Written by: John Lynn
After my previous interviews with EMR vendor CEO’s, a couple people requested that I do an interview with Randall Oates, President of SOAPware EMR. Thanks to their help I was able to connect with Randall and the following is my email interview with Randall Oates.
Give us a short history of SOAPware. Why were you orginally an EMR only (no practice management system – PMS)?
I divide SOAPware’s history into 4 stages:
1. 1987 to 1992 – Prototype stage – I created the prototype for SOAPware using a program called Hypercard on early Apple Macintosh computers while building a very large and active medical practice in Springdale, Arkansas. I was already using a computerized billing systems, and had no interest in developing one.
2. 1992 to 1994 – Start-up – Greg Lose, a real programmer, came in to turn the prototype into a commercial product. He continues to lead the way doing research and development.
3. 1994 to 2005 – Market dominance in small practices – David Powell came on as CEO. In 2005, there was not an EMR product installed in more sites than SOAPware.
4. 2005 to present – Focus on transition to next generation, comprehensive EMR – We retreated from major marketing, and engaged a complete rewrite of the software. We are now focusing almost all resources on completing the product suite and simplifying what is presently an often an overly-complex interface.
In 2004, only 12% of new EMR customers were shopping for a combined EMR/PMS. Now, it is over 70%. This emphasizes our need to have the fully integrated product as soon as is possible. A need for integrated billing system as well as transitioning to a much more robust product has accentuated our temporary retreat. In spite of this, we have continued to experience growth in every quarter (compared to the same in the previous year). However, our dominance has briefly waned a bit.
Greg, David, and I remain as the principals in the company. One year ago, a fairly accurate summary was published at MDNG – The EHR Trailblazers. Until 2005, it was our intent to keep a focus on the EMR and links in order to interface with PMS systems. However, in 2008, it became apparent that an overwhelming majority of EMR users want a fully integrated, rather than interfaced, EMR-PMS. So, we launched into development of our fully integrated PMS that is now in an alpha-testing phase. It uses the same database as the EMR, is written in the same computer language, and does not require a separate installer. BTW, if anyone knows any good C#, .net programmers that want to join a great team, we are hiring. However, the next few need to be willing to relocate to either Fayetteville, AR. or Denver, CO.
Why do you think the industry shifted to integrated EMR and PMS?
The EMR market has passed out of the early adopter phase, and is presently in the chasm that leads up to the phase of mass adoption. Early adopters were not as intimidated by interfaces between vendors as are the masses. Even though the overall cost and hassles are often less with an interfaced EMR-PMS than with many of the currently available “fully integrated” systems, the perception by the masses is otherwise.
Even though we will soon release our fully integrated system, we will continue to work with interfaced solutions.
Do you still think that it’s reasonable to have a separate EMR and PMS?
Short term, and as long as we continue to have little of the billing information actually entered at the point of care by clinicians, interfaced systems will have utility. However, by 2013, when ICD-10 coding is required, and certainly by 2015 when SNOMED-CT coding is required for diagnoses, it will no longer be practical for physicians to delegate the task of selecting billing codes. Billing claims will be moving from including 14.000 ICD-9 CM diagnosis codes to including over 120,000 ICD-10 codes. It will not be practical for billing clerks, alone, to be able to get to the required level of specificity. The paper superbills physicians tend to use, today, will have to expand from one page to at least ten pages. This, along with the need for clinicians to perform accurate reporting of “performance measures” at the point of care, will likely render interfaced systems (with billing clerks expected to enter the data) as too cumbersome and limited to be practical.
The irony with this question is that a majority of so-called “integrated” systems are really separate EMR and PMS systems that just happen to be sold by a single vendor. With very few exceptions, the EMR and the PMS have been created by separate teams and then have been later interfaced, or glued together, in some fashion. It is not unusual for them to be written in completely different computer languages. They often even use different databases, and even require separate installers. Going forward, these can only be cumbersome, at best.
Tell us about your methods for training people who purchase SOAPware.
We have focused on minimizing the necessity for formal classes and thus minimized the direct and indirect costs for training. Few small practices can afford the luxury of closing the practice to attend a bunch of classes. Our focus is to take a more asynchronous approach. We advocate for most of the staff in medical practices begin with a 2-3 hours introduction going through a series of free, interactive videos which are then, ideally, followed by 30-60 minute question-answer sessions delivered remotely. In order for this to be most successful, this general staff training has been preceded by a thorough practice readiness assessment and “pilot” implementation projects where much of the site-specific customization have been created in advance. We have a collection of Implementation Milestones documents to follow. General staff training is fairly late and of lesser importance than other the other implementation challenges. We are in the process of moving the Milestone documents to a SharePoint wiki in order for our implementation facilitators to be able to more efficiently monitor the implementation process and collaborate at whatever level the practice needs.
