DrChrono (YC W11) Makes The iPad A Doctor’s Best Friend In The Exam Room(techcrunch.com)
techcrunch.com
DrChrono (YC W11) Makes The iPad A Doctor’s Best Friend In The Exam Room
http://techcrunch.com/2011/02/23/drchrono-makes-the-ipad-a-doctors-best-friend-in-the-exam-room/
22 comments
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.
yeah, the medical coders will occasionally have coaching sessions for their doctors on how to drop more valuable words in their notes, but I haven't seen docs get much more in the weeds with the money.
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.
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 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.
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.
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..
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.
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.
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.
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..
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..
I don't know anything about this industry, but the UI looks stunning.
The UI looks like a HIPAA violation as soon as the Katelyn can see that Boris is in Exam Room 3.
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.
Fucking programmers.
There is a clear divide between the clinical tools on the iPad and practice management (medical billing and invoicing) tools for Doctors.
The drchrono EMR is fully compliant with HIPAA. One of the screenshots shows the Dr. the overview of patients coming in for the day (that view isn't for patients to use.)
Having the charting function next to the schedule is problematic for any medical staff which writes their notes while with the patient - and that's a practice many experienced healthcare professionals use because it allows them to spend more time with the patient without spending more time per patient and it allows them to get answers to questions which arise during the writing.
I've been to two separate dental practices that are under the exact same HIPAA scrutiny as doctor's offices and they have a printout of exactly who they are seeing at what time and in what operatory taped on the wall when you enter.
Somehow I doubt an iPad being clutched in the doctor's bosom as they read it is anymore a violation than that.
Somehow I doubt an iPad being clutched in the doctor's bosom as they read it is anymore a violation than that.
HIPAA is why sign-in sheets such as these are common.
http://hipaasignin.com/info/info.html
http://hipaasignin.com/info/info.html
Not much worse than the paper sign-in log where I can see the name, address, phone number, and physician's name for the 10 people who came in before me.
this is revolutionary...wow.
Good luck with this one. After spending a couple of years working on something like this, I found the following:
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.
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.
This is great feedback! drchrono has a really customizable form builder tool that lets users build out their legacy paper clinical forms on our website and then have those forms recreated on the iPad to be filled out as the doctor sees patients.
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.
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.
I'm a doctor. I failed to use a special character in my password during signup so my domain/username got reserved but it wasn't obvious until I was informed of failure, tried again, and was told not once but twice that my username was already taken. I decided to try reseting my password, and then found two emails in my inbox, one to confirm, and one to reset my password. All on my iPad, but through the website. Very confusing.
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...
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...
Please email [email protected] and someone can help you with that issue right away! We have an amazing support team ready to help!
My wife is an ER physician and I went down the path of a similar idea as well, because I saw how awful her life was in trying to maintain meaningful records for her patients. #1 is very true - especially when you take into account all the various medical specialties in the industry.
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.
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.
Speech to text is one cool feature we are integrating now, but is still just one feature.
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.
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.
True, hospitals and doctor's offices are completely different animals. I was only looking at hospitals at the time, which has the added disadvantage of requiring long sales cycles. Doctor's offices should be a much easier sell.
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!
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!
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).
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.
13% of physicians have iPads? And 1.5% of all iPads went to physicians?
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...
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...
> 13% of physicians have iPads?
anecdotal evidence from the conference of 30,000 orthopods in San Diego last week, that seems very plausible.
anecdotal evidence from the conference of 30,000 orthopods in San Diego last week, that seems very plausible.
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.
Keyboards for the iPad already exist. The future is a touch screen, and an external keyboard (probably should also mention big screens, with gpus, hooked to iPhone docks, in order to offer a fully personalized desktop experience, running off your mobile device.)
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.
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.
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!
Dictating the note would be huge.
[deleted]
Many of us have looked extensively at pads long before this, and concluded that they are not ideal. They may have other support uses.
I agree, using an iPad's touchscreen is better for information display & retrieval, than for information recording.
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.
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.
Before the iPad, the "state of the art" touchscreen was an 11 pound laptop with 2 hours of battery life and a reversible top-cover/"touch" screen that required a stylus to use. The iPad is a REVOLUTION in tablet computing for physicians.
Please tell me that you don't actually believe this and were just speaking for effect, as it isn't even remotely close to the truth.
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.
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.
