A Specialized and Structured EMR: Interview with Modernizing Medicine
by Shiv Gaglani on Aug 20, 2013 • 2:55 pm
In large part due to 2009′s Health Information Technology for Economic and Clinical Health (HITECH) Act, there has been a proliferation of electronic medical record systems. Many of the largest providers, such as Johns Hopkins and Kaiser Permanente, have seen a consolidation onto large systems like Epic, while many small to middle-sized providers continue to use direct to consumer type systems such as Practice Fusion. These systems are competing for market share and thus have built products that can be used by everyone from family physicians to neurosurgeons, often in a one-size-fits-all fashion.
We recently came across a relatively new EMR company called Modernizing Medicine, which had a presence at both TEDMED and CONVERGE this year, that announced today that it received $14 million in equity funding. Their approach is to build focused systems for key specialties, starting with dermatology and moving to ophthalmology and even orthopedic and plastic surgery. We had the opportunity to speak with Modernizing Medicine’s CEO and Co-founder, Daniel Cane, who is no stranger to building tech solutions for large industries; as an undergraduate at Cornell in the late 1990s he co-founded Blackboard, the largest learning management system in education.
Shiv Gaglani, Medgadget: As the founder of Blackboard, Inc., you have a significant background in education technology. How did you make the move to healthcare with Modernizing Medicine?
Daniel Cane: The short story is that it needed to happen. I realized there were many parallels between my experiences in educational technology and my interest in healthcare technology. From my Blackboard experience, I saw the degree to which technology could transform an industry – in that case, education. Education had not deviated much from the “sage-on-a-stage” model of teaching dating back to the Greeks, but over the last two decades we applied enough innovation and technological voltage to the industry to get it to move. Today we have MOOCs (Massive Online Open Courses) and the notion of anytime, anywhere access to education. It’s a very different world we live in today than when I was an undergrad at Cornell University in the late 1990s.
After I took Blackboard public and sold it to Providence Equity, I was appalled to learn that the healthcare industry – which is even bigger than the education industry – was so resistant to change. The past 20 years of innovation hadn’t moved the needle. When I moved back to South Florida I was shocked to see that even the specialist physicians were still using paper charts! Those who had switched over to electronic medical records (EMR) were using generic systems designed for internal medicine, and not optimized for their specialty.
That’s when I met my co-founder, Dr. Michael Sherling, who is a dermatologist, and realized that we had a huge opportunity to develop innovative systems by taking the time to understand specialty-based medicine. So again, the very short version is that Modernizing Medicine needed to happen because no one else was doing it.
Medgadget: What is unique about Modernizing Medicine?
Cane: Modernizing Medicine is a cloud-based, tablet EMR system specifically designed for specialists. Generic EMR systems are built with internists and general practitioners in mind. For these doctors it’s hard to predict the patient profile since they see such a diverse array of conditions and diseases. As you move to specialty systems, you have a decently good idea of what the doctor’s day will be like. Thus we’ve pre-programmed medical and billing expertise into our EMR system that saves our providers a few minutes for each patient they see. And when they’re seeing upwards of 50 patients a day, that means the difference between getting their work done by 5 pm or 7 pm.
Also, due to how structured our data is, we have developed a sophisticated adaptive learning platform. Our Electronic Medical Assistant® (EMA™) adapts to each provider’s unique style of practice and integrates seamlessly into practice workflow. For example, EMA learns what the provider’s preferred mode of treatment is for psoriasis and can provide insight into what peers both in his or her practice or in the broader dermatologic community are doing.
Another unique aspect, from an organizational structure, is that we are the only EMR company that I know of that hires physicians. We have 14 physicians on staff who still maintain private practices but work in our office 2-4 days a week. They are using our internal programming language that allows the quick and accurate capture of medical information through our touch-based systems. For example, we have 3 orthopedic surgeons on staff who directly program in orthopedic knowledge base into the system. Thus, out of the box EMA knows every disease in orthopedics, approaches to surgeries, drug regimens, etc. Another reason we have these physicians on staff is that medical knowledge is always changing so we strive to keep the system as up-to-date as possible. The beautiful thing about the cloud-based approach is that when a doctor in, say, Alaska wants something in the system, everyone else in the network will get that upgrade immediately as well.
Medgadget: Can you describe what the uptake of the system has been like?
