1. The Dragon Medical Solution

2. Presentation Summary The Challenge: Documenting Care in an EMR The Solution: Speech Enable Your EMR Dragon Medical: Overview / Demonstration Dragon Medical: Case Studies

3. The Challenge: Documenting Care in an EMR Becoming a Near - Requirement 1.Clinical documentation Rapid Adoption of EMRs – ‘Market” demanding electronic documentation instantly available – US Government 10 year plan for ‘an EMR for every American’ – 100% EMR adoption by 2014 2.Remuneration evolving from ‘fee for service’ to ‘pay for performance’  Reimbursement levels flat / declining from 2008 on  You don’t get paid for what you do…but what you document. More documentation is needed…but created in a more cumbersome way … just to maintain reimbursement levels. = HIGHER DOCUMENTATION COSTS = LOWER PRODUCTIVITY

4. Template-based notes in an EMR are lower quality … – don’t support ability to personalize for each specific patient encounter – “Point and click” interface lacks patient narrative and medical decision-making – Generate “cookie-cutter” reports …and EMRs impact productivity and profitability “Point and click” slows physicians down – Studies have shown that EMRs do not in themselves lead to higher reimbursement – Physicians didn’t go to medical school to become typists – Transcription prohibitively costly – oftentimes eliminated to pay for EMR The Challenge: Documenting Care in an EMR Requires Using “Point and Click” Templates

5. The Solution: Use Dragon ® Medical 10 to “Speech Enable” Your EMR “Hands-free” Use of EMRs – Dictation – Navigation The Market Leader – 80,000+ clinicians – All Windows®-based EMRs Increase Physician Productivity Improve Patient Care Eliminate Transcription Maximize Reimbursement Faster Adoption of EMR Provider PC with Dragon Medical & PowerMic II EMR System

6. Dragon Medical Lets Physicians Dictate in their Own Words, Complementing the Rigid Structure of an EMR Dragon Medical’s Impact on EMR Use – Survey Results 1  “It significantly improves or improves EMR use and facilitates the practice of medicine…” (80%)  “it speeds my EMR use up so much I see the same or more patients prior to going live with the EMR…” (80%)  “Thanks to Dragon, there’s been no increase in patient backlog…” (75%)  “I’m coding at higher RVU / billing levels using Dragon...” (75%) Structured “point and click” data entry Dragon-dictated narrative: History of Present Illness, Assessment and Treatment Plan Dragon-driven navigation – command/control 1 Source: Survey of AHLTA EMR and Dragon Medical Physician Users, Telemedicine and Advanced Technology Research Center (TATRC), U.S. Army Medical Research and Materiel Command,

7. Typing in EMR Speech Recognition Helps Clinicians Regain Productivity Lost When Adopting an EMR Productivity Loss Productivity Documentation method Phone dictation Speech driven EMR New point of reference for self-edit speech  Compare self-edit speech with the speed and accuracy of typing.

8. Dragon Medical 10 Demonstration

9. Proven Value Proposition Increase Physician Productivity –25% faster Using an EMR Improve Patient Care – Higher-Quality, More Complete Notes Eliminate Transcription – Save $10,000+ / Year Per Physician Higher Reimbursement – Increase $10,000+/ Year Per Physician Faster Adoption of EMR Return on Investment in 1-2 Months

10. Dragon Medical: Case Studies Community Medical Center University of Rochester Med Center Group Health Cooperative Fallon Clinic

11. Dragon Medical Case Study – Community Medical Center Challenge: Automate the creation of medical records in the organization’s Emergency department EDIM application to improve patient care and increase the use of the EMR system Solution: Deploy a 20-user Dragon Medical software license to eliminate the need to hand type information into the EMR application Results: A reduction of over $500,000 in transcription costs in the first year, with the software paying for itself in the first few months of use; reduced malpractice liability and a measurable improvement in patient care

12. Case Study: Group Health Cooperative Overview: 900 Physician, Multi-Specialty Clinic (Seattle, WA) 100% Commitment to EpicCare EMR Challenge: Enhance Epic Adoption: Offering a Way to Dictate Narrative into EMR Solution: Roll Out Dragon Medical on System-Wide Basis Results: Accelerated Physician adoption of Epic Reduced Time Spent Documenting Care Achieved Higher Quality of Patient Care Enhanced Provider Satisfaction Improved Quality of Documentation Raised Confidence of Higher Coding Levels Eliminated 80+% Transcription Costs “Dragon has really shortened the process of creating notes. It shortens my day by 1–1.5 hours because I no longer have to log in from home to complete charts.” Dr. Dean Carr Primary Care Physician “I often use my voice to trigger a command in Epic which pulls in labs info—with a single command… It’s fun! It makes a tedious task more enjoyable.” Dr. John Kaschko Primary Care Physician “The complