Podcast interview with Keith Belton of Nuance Communications (transcript)

This is a transcript of my recent podcast interview with Keith Belton from Nuance Communications.David E. Williams:  This is David Willams, cofounder of MedPharma Partners and author of the Health Business Blog. A few days ago Nuance Communications released version 10 of its speech recognition software, Dragon Medical. I am speaking today with Keith Belton in the healthcare division about the new launch.Keith, thanks for being with me today.Keith Belton:  David always a pleasure.David:  Keith what exactly is Dragon Medical, and who uses it?Keith:  Dragon Medical is the leading speech recognition product used by medical clinicians --physicians and nurses-- in the United States to document patient encounters.David: And do they use it as a standalone or is it used in conjunction with other systems?Keith: Dragon Medical is designed to interact very tightly and efficiently with EMR systems such as eClinicalWorks, Epic or Allscripts. Dragon Medical is a technology that allows physicians to navigate their EMR via speech commands and also allow the clinician to dictate what we call the medical decision making into note. It's a very powerful tool that makes EMRs faster to use. It allows them to dictate more complete records in less time than by dictating or typing.David:  You are up to version 10 of this software. What are some of the key they things in the new release and why are they there?Keith:  Dragon Medical 10 provides a full suite of capabilities that allow it to be used more tightly and easily with the EMR, and also makes the speech recognition experience faster and better. Speech recognition technology is all about speed and accuracy, and Dragon Medical 10 is an enormous advance over Dragon Medical 9, which in itself was a great product.Dragon Medical 10 is 20 percent more accurate out of the box than Dragon Medical 9. It's almost 40 percent more accurate than nonmedical versions of Dragon. We sell a product for the nonmedical space for home and business use. Dragon Medical also allows the clinician to dictate anywhere in the EMR. So they can be looking at lab tests or patient history and be dictating, and when they are completed Dragon Medical puts that dictation right into the patient's notes.There are also a number of features that make it a truly enterprise product. We are now working with major healthcare organizations that are having hundreds or even thousands of Dragon Medical users using it with the EMR system. And it is really the first industrial strength version of Dragon Medical that really allows a chief information officer to install it and deploy it enterprise-wide across hospitals and clinics, and have it for use effectively and provide a low total cost of ownership.David: Why is it so much better than just using software that isn't setup specifically for medical use?Keith:  We have done some analysis on the accuracy issue, and for clinicians who are seeing 30, 40, 50 patients a day, they are being pushed by the use of the EMR's to spend more time documenting care. And of course what that means is less time with patients and longer days. So, the increased accuracy of having medical vocabularies that cover almost 80 specialties means clinicians: a) don't have to spend time adding words to the vocabulary because each medical vocabulary within Medical Dragon has the words. And b) it reduces almost to zero the amount of corrections.So if you are a pediatric oncologist, gerontologist, psychiatrist or an emergency physician you simply load up Dragon Medical, and you choose the specialty that you work in, and physicians know with confidence that the words that they are going to be using are going to be there. So right out of the box they will be getting accuracy in the high 90's, and it makes for a very, very high confidence experience.One of the other features I forgot to mention David, in version 10, is a whole new dimension that Dragon Medical brings to handling people with non-native accents. So if you are from India, Pakistan, China or Mexico  with version 9 out of the box your accuracy level was probably going to be 15 to 20 percent lower than what you and I might be getting out of the box.Version 10 is a game changing technology. It listens to your speech and after about 10 minutes, loads one of eight region specific language accent models, and these accent models essentially boosts a person who is a nonnative speaker to about the same out of the box accuracy that you or I might get. And, since we think about 20 percent of all physicians in this country are non-native speakers, that's a huge, huge boom, and it's a major obstacle taken away for a large urban ambulatory center or teaching hospital that might previously been hesitant about using the technology because they might have had a high degree of non-native speakers.David:  You talked about the out of the box functionality and then being able to select your own accent. Could you tell me a little bit about what training is needed, so that it can recognize the user's voice well? It sounds like the accent correction allows somebody to zoom up a lot faster on the curve, but can it go from there? Does it learn from my individual voice over time?Keith:  Absolutely. As with all Dragon products as soon as you start speaking into the system you are giving Dragon Medical data. By not correcting things you are validating that the words that you said were correct, and that improves your accuracy and allows your language model to adapt. And when you make corrections, when it mis-recognizes occasionally, and even at 99 percent accuracy which is what many folks achieve shortly after using the product, there is always going to be a word or two to correct.... When you change the system you give it data and it adapts. And over time, the accuracy is going to get better and better.David:  Now, I could imagine that there may be some new issues that are introduced with a technology like this. So, I am thinking about drugs with similar sounding names. You know there is a focus on how drugs names are written, so the pharmacist doesn't make a mistake. But what about drugs that sound similar? Are there any particular steps that are taken to counter that problem?Keith:  One of the things that we have done with version 10, as we do with all our releases, is we go out and we look at the national drug indices and lists of approved over the counter and prescription drugs. So we have a full database of all the scripts that are written in this country.A

lso as part of our improving language with each new release, we collect literary tens of millions of notes, which have been dictated in Dragon Medical. And also in the other part of our business, we have a very large speech recognition-driven back end transcription business. We are allowed the ability to tap those  deidentified patient records to look at drug data. So we feel we have a very complete database.

