindication. Physicians using the product will occasionally get (inaudible) it's kind of a backup tool. The VA for instance when they implemented their electronic medical record recently reported they saw an 80 percent reduction in medication errors from before they had the electronic health record to when they have it now.
Dr. Eric Fishman: Now, you've mentioned the American Academy of Neurology, the American Academy of Family Physicians and other austere entities that have done studies and I imagine that these are queries of their members as to which electronic health record programs they're using and how they like them. And in these studies, I would anticipate they're quite a number of different electronic health records that you are compared against. Are you able to give, in addition to the qualitative information that e-MDs ranked well, can you give us some specific indications as to in what methods, what manners e-MDs ranked well?
Dr. Michael Stearns: Sure. The AFP, the American Academy of Family Physicians study is available online and it compares how about 13 different vendors did in a number of different settings. It looks at ease of use, evidenced based medicine, more data collection, and it looks at immunizations, prescription tools, a long list of things and kind of looks at the responses to members to how highly they ranked these tools. That is a very valuable survey especially for primary care physicians, family physicians.
The American Academy of Neurology, for the last three years or for three years, they did an in-depth evaluation of products. They selected the tools they thought were the best, the EHRs that were the best and they gave a script. And it was like taking your oral boards over again getting in front of about 15 members of the Academy and they did in-depth evaluation of the product and asked a lot of tough questions and then rated you afterwards. So that's very useful.
The one that's really very under recognized, which CMS felt when we talked to them, was probably the best one available, is the American College of Physician's study.
Dr. Eric Fishman: Tell me about the ACP study. I understand that that was done in a more sophisticated fashion if you will.
Dr. Michael Stearns: The ACP program they did was called the HR Partners program I believe and it's only available to members unfortunately. It wasn't really promoted by the ACP outside of their membership of course. But when it was looked at objectively by others, like CMS, the Centers for Medicare and Medicaid Services, they were looking for objective information to share with doctors and they heard about this and they thought it was great, very interesting and they're considering using it as a reference tool.
Dr. Eric Fishman: When was the ACP study done?
Dr. Michael Stearns: They did one last year. They had only limited enrollment. They had five, what you might consider top tier vendors, evaluated. The evaluation they did was they sent out a request to members for them to participate. Then they did not allow however members to call in and say I've got a great EHR which eliminated a lot of bias because that way, the vendors couldn't reach out to their internists and say please call and fill out the survey to make us look good. So it was much more objective than the other evaluations that have been done in the past. They also went on site visits. They went to a clinic using that particular tool and evaluated its performance and did a nice write-up on that for each vendor.
They also did an RFI so they evaluated what the vendor stated the product could do and got background information on the vendor so it's a little bit more vendor marketing. They also identified key things in the RFI that they felt would be of value from their standpoint and they did an in-depth online product demo. Each vendor had to do that. So they had four components that were very solid. The survey was the one really where they compared the features and these are based on the internists using that product's rating of how it worked and they had up to four stars. Nobody got four stars, including us unfortunately, but we were the only one to reach three stars.
Dr. Eric Fishman: Very good.
Dr. Michael Stearns: The other top tier vendors all reached a two-star level and that study's available to ACP members.
Dr. Eric Fishman: Understand. Speaking about features, can you tell me about some specific features of e-MDs? For instance, I'm particularly interested in a patient portal, or the ability for patients to interface with e-MDs, possibly from their own home for instance.
Dr. Michael Stearns: Yes, that's a great question. We have our patient portal which is very popular. The thing the docs identify right away is the ability to get a normal lab value, say a normal pap smear. Just click a box and that information goes to the patient so they don't have to get staff involved with sending out normal results.
Dr. Eric Fishman: That must save a tremendous amount of time for the office and also give great patient care.
Dr. Michael Stearns: Right.
Dr. Eric Fishman: Are patients also able to, for instance, make appointments, change appointments online?
Dr. Michael Stearns: Yes, make appointments and they're also able to fill out the history. We use another companion product called Instant Medical History, where patients can do their own HPI, ROS, past medical history. It's really nice for say, mothers with small children. They don't have to bring their kids in to run around the waiting room. They can fill all that out before they get there. So it really makes it more efficient for them once they arrive.
Dr. Eric Fishman: And so it would seem as if a patient can get at least the same quality of medical care, if not better and spend less time in the actual office?
Dr. Michael Stearns: Exactly. This also supports e-visits which is an emerging trend. CMS is not paying for those. I recently gave a talk to the American Association of Professional Coders on this. It was an audio program televised nationally just last week. The e-visit trend's basic concept is there's a fee that a patient pays for using an email interaction with a physician. But the value to the physician is not so much to get a big block of unstructured text, it's more to get some structure. So if patients are using some sort of algorithm and this is where this instant medical history in the patient portal program seems to offer a lot of benefit, docs can review that in a very short period of time and they say, get paid $25 for that visit and it saves the patient the trouble of coming in.
