

DrChrono (YC W11) Makes The iPad A Doctor’s Best Friend In The Exam Room - nikhilpandit
http://techcrunch.com/2011/02/23/drchrono-makes-the-ipad-a-doctors-best-friend-in-the-exam-room/

======
benmathes
Good luck with this one. After spending a couple of years working on something
like this, I found the following:

    
    
      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.
    

#1 means you need to build heavily-configurable software, and #2 means the
doctors don't have the time or energy to learn and configure your software. At
best you can get the practice managers to force it down the doctor's throats,
which doesn't exactly help either.

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_.

~~~
jpeterson
My guess is that this is more targeted to the "hip" crowd among MDs who
embrace this sort of thing (of which there are quite a few).

~~~
Skeletor
Over 120,000 doctors in the US own an iPad and doctors (even non-"hip" ones)
get immediately that the iPad is the ideal platform to use in the examroom.

~~~
niels_olson
iPad is not the best. Massive, rapid text entry on an iPad sucks. I took an
iPad and a cr48 to the a big orthopaedics conference last week, and the cr48
was the hands down winner, using nothing but qemacs. Fundamentally, on the
ipad, character recognition or dictation would be best, but I can barely read
my own writing sometimes! The iPad would be a lot better if the input
precision was as good as the output resolution. If you've tried any drawing
apps on these things, you know what I mean. Wacom tablets have much better
input precision, or at least they seem to. I want Pilot G-2 0.5 mm black
speed, precision, and reliability. Right now only a keyboard comes close.

~~~
Skeletor
We are very close to launching an integrated clinical speech to text product
in our iPad application that should remove the need for most typing!

~~~
niels_olson
Dictating the note would be huge.

------
flyosity
This is probably a solid idea (I have a friend working on a similar app) but
I've gotta say, the user interface looks horrendous. Form fields slapped
anywhere, nothing is aligned with anything else, the sizes of UI elements are
all over the place so there's no visual hierarchy, it looks incredibly
amateurish.

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.

~~~
Skeletor
Wait, interface builder isn't supposed to explode when you use it?

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!

------
togasystems
I just finished a large project for a healthcare company in Canada. I wish the
drchrono team the best of luck. Here are some pointers to watch out for in the
healthcare industry.

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.

------
tom_b
I work with electronic medical records on the research side, integrating
clinical patient data with medical research and clinical trials. However, I
work with a large teaching hospital rather than small practices.

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 . . .

~~~
niels_olson
>you'll have to go around the heavily entrenched IT groups

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.

------
2mur
I'm a physician. I would love to hear about you implemented HIPAA compliance
for both the iOS app and for the web service. I think it is a huge problem for
any healthcare startup with potentially serious penalties (even criminal!) for
mis-implementation. It is a serious third rail.

~~~
niels_olson
I'm a physician too. I would definitely be interested in this also. However,
having developed a web app in med school, my experience was the HIPAA security
rule is pretty weakly specified compared to credit card auditing. PGP is
specifically mentioned as a best practice last I read, and plain fax in the
same rank of good enough. Seriously, you're relying on an underfunded agency
with a distinct lack of crypto expertise for auditing. Compare that to, say,
FIPS and other serious requirements that NIST manages.

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.

~~~
2mur
I think the requirements are fairly nebulous at best and mostly aimed at
documenting your practices for access, and (god-forbid) breach/compromise. I
think that you are covered if you cover these things in you operating
procedures, but that is just from my own cursory research.

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.

~~~
niels_olson
Here's the combined rules. The security rule starts on page 38.

[http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyr...](http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf)

>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

------
Groxx
Speaking as a _patient_ , I've vastly preferred my visits to doctors who had a
laptop with an inverted touch screen. Fewer questions about what was already
in my (occasionally quite large) medical history - they could find it. Access
to the relevant info like X-rays or blood tests, with more information than
printouts carry, and adjustable contrast on digital X-rays. And the full
history of _every_ similar test I've ever had. My visits have been faster and
far more useful _every single time_.

