HIStalk Interviews Ramsey Evans of Prognosis

Robert Ramsey Evans III, MBA is president and CEO of Prognosis Health Information Systems of Houston, TX.

Tell me about Prognosis.

Prognosis is an EHR software company. We deliver a comprehensive software solution to our hospital clients. The ChartAccess EMR/EHR is a Web-based software application that provides clinicians with a complete view of the patients and their data and to support the optimal safe patient care.

I know of only a couple of handfuls of vendors that offer inpatient EHRs and I’ve heard the least about Prognosis. Why is that?

We were founded in 2006 with the development of the certification criteria. The genesis of our company was a medical records service company, a clinical informatics specialist — mainly out of the Houston Medical Center — along with a software group came together and developed a software application called ChartAccess in 2006, with the advent of that certification criteria. We looked at it as an opportunity of leveling the playing field with there being so many established vendors in the inpatient side.

Most vendors started as technologists building custom hospital applications and then taking it from there. Your approach sounds more like you started with the traditional paper medical records or some form of electronic medical records and built the application around that. How was your approach different?

You nailed it. We married what the medical record looked like in yesterday and today’s environment with a clinical perspective and brought the Web 2.0 web services technologies to marry our application. We started with CPOE and eMAR. That was the first certification criteria focus in 2007. Then we built out from that clinical base CPOE.

What advantages did that give you, having not gone through those generations of rebuilds where the technology changes? You are, I assume, still on your original technology. Has that been an advantage from a maintenance standpoint?

Absolutely. From a support standpoint, our infrastructure requirements are very limited. We can do traditional on-premise. A lot of our hospitals aren’t ready to get rid of their servers yet, but we also can do the SaaS model but it has reduced our maintaining of hardware. Also, with the updates that go to our clients, it’s seamless. There’s no PC to update, it’s just through the Web.

Are your sales primarily hospitals implementing their first EHR system, or is it a replacement market?

Almost all of ours are first-time. They’re in a paper environment. They may have some ancillaries — you know, lab information system or a RIS or PACS system in terms of clinical — but in most cases, they have nothing in terms of a CPOE, the core medical record.

Does that make it easier or make it harder for you to implement, where you’re not replacing someone else’s system?

I would say we have clients that are net new hospitals that are just opened. That’s like a whiteboard. Those clients actually are the easiest. They don’t have a system and they don’t have a paper process. But then when you go into the implementation phase for a hospital that’s doing a paper process, the biggest piece is change management.

You can deliver a great product in the newest technology, but we spend a lot of time on that workflow migration from the paper to the pure electronic. That part of it is, I guess, a little more difficult up front, but that carries big-time dividends when you go live, as long you’re able to take care of the people.

Small and rural hospitals are pretty underrepresented in the land of HIT, so you don’t hear a lot about them. A lot of folks think a 300-bed hospital is tiny. How would you explain what it’s like in the hospitals of the size that you implement that might not be what people would expect?

Most all of those folks are wearing two and three hats. They don’t really have a whole lot of time to spend learning new things. Your IT directors, a lot of times, are also doing something else like running an ambulance team, etc.

You have to be able to come in and work around their schedules. In most cases, it’s like a small business. They’re having to do a lot of other things, so you have to make the implementation process and the training and go- live process as flexible and easy as possible.

The other perception might be that because they’re small, they’re expectations are lower as far as the systems that they purchase. Do you find that to be true?

Absolutely not. They have the same needs as a large hospital. They still have the same emergency departments. They have Level 4 trauma. Their needs are just as great as a big hospital. It’s just they have fewer folks to take care of.

A lot of the HITECH money is probably going to go to these small hospitals that are finally encouraged enough to really be interested in automation. What advantages do think that Prognosis offers them over your bigger and more established competitors in that small and rural hospital market?

We can get them to Meaningful Use from start to finish and in a rapid fashion. We have clients that have made it in 4-6 months and less. Then, with Meaningful Use Level 1 attestation starting October 1, there’s a squeeze here. We’re seeing that in the marketplace and able to help them on keeping those implementation cycles down so that they can achieve their stated goals.

Do those customers perceive that a fairly new, privately-held company holds more risk to them than a vendor that is larger and publicly traded?

Yes, we had to deal with that on a very regular basis earlier in our life cycle. As we have gotten a bigger reputation in terms of delivery, that has gone away at some levels. But in our target market, most of those hospitals require the same type of due diligence of a small, private company versus a big company in terms of their ability to deliver, like checking references. That’s where we have focused in making sure that all of our sites are reference sites.