Lastly, and most expensively, one-on-one SOAPware training can be arranged both remotely and on-site in the same fashion that most other vendors offer.
We also have The Path in our online wiki called SOAPedia. It is a step-by-step implementation guide that some practices (those with good leadership and change management skills) can utilize to train/implement on a fairly independent and very inexpensive basis.
Are you seeing or do you anticipate having the EMR backlog (ie. long wait times for training and implementation support) that so many people are talking about?
We already have waiting times for our training services, and this is likely to worsen in the short term. Long term, we are engaging several initiatives in order to be able to quickly scale up for the demand. Not only are we hiring more training staff, but we are creating a new “partner” program that is fairly unique. For example, our current users will be encouraged to become certified SOAPware trainers in their own communities. (Intuit has done this with great success with QuickBooks, and disrupted an entire industry as a result.)
Ideally, after the initial 2-3 hours of interactive video training, new users will go into practices using SOAPware, live, and actually see/use the system. By doing this, a new user can take a morning to get the video introduction, spend the afternoon working with the system in action, and then be good to go live the second day.
Will SOAPware be participating in the ARRA EMR stimulus money program?
Yes, we expect a majority of our users to participate in the ARRA bonus program rewarding practices that demonstrate meaningful use of a certified EMR.
I see that you’re CCHIT 2007 certified. What’s SOAPware’s plans in regards to future certifications? Will you be going for HHS certification, CCHIT 2011 Certification or Preliminary ARRA Certified?
We will definitely be going for HHS certification so that our users can qualify for the ARRA bonus payments. Whether or not we will also go for CCHIT certification in the future remains to be determined. Presently, CCHIT is the only entity on the immediate horizon to certify for HHS, but other certifying entities are likely in the works. It is just too early to announce who we will utilize for future, HHS certification.
Tell us about 3 specific features which make SOAPware special.
1. SOAPware fully supports the use of either free-text narratives or fully structured data in almost all areas of the medical record via what we call SMARText. In contrast, most EMR’s are predominantly one or the other:
Paper Behind Glass – Most low cost, simple EMR’s are more of this type in that they simply display the familiar free-text narratives that physicians now prefer. Over 90% of systems that are actually being used at the point of care are of this type. If a physician likes the EMR, it is probably of this type. Sadly, the problem with using an EMR in this fashion is that little computer-readable information is present that can be exchanged with other systems. This will force clinicians using these systems to have to upgrade to versions with kludges allowing them to navigate to secondary screens with add-on workflows in order to click-in all the needed, structured data items. This will lower physician productivity because every time the physician hikes in to see a patient, they will have to sit down and spend a lot of time “picking off all the ticks.” So, the easy to use and more popular, “paper behind glass” EMR’s will soon be just as cumbersome and inefficient as the current generation of comprehensive offerings. However, an advantage, today, of this type is that it can be implemented with less effort, training, etc. After all, it is mostly about just moving the paper behind glass. While efficiencies can be gained in the process, the tendency is to mostly persist with often inefficient workflows.
Comprehensive Systems – are typically more expensive and require dozens to hundreds of clicks by the clinician for each patient encounter. Physicians, by a large majority, detest these systems. Surveys also confirm far less than 10% of physician EMR users (even those having access to comprehensive systems) are actually using their system in comprehensive fashions. The physicians actually using the current generation of comprehensive systems in a comprehensive fashion have usually seen significant and long term losses in productivity, or they are in low volume situations from the beginning. These systems typically handle the often necessary and important narrative, free-text in awkward fashions. Having to start EMR use in a comprehensive fashion causes training and initial customizations to be generally very complex, expensive and disruptive to overall practice efficiencies. It is sort of like forcing doctors to jump to the 10th ladder rung rather than starting on the first rung. The high failure rates with these systems is presently the key reason the EMR industry is receiving such low marks and experiencing low adoption rates.
Typically, what these systems do best is deliver great sales presentations and influence to many of the decision makers serving larger practices. Too often, the decision makers tend to be individuals who will rarely actually use the EMR while seeing patients.
SOAPware can either be used either as paper behind glass or as a comprehensive system collecting real data. More importantly, our design facilitates a gradual migration from the simple free-text narrative to as much structured data as is necessary, and in fashions that are less likely to lower physician productivity along the way.