Dr. Eric Fishman: Certainly.
Dr. Michael Stearns: Now, there's a lot of issues around still a new technology and there's some concerns medical, legal et cetera about how this is going to work of course but the ideal setting might be one doctor said I've got female patients who are prone to urinary tract infections. They know exactly what it is. They come in, they get seen and they get a UA and it's always positive and they would be comfortable potentially with, in certain situations, managing that through an email correspondence.
Dr. Eric Fishman: It certainly seems much more efficient and saves the federal government a lot of money if they're paying the bill. It saves whoever is paying the bill a lot of money.
Dr. Michael Stearns: And interestingly, it has the potential to generate additional revenue for physicians because they can very efficiently go through and they can also do it when they have time available. So if a patient doesn't arrive for a visit, the patient cancels and they have an opening in their schedule they can manage the visits. So that's an evolving trend but I think that potentially has some value for the whole health information technology implementation.
Dr. Eric Fishman: I understand that e-MDs is very well connected with a variety of different entities outside of itself such was with respect to the RIOs or the DHIEs and maybe you could explain that a little bit.
Dr. Michael Stearns: Right. The first part is the access to medication history (inaudible). The second part is the conduit care document which is the --
Dr. Eric Fishman: That's the CCD?
Dr. Michael Stearns: -- CCD. Right. And that right now is kind of the fundamental underpinnings of the HIEs, Health Information Exchange and the RIOS. If you're certified, if there's a certification commission for health information technology the CCHIT, they certify products each year. And in 2008, the most recent one, if you're certified in that, you have to be able to send and receive this information packet called the CCD.
Dr. Eric Fishman: And can you tell me the relationship between CCD and CCR?
Dr. Michael Stearns: Right. CCR was the original kind of communication tool developed I believe by ASTM and it was a huge breakthrough in the ability to communicate between enterprises. We adopted the CCR right away. I think Google Health's adopted the CCR and it's still an actively used component. However, there's some conflict between the HL7-CDA and that was eventually resolved and what came out of that was a combination tool called the CCD. The CCR is Continuity Care Records, CCD is Continuity Care Document. So CCD now is a required standard and this is where it's mandated now that if you have a current product and it says acute care vendors as well as ambulatory vendors. Acute care vendors I don't think they're required this year but they're about to be required.
The beauty of it is if a patient is seen in a clinic and seen by say the cardiologist and they go back to the internist, the medication, everything is updated in the CCD. It gets published to the Internet and there's a lot of security provisions obviously and privacy protection, published to the Internet and a privileged provider can then with the patient - the patient has to provide consent of course - the patient provides consent and the next doctor is in the network, as a privileged provider then he can download that information. Right now, it's viewable information but in the near future that will become structured data that can be imported.
Dr. Eric Fishman: Now you've mentioned Google Health and there's also Microsoft Healthvault. I assume that e-MDs is fully compatible with personal health record software of that nature?
Dr. Michael Stearns: Our database model is very similar to Google Health so we have active plans to connect with them this year. Probably by the summer we'll be connected with Google Health. We've also been talking with Microsoft and there's a bunch of different ways that we can connect through some other third parties as well.
Dr. Eric Fishman: Dr. Sterns, I understand that e-MDs has 19,000 users across almost the entire country and I understand that thousands and thousands of them are practicing physicians and others are the staff from these offices. I understand further that the implementation rates for e-MDs has been growing rapidly. Do you anticipate that that will change with the stimulus act in a meaningful fashion?
Dr. Michael Stearns: There's some interesting challenges right now. The New England Journal of Medicine published a study that was funded by the Office of National Coordinator funded by the federal government to evaluate the usage of EHRs and Dr. Blumenthal is one of the authors who's now our national coordinator and they found that 17 percent of physicians have elected to go with an EHR but amazingly, four percent were meaningful users or effective users the term they used. So that's a 96 percent potential. They are roughly 340, 350,000 practicing physicians who are, you know, who see patients in ambulatory care that would be potentially in the market for an ambulatory vendor. So we have well over 300,000 physicians who need to implement EHRs.
The challenge will be how we can possibly take on that many providers with all the combined resources of all the companies right now. So we're making some fairly dramatic steps in preparation for that. We have invested heavily in cognitive engineering which is where we hired a third party company to come in and evaluate every nuance of our product. And later this year, we're releasing a version of our product which is enhanced by cognitive engineering and it's a very dramatic difference. The goal is for eventually, this will be down the road a little bit, we will have greatly reduced training burden.