Can you give me some idea of the size of the company in terms of number of installed sites or employees? Whatever you’re comfortable sharing.

I can. We’re working with about 60 or so hospitals right now in various stages, either all the way fully implemented all the way through to early stages of contracts.

You just had an announcement not very long ago about a relationship with Order Optimizer. What value does that bring to your customers?

That really enhances our CPOE since, as we mentioned earlier, CPOE is where we were born. Those clinicians that elect that option — that upgrade, if you will — are able to merge order sets and code morbidity, and it really cuts down on their amount of time they have to be in the system and they can get back to their patient.

We have found that most of the clinicians that are using our system, as they get very acquainted with the electronic process, that is a natural step in achieving evidence-based medicine.

If you look at your technology advantages in areas where you’ve innovated, what would you say are the benefits that you offer there?

We’re Web-native. One of the biggest pieces in this puzzle, from our perspective, is mobility — being able to access the system from anywhere, wherever the clinician is in the hospital or outside the hospital.

We’ve already developed our platform on the iPhone. The iPad will be next month. In terms of being able to give the clinicians the access to the system from wherever they are, and being able to have that user interface where they can stay off of the keyboard and can be taking care of the patient.

Sounds like you’re pretty comfortable with the status of certification and Meaningful Use and that your customers will have time to ramp up and get going in time. Is there anything that concerns you, or that you were disappointed, at what came out of Meaningful Use?

We made a calculated step. We built in almost all the recommended Meaningful Use pieces into our product, before April, after they were announced in January. So when the announcement came, almost all of our clients were absolutely happy because we were already on our way. The reduced list makes them feel even more comfortable with achieving it if they’re not already there. But we all know they’re coming and we’re planning ahead and staying ahead of that curve instead of reactive.

There is at least anecdotal evidence that hospitals are driving some of the physician practice decisions for EHRs through some type of support. What do you say to a customer who comes to you and wants to integrate their physician practices that are either owned or affiliated with their inpatient practice?

We think the open architecture approach … we offer the whole solution, but we don’t force hospitals and their clinics to replace anything if they’re happy with it. So, we take both ways. If they want that to happen, then it’s not a big hurdle for us because of our architecture. Then if they want to replace, or if they don’t have something, we know that you have to come with a total solution.

Tell me the modules that you have and those that you generally have to advise the customer to seek elsewhere.

We have everything from billing/financial from the front end registration: general financials, general ledger all the way through everything in the clinical world: CPOE, eMAR, radiology, lab, pharmacy, and HIM. We do not have PACs. We recommend PACS solutions.

And you have clinical decision support, I assume?

Absolutely. That’s one of our strengths when we’re talking to our users. It provides plenty of clinical decision support as well as care plans so that they can meet their measures.

When you look at your reference sites, what results have they seen from their implementation?

In all of our reference sites, they’ve been able to access the information at the point of care. That’s the biggest pat on our back we get is that they are able to see everything in real time and be able to make better decisions at the point of care. That’s the biggest we’ve seen.

Then, access to data. They’re all looking at the same thing. Maybe if a doc is on the phone with a nurse from wherever he or she is, they’re able to view the same information in the same system, whether they’re in lab or radiology, and be able to make real-time decisions.

One of the difficult parts of why vendors typically failed at selling to small hospitals is they’re a hard group to market and sell to and they’re also a tough group to implement in a cost-effective way. How do you do it differently than a big vendor who just tries to take the same product and stick it in a 50-bed hospital?

We take the approach that every hospital is an individual and is different. But in our product, you’re able to, instead of customize, we configure. Our architecture allows everyone to have their own workspaces. We take their desk setting, if you will — a nurse’s desk setting — and we convert that, somewhat, into their landing screen. Their landing screen allows them to match their workflow.

It’s not hard coded, it’s just a configuration at the client level, the individual level, and that remains throughout. It recognizes their permissions, etc. so they don’t have to come back. On the cost side, that is one of the things that the intuitiveness of our system allows folks to … if a clinician is able to use normal applications like Outlook, in a relatively short time they can figure out about 80% of what they want with support and training from us.

Where do you take the company from here?

We’re very excited about Meaningful Use being defined on July 13th. We’ve already seen a big increase in requests for demonstrations, so we’re going to continue to execute our plan to deliver our solution to the hospitals and stay at the front on the development side of Meaningful Use and the newest and best practices using the newest tools that we continue to embed into our product.

Any concluding thoughts?

We are very excited to be a part of this transformational time in healthcare and look forward to participating. As we look back, although challenging for the hospitals in terms of change management, we’ll surely help on the cost and patient care side.