I don't understand your comment. Hardware isn't the issue. Physicians were early adopters of a variety of devices, starting with PDAs, thence to pads quite a bit more sophisticated than your odd and ancient example, all to try to solve the same problem your platform purports to assist with.
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.
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.
after working in a hospital and seeing older doctors hire people just to answer and reply emails.. I think this market assumption may be correct.
Hospitals and private practice healthcare offices are two entirely different worlds. In a small healthcare practice the doctor will be paying each staff member as an employee.
Company launches practice management software. Film at 11.
Wow, it's almost as if we weren't on a social news site catered toward companies and their launching products.
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.
how is this better than the existing computer systems doctors use? (It's on a iPad doesn't cut it IMHO)
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!)
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!)
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.
Works pretty well for doctors surgeries anyway.
But I have no idea how things work in the US so maybe it's completely different.
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.
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.
I applaud your effort. I think dictation is going to be crucial. Keep pushing!
I am wondering if you are worried about the new Apple policy changes. Specifically the 30% subscription in-app. Do you feel this applies to this type of SaaS app?
Didn't Jobs say they don't consider SaaS apps to be affected by that?
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.
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.
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!
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!
So what happens when Apple pulls this app for $arbitrary_reason? Are your medical records gone?
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.
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.
What about their recent changes to billing models? Do the doctors pay your $99 fee through the iPad's in app purchasing?
Apps for corporate use go thru different qualification. Does this app fall under those rules?
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.
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.
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.
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.
"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!
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!
I'm not sure if this is going to be relevant to you but it popped into my head whilst reading through the comments and in particular your note about speech to text.
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.
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.
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.
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.
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.
What about a number interface -- hit a button to bring up an oversized numeric pad?
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/
http://jayparkinsonmd.com/
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.
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.
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 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.
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.
Here's the combined rules. The security rule starts on page 38.
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
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 started working in the medical billing space 2.5 years ago, the surprising thing is that all of this information is already out there. Medical billing condition/procedure codes that are electronically reported by 90% of doctor's offices already disclose all of this information across secure channels to insurance companies and government payers.
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.
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.
Ding ding ding. That's the elephant in the room, I was surprised the article neglected to mention it.
Ding ding nothin'. Physician fear of the unknown is the elephant in the room. If you know anything about crypto and read the hipaa security rule, it's very underspecified. The Gov't will be the first one to bear culpability if they push too hard on this. That said, no serious data custodian is going to lack for vastly more than adequate tools for data security.
Sorry, still disagree. Software gets into healthcare one of two ways: a.) pre-packaged from big vendors or b.) contracted custom code. It doesn't get in from Apple's App Store, no matter how much we wish it did.
The Gov't will be the first one to bear culpability if they push too hard on this.
Riiight.
The Gov't will be the first one to bear culpability if they push too hard on this.
Riiight.
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.
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.
iPad's are better for interacting with patients because they force the applications to require less typing. Laptops and keyboards engross users more than touch screens. (Imagine someone using an iPad vs. a laptop even in a social setting like watching TV or having a cup of coffee.) Doctors looking at paper charts are fast becoming an anachronism and the government policies are speeding this along.
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.)
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.)
You just reminded me of something. Many doctors I've spoken to don't want to use a mobile device to look up information while in the presence of a patient. It's not good bedside manner and can hurt the doctor's credibility as a medical expert (a patient may think, "Gosh, I could have downloaded that app and looked up that info myself!"). There may be a few exceptions, of course, but that seems to be the more common use case.
What you say may be true for some, but I don't mind looking stuff up in the room with a patient. Most of us try to do what's in the patient's best interests, which definitely includes in my case trying to refresh my highly fallible memory.
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.
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.
> innovative and secure ways to track and make use of
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".
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".
Having a doctor that reads and post here on HN is like gold for anybody developing medical software. You and the folks behind DrChrono really should touch base.
Every GP I've ever been to in Australia has a computer on their desk and uses it for prescriptions and patient history, in that sense an iPad may be less impersonal than being behind a screen or turning away to look at a screen. Hospitals tend to be different though as they are on the go - though there is no way any Doctor in a hospital is going to be allowed to bring in their own system of medical records. Every surgery is going to have at least those other questions you've mentioned though.
This comment deserves a lot of up votes.
I think this is the most ironic thing I've seen in the past year.
I meant his. Jeez, guys :-P
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!
The market has been BEGGING for this, and this looks like it might be the right answer. Good luck!
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.
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.
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)
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)
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....
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....
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 . . .
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 . . .
>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.
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.
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.