Other than SOAPware, I only know of 2 other mainstream EMR’s, eMDs and Medtuity, that practically allow for the actual items in the medical record documentation to be linked to the multiple coding systems (i.e. can encapsulate SNOMED-CT, LOINC, RxNorm, codes etc.) that meaningful use is going to require. Some other systems might come close, but are so inflexible that typical practices can’t afford the custom programming required to change the actual items physicians use to create encounter documentation. What is truly unique with the current generation of the SOAPware EMR is that most updates of these data items can also be performed online and automatically at any time without having to purchase new versions.
2. The basic layout of the chart can be instantly individualized/switched to be most efficient for different roles (i.e. doctor vs. nurse), patient types (e.g. pediatric or diabetic), and amount of monitor space available.
3. External documents of almost any type (text, video, audio, spreadsheets, pdf, etc.) can be dragged-and-dropped just about anywhere in the SOAPware electronic chart. This is a very unique aspect that provides the equivalent of a first level (i.e. manual) interface to just about any other system.
Describe SOAPware’s integration with Dragon NaturallySpeaking. How many of your clients use DNS?
Somewhere between 10 and 30% of SOAPware users use DNS. I strongly advocate its use for those “snippets” of narrative, free-text information that are unique to each patient. For example, if a mother is stressed out because grandma-in-law is visiting again, this will never fit very well in a templated or structured entry, but may be the most relevant data item for a patient presenting with a headache. I do not advocate simply replacing dictation with DNS, as that will not meet the need to have structured, reportable information in the record. Again, dictation, alone, can only create paper behind glass, and can only leave the practice in the dark ages.
The other down side to DNS is that it does not yet function ideally in either ASP or cloud-based solutions. While the past ASP approach to delivering technology solutions to practices has not seen great success, the emerging cloud-based solutions will likely trigger the EMR revolution. For example, our hosted, cloud-based solution, allows for the practice to have their own, virtual server in the Internet cloud. This removes the expense and hassles of attempting to maintain a clinic server, network, back-ups, etc, but the practices are not just limited to only the software and solutions that the typical, more limited ASP approach can offer. I just hope the engineers can figure out how to make speech recognition more fully compatible with these hosted, virtual, or cloud-based solutions before the end of 2010.
What do you think is missing in the EMR world now?
1. What is mainly missing is an accurate perception of reality. That is… recognition that it is nothing less than insanity to expect physicians to become data entry clerks! In the future, we are going to look at the current approaches to EMR implementation in the same fashion as we now view the practice of leeching and blood-letting of the past. Data entry should rarely be performed by clinicians! Instead, it should be done via other avenues such as the patient, medical assistants, and data gleaned from information that already exists, but is siloed into some other information system. The EMR technology, as well as changes in the practice workflows, should be used to liberate physicians from most data entry, and not increase that burden. Watch for some exciting announcements in 2010 as to how that can be most effective accomplished in a practical fashion using SOAPware.
2. A proper understanding of the necessary process changes practice need to make before even considering the available EMR solutions is generally missing. Along with this is a dearth of approaches advocating tolerable, incremental evolutions. To better understand the later, see- Ten Steps to a Patient-Centered Medical Home . Instead, vendors and “decision makers” tend to advocate destructive, big bang styles of implementations, because they perceive the technologies and process changes available to them don’t really support incremental change.
3. We are missing standards allowing for the sharing of information that is patient-centric rather than industry-centric. The former tend to be easier and more practical for patients and small medical practices. The later tend to be what the current, moneyed-controlling entities in healthcare prefer.
4. EMR’s need standards in order to be more open-platform in order to support best-of-breed solutions. No single vendor can deliver a monolithic application that is ideal for almost any specific practice.
You’re a pretty avid blogger. Do you write all the posts or is it just your name and picture? Why do you blog?
Nobody else writes any of my blog posts, but I often quote/reference others. My blog is more therapy for me than anything else. It is my tool to speak out as well as communicate what I think physicians need to know regarding challenges before them.
At times, I offer periodic updates that are more specific for SOAPware users. We have a very large community of SOAPware version 4 users (i.e. paper behind glass method) that now need to begin the process of migrating to more comprehensive use of information. This needs to be properly managed via clinician leadership and practice readiness assessments in order to be most efficient. These practices need to upgrade within the next few months, because the second half of 2010 needs to be free to add in the registry (i.e. population reporting) and patient portal (i.e. electronic communications) that are to follow the release of our integrated billing system. Again, these, more comprehensive functions, need to be added only after careful planning and practice preparation.
Are there other blogs or websites that you visit regularly for EMR information?
Too many to mention, but my favorites are:
The Healthcare Blog
Histalk and HisPractice
Life as a Healthcare CIO
Thanks to Randall Oates for taking the time to answer these questions. Some really informative information. Let me know if there are other people you’d like interviewed and I’ll see what I can do.