Dr. Eric Fishman: How long does it take to train - I'll pick a random number - a three physician office? How many days will it take of your staff's time to physically go to an office and train the physicians, the staff and everyone involved?
Dr. Michael Stearns: It's going to take probably for one provider it's about three days. So if you have the simplest model for a single provider. For a larger group, you're going to have a much more complicated project management. It has to be really done as you would almost like building a bridge.
Dr. Eric Fishman: If it's three days for one provider, can I multiply that and it's nine days for three providers or is there a certain (inaudible).
Dr. Michael Stearns: No, if it's two providers you may just do three or you may do four and that would be for the EHR. For practice management, you would want probably a separate set of time. So a typical solo physician and staff, say they've got six, seven staff, you'll spend three days doing practice management and you might at the same time have another person there to do the EHR or you may do them separate time blocks. We'd encourage doctors going live with EHRs to strongly consider the voice recognition tools because when you first go live, you haven't had a chance generally to go and refine every one of your templates. So we see it as a great starting tool. It really makes you more efficient when you first start to use the electronic health record and you always have that as a fallback
Dr. Eric Fishman: How long does it take a physician to have a very full grasp of the reach of the different templates that are available?
Dr. Michael Stearns: Depends on the specialty. If it's something where the visits are fairly repetitive, then it's (inaudible) so more of the specialties it's usually a bit easier but they generally have a hard time. There's not as much generic content for them to start with usually so you usually have to do more content work. However, once they're got those defined the primary care docs are going to have more templates available at their disposal and they've got more variety to choose from.
Dr. Eric Fishman: I bet it's a lot fun. It allows a physician who's been out of their residency for many years to re-think the process of medicine and it's like a review course for the boards I bet.
Dr. Michael Stearns: Yes and it's the tools though because you have to match what a doctor thinks, follow the algorithm. So a patient comes in with chest pain. What's your next question? So you have to think through that. It's very algorithmic. Now what it does do though however, it protects you from sometimes getting distracted because it kind of keeps you entrenched in an algorithm. I think we're going to be working with some medical schools in the future, we're talking to a few right now, where we'd like to see if a group of medical students, using templates that are embedded by say the professors at the university, compared to a control group that does a more standard preparation to see how they perform better because it's basically the extenuated knowledge of an expert is flowing the template.
Now, there's a lot of challenges with templates. There's where the voice recognition, certain settings they work, reasonably well, they're also very good for capturing structured data.
Dr. Eric Fishman: I've forgotten a little bit since medical school myself and it wouldn't be a bad idea to be reminded about some of the questions that you're supposed to be asking when a patient presents to the office.
Dr. Michael Stearns: Right. And we also have a dermatologist to reuse our product who has written about 300 templates. She reviews literature each month, identifies clinical guidelines that she wants to incorporate into the templates. Very impressive. That's very labor intensive but one doctor is able to do that.
Dr. Eric Fishman: If a doctor in the system of the e-MDs users produces templates are they readily available to other physicians?
Dr. Eric Fishman: Right. It's standard. So she contributed about 125 the ones she thought were most applicable to us. She gave those to us and we put them into our product and they're available to all users now. But that's very important. Now, clinical guidelines being built into the EHR is another area which is really going to help prevent medical errors and improve preventative medicine. But there's a huge challenge with the content maintenance efforts. So the AMA and the NCQA have gotten together and we're working with them on a program that will allow you to import a file that will update the templates within your system with new clinical guidelines.
Dr. Eric Fishman: You're calling them clinical guidelines. I've also heard them called clinical practice guidelines. This is the same?
Dr. Michael Stearns: Yes, right. So ideally, we'll be able to see practice modifications. A lot of these are fairly subtle things or either things easy to forget so the tools just kind of act as a reminder. Some physicians are reluctant to the idea that we're going to improve the quality of care you provide but I'm rare to see a doc who's using a product for a period of time and not realize "there's several things that I'm glad that the system reminded me of." It might even be an expanded differential diagnosis. They go through and see a patient with a headache and it turns out to be temporal in origin. They may not have thought of something, you know, tooth abscess or something and it's like, you know, it's good to at least have that pop up as a consideration. Again, these are all optional things. We don't force it upon the physician. We try to make it so it's there if they need it just one step away. You can also connect the system to other content resources like UpToDate and others which are available so you can swing to that if you want that but it's timely. It's where you need it.
Dr. Eric Fishman: At the point of care.
Dr. Michael Stearns: Exactly. It's when you need the information not something you have to remember to look up or go to the library or something or go online and just do a Google search.
Dr. Eric Fishman: Dr. Sterns, I thank you very much. It's been a pleasure speaking with you today and I thank you for joining us.
Dr. Michael Stearns: Nice talking with you. Thanks for your time.