The other thing I would say David, is that, the language model when you are dictating is looking not just at the word and trying to understand that word, but it's looking at that word in the context of the words and paragraphs you said before.So if you are specialist X, Dragon Medical automatically knows there is really a subset of favorite drugs that specialists in that specialty use and that automatically makes the accuracy of a particular drug in that specialty higher than a drug which might not be used in another specialty. Dragon Medical itself selects the medications for that specialty when the user begins a session, and it assigns a lower probability, if you will, to the drugs that don't work in that particular specialty.David:  Another issue that's come up is that JCAHO has been focusing on various "do not use" abbreviations, abbreviations that can be confused woth one another or are ambiguous. What do you do if a doctor spits one of those out?Keith:  Another major feature I neglected to mention is that we have a new medical abbreviations wizard that when you start to use the system presents to a physician a list of common abbreviations, QID, CABG. It is designed out of the box to follow the Joint Commission guidelines on what are approved and not approved expansions of abbreviations.We do, of course, give the physician the ability to override that, but the system is set up in default mode to automatically handle abbreviations in the way that the Joint Commission specifies. What it does is allows the physician to say QID, and it automatically expands to a Joint Commission improved, "Give the patient four times daily" abbreviation expansion. So that's another powerful quality and safety capability within Dragon 10.David:  Now, what happens if a physician has some stock language they like to use for a treatment plan or something like that where they might typically cut and paste it. Is there an equivalent of a vocal cut and paste?Keith:  Exactly. Dragon Medical has Dragon Templates, which are exactly what you described. So you and I can be physicians, and we both may have a normal chest exam. When you say "normal chest" you can predefine a sentence, two sentences, a paragraph that looks like your normal chest. I can say "normal chest" and have my particular paragraph pop up.

What's very powerful in Dragon 10 is it allows you to put fill-in-the-blanks fields with pull down menus and values so that you can use that template not just as a flat block of text, but you can have your cursor automatically stop at the first place you are looking for --perhaps a blood pressure or a mild, moderate, severe modifier-- within the paragraph. So with Dragon 10 you not only can create these text based macros, these text based templates, but it allows you to now put variability within them, which makes them even more flexible and more powerful.David:  And what's the cost of the software? Are there any other hardware or other sorts of costs that a person would incur if they wanted to get the system?Keith:  Dragon Medical comes with a standard recommended specification. So one gig of memory. There's a certain processor speed, which is not inconsistent with a standard machine that a clinician would be using in a medical setting. The price of Dragon 10 has not changed from version 9, so the list price for one physician is $1599 to purchase with an 18% annual maintenance, which allows them to get future upgrades for free. The price of Dragon Medical hasn't changed.We provide an enterprise site license version that large institutions will purchase where we simply work with the information technology department to essentially inventory the number of clinicians, and they buy a license for all their clinicians. There's also a small practice Dragon Medical for physicians  practices that have five or less doctors  that have a smaller set of features, don't have all the features of the full Dragon Medical box system. That's priced at $1199.David:  So it sounds like it's not a big capital expense. But just the same, as physicians are always looking at how they spend their dollar, would you say there's an actual hard return on investment for this or is it just something that makes the practice flow a little bit better?Keith:  Well, one thing I can say, David, unequivocally is that Dragon Medical 10 has the highest return on investment of any health care information technology product. There's a number of dimensions on the payback. So at $1600 a user, the payback just on eliminating transcription alone is about three or four months. Most physicians who use transcription are spending between $5,000 and $10,000 a year in transcription. At $1600 you can see it's a few months... I think somebody calculated 37 days for one of our particular customers.But the transcription savings is really only one small part of the value proposition. I talked a little bit earlier about how Dragon Medical allows doctors to provide that Medical decision making in the note, and there's an old maxim in medicine that says, "You don't get paid for what you do. You get paid for what you document."Medicare and private insurers pay based upon what you document in the note, and the information that they're looking at in the note includes key elements  the history of the present illness, the assessments of what the patient has, and the plan. Those three elements are collectively referred to as medical decision-making.If you're using an EMR system alone and you're using the templates only, you're really not able to describe the richness of the encounter and your assessment and plan. Medicare will score and a private insurer will score that encounter lower than if you take the time to dictate the extra couple of sentences that give that flavor and the richness of your thought. So we're seeing physicians who are telling us that their generating $500, $1000, $1500 a year more with Dragon Medical dictation.Plus we're also hearing from clinicians that Dragon Medical makes you about 25 percent more productive in an EMR, which means that those doctors who want to can add to their practice volume, add a couple of extra patients a day. If you are adding a couple of extra patients a day, that's thousands of dollars a year in additional revenue.So while we're not looking at Dragon Medical as a device to make physicians richer, you can see that the payback for Dragon is probably weeks. If you take advantage of the transcription savings, the increase in reimbursement per encounter on certain cases, and the higher volume that you can see, it's $10,000; $15,000; $20,000 of additional benefit, compared to $1600 for Dragon Medical.David:  So, Keith, the product sounds very interesting and cutting edge, is it something that's just being picked up by the early adopters or is it a mainstream product?Keith:  So, David, we did our calculations this summer, and we found out that about 70,000 clinicians in the United States today are using Dragon Medical to drive their EMR systems. This represents about 15% of the clinicians in this country. That may not sound like much, but we only started keeping score about four years ago.So sometime in the middle of next year, we expect that about a quarter of all physicians in this country are going to be using Dragon Medical. That's a very, very powerful statement on the value of front end speech recognition with an EMR.David:  I've been speaking today with Keith Belton of the healthcare division at Nuance Communications. We've been talking about the newly-released Dragon Medical version 10..
Keith, thanks for your time today.Keith:  David, it's a pleasure.