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.

~~~
dagw
The tech has been around for years, the hard problem is getting the doctors to
actually use the tech. The doctor I used to go to seemed to have no idea who I
was I why I was there every time I showed up for an appointment, despite the
fact that there was a perfectly good computer standing on his desk where he
could quickly have looked up everything he needed to know.

------
dr_
Personally I am pleased to see more of an effort being made of late with
advancing health care technology. It's a fact - doctors are using the iPad. I
see more and more of them in the hospital. I'm not certain whether this will
lead to widespread adoption or is just a novelty. In our hospital you can use
the iPad to first log into the hospitals Windows based network, then log into
HMS, which only works with Internet Explorer. Given how tedious a process this
is, and to perform order entry using this technique, to me doesn't seem like
its going to last long. I'm thinking a 11" MBA would come in more handy.

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.

------
alphaoverlord
I'm interested in learning how DrChrono is planning to market to physicians.

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.

~~~
Skeletor
Most US private practice healthcare providers (roughly 80%) practice in small
groups of 1-5 physicians. That is our target market and still the way that the
majority of personal healthcare is delivered in the US!

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.

~~~
alphaoverlord
"The percentage of U.S. physicians who own their own practice has been
declining at an annual rate of approximately 2% for at least the past 25
years."

<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!

------
jrockway
So what happens when Apple pulls this app for $arbitrary_reason? Are your
medical records gone?

~~~
Skeletor
The iPad is a front end for <https://drchrono.com> which is a full SaaS
product in its own right to manage all of the backend of the doctor's office.

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.

~~~
dools
What about their recent changes to billing models? Do the doctors pay your $99
fee through the iPad's in app purchasing?

------
ihodes
It seems as though people may not know what exactly goes on in an exam room,
and how exactly is the one taking notes. Often, especially with specialists,
there's an MA or RN taking notes. Note only that, but this seems vastly
superior to digging through a pile of charts or working with an ungainly EMR
system.

The market has been BEGGING for this, and this looks like it might be the
right answer. Good luck!

------
atgm
The idea of doctors using iPads scares me; I know plenty of people who make
casual typos with numbers on the iPhone or iPad as it is -- the last place I
want someone doing that is in a hospital or doctor's office.

~~~
Skeletor
You bring up a really good point. Moving to electronic systems has both huge
benefits and some risks that have to be mitigated.

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.

~~~
atgm
What about a number interface -- hit a button to bring up an oversized numeric
pad?

------
JSig
Three years ago when we took my daughter to her first pediatrician
appointment, the doctor brought a laptop into the examining room with her. The
doctor barely looked at my kid. She just sat there typing away looking at her
machine. In my mind technology had become a barrier to the doctor/patient
(parent) relationship. It was very frustrating. But, there were many things
frustrating about that Dr. so it could have just been her. We quickly found a
much better one.

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....

------
slee029
I wonder if having an Ipad-enabled EHR system will be a compelling enough
proposition to migrate practitioners from existing experienced vendors with a
track record. I would imagine if you already have a system, even if it is an
old expensive legacy system, you would not switch simply because of an IPad
enabled device.

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.

------
robryan
My girlfriend does some admin work at a hospital that uses meditech software,
seems like the kind of old bulky enterprise software startups are trying to
replace. It covers a lot of areas in hospital admin as far as I know, more
than just the doctors interactions with patients. I have mnetioned it would be
great for doctors to take out the middle man and use things like ipads so this
seems great for that.

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)

------
atirip
That's another "burning platform" in a week from YC (the other one was that
fax-in-a-browser thing). The correct solution to this kind of problem is
government backed centralized system. Like in Estonia:
<http://eng.e-tervis.ee/overview.html> . Sooner or later all countries will
have this kind of solutions in place and sadly, DrChrono will die..

~~~
viggity
The growth of the internet was impeded by a government backed centralized
service in France, it was called Minitel.

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.

~~~
atirip
It works that way in Estonia, that all the doctors are _forced_ to use that
system, which results to a wonderful thing where _every_ doctor has access to
_all_ data there is about you - so when you lie unconcius on the street, 911
knows all your allergies, illnesses and treatments etc in that second.

------
jason_slack
I worked on an EMR app for a while and DrChrono feels very childish. HIPAA
compliance seems like a back seat at this point instead of first priority.

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..

------
kmfrk
I really don't like your UI, but on another note, Jay Parkinson is the guy you
should seek out and ask for advice. He's probably _the_ go-to guy in
innovating health sector tech.

<http://jayparkinsonmd.com/>

~~~
Skeletor
We actually have a quote from Jay Parkinson about us on our homepage!
Constantly improving the application (including the UI) is our company's
mantra.

~~~
thuc
i think your ipad emr is a great start to the mobile emr space. and jay is the
man! looking fwd to seeing drchrono grow.

------
allangrant
I don't know anything about this industry, but the UI looks stunning.

~~~
brudgers
The UI looks like a HIPAA violation as soon as the Katelyn can see that Boris
is in Exam Room 3.

~~~
jrockway
I'm also a little uncomfortable with having my balance due more visible to my
doctor than what my medical problems are. Doctors should deal with medicine,
office clerks should deal with the balance due. Having emotional information
like money on the info screen can adversely affect the emotional
doctor/patient relationship in a way that's completely unnecessary.

Fucking programmers.

~~~
Skeletor
There is a clear divide between the clinical tools on the iPad and practice
management (medical billing and invoicing) tools for Doctors.

~~~
ceejayoz
Not in the screenshot TechCrunch is using to illustrate their article there's
not.

~~~
brudgers
It appears that it may be two screen shots in landscape mode.

------
axod
how is this better than the existing computer systems doctors use? (It's on a
iPad doesn't cut it IMHO)

~~~
Skeletor
Being on the iPad is a huge win since the Doctor won't have their back turned
to the patient while using the system. The base EHR (Electronic Health Record)
system is also FREE and a doctor can start using it right after downloading
the free App from iTunes.

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!)

~~~
axod
Back turned? :/ Over here (UK) there's a desk, in a corner, with a chair next
to it. The doc sits at the desk, using the computer, facing you sitting on the
chair to the side.

Works pretty well for doctors surgeries anyway.

But I have no idea how things work in the US so maybe it's completely
different.

~~~
Skeletor
Several clinical studies have shown that patients will have better healthcare
outcomes if their doctors make eye contact with them. One of the reasons I co-
founded drchrono was because I went to a lot of doctor visits with my Father
when he was ill and sat through countless appointments where the doctor spent
10 minutes talking to us over their shoulder.

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.

~~~
niels_olson
I applaud your effort. I think dictation is going to be crucial. Keep pushing!

------
logjam
I understand the motivation for these applications, but anything that, in a
room with a patient, takes one away from interacting with the patient has
drawbacks. A lot of docs are taught NOT to use this kind of device in the
room. Even burying your nose in the patient's chart, of course, is
problematic. Using it outside may have its advantages, but in the room it's
ideally two humans and not much between them.

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.

~~~
niels_olson
This comment deserves a lot of up votes.

~~~
Groxx
I think this is the most ironic thing I've seen in the past year.

------
krazook
this is revolutionary...wow.

------
earino
Company launches practice management software. Film at 11.

~~~
muhfuhkuh
Wow, it's almost as if we weren't on a social news site catered toward
companies and their launching products.

~~~
earino
Living in Nashville, a healthcare center, and having personally seen >100
million dollars blown by healthcare startups, have made me very cynical. HCA
is about to "go public" again making the Frist family another 15 million
dollars while healthcare informatics continually gets underinvestment and
underdevelopment. An iPad app isn't what healthcare IT needs. A drastic
smashing of the legacy of MUMPS and overgrown piss poor legacy solutions will
require a large health crisis, with opportunities blown due to bad processes
and bad systems.