Cane: Adoption has been nothing short of extraordinary. We have over 15 percent of the entire US dermatology market and have just been operating for 2 years now. In absolute terms this is close to 3,000 providers at over 1,000 practices. We’ve achieved this adoption because EMA works and really saves time.
EMA Ophthalmology™ is our second product and at this point we have a couple of hundred providers. We also signed an interesting white label deal for EMA Optometry™ that will roll out our application to tens of thousands of optometrists soon.
We’re just getting started in EMA Orthopedics™ and other specialties. That reminds me, one of our unique features that these specialists love is the EMA Interactive Anatomical Atlas™, our highly visual system with a built-in 3D anatomy viewer that they can interact with as they perform a patient’s history and physical.
Medgadget: Can you describe the technology behind Modernizing Medicine?
Cane: Every second of a provider’s time is precious and you want to give your end users the best, highest-fidelity experience using your product. That means we have to make a substantial investment in application design, usability and infrastructure. Our back-end is all Java — profiled, streamlined and optimized. The database is mySQL running in a high-performance Continuant Tungsten cluster. On the iPad it’s an entirely native Objective-C application — you simply can’t get the same feel using the web browser on these devices. For those who prefer desktops or notebooks, we have a very clean HTML5 based UI as well. The entire system is hosted on secure, HIPAA compliant dedicated instances at Amazon. There are massive redundancies throughout the stack with no single points of failure, and to be extra, extra safe, we replicate the entire stack to a disaster recovery datacenter on the opposite coast.
Medgadget: It’s becoming clear that EMR systems should not just record data, but also have back-end analysis systems to glean insight from the data. Does Modernizing Medicine do this?
Cane: Definitely! We have an application called EMA Grand Rounds™ that takes advantage of our highly structured data set to accomplish this. For any given patient profile I can tell you the percentage breakdown of what treatments are used – not just by you but also by your peers. For example, EMA will tell you what percentage of time you use Drug X versus Drug Y for 20-30 year old male patients with psoriasis, and whether your peers’ habits differ. An important point here is that because we’re so specialty specific we have a tremendous data set of specialty disorders, e.g. 141,000 psoriasis patients. This gives us more insight into these disorders.
In the last six months we’ve begun developing what I believe will be how we really modernize medicine. We are beginning to track outcomes data on patients in our system. To this end, we created a team of experts and spent months and months figuring out what the appropriately validated scales are that we could bake into EMA. We’re getting to the holy grail of evidence: instead of relative, we can have objective outcomes. Currently we are in the process of hiring more scientists and have partnered with academic institutions to look at our de-identified data stores.
Medgadget: How do you see advanced clinical decision support tools like IBM’s Watson changing the game?
Cane: Watson is trying to digest gobs and gobs of unstructured data to try to form relationships and understanding. It’s incredibly good at some things, but on other things its answers do not make sense (remember Jeopardy). Rather than deriving knowledge from unstructured data, we are interested in looking at copious amounts of structured data. Our challenge has been inputting the data in a structured way in the first place, which we’ve solved using touch-base data entry process. I see a potentially ideal marriage between both the Watson and Modernizing Medicine approaches since both structured (e.g. physical exam) and unstructured data sets (e.g. clinical studies) will remain important.
Medgadget: Are there any broad trends in medical technology that you’re particularly interested about?
Cane: Absolutely. We are very involved with and always learning more about telemedicine — an area that is particularly well suited for our domain and products. Of course, the impact of real-time analysis of “big data” in the hands of the providers is something we believe in. The most important broad trend we are passionate about is not technology for technology’s sake, but rather how we harness all of this new emerging technology to make patients better. Technology + data = modernizing medicine.
Medgadget: Can you compare your work in the education and healthcare industries and draw any insight into similarities and differences?
Cane: The similarities between the education and healthcare industries are uncanny. Both are goliath, multi-trillion dollar global sectors that are tremendously resistant to change. If you look at other industries, like banking for example, we’ve been able to “check our balance” for over a decade. Thanks in part to Blackboard, we can check our grades, collaborate on group projects and communicate with our instructors at anytime, from anywhere. Healthcare has been very lightly kissed by cloud and mobile technology. I think the reason is simple — healthcare is not a vertical at all — it’s 100+ verticals all rolled into one brand. There are huge differences between a surgical specialty practice, primary care and hospital systems. The result of a one-size-fits all mentality in healthcare is a lowest common denominator approach to building solutions which has led to generic, yet shockingly expensive, products that are not well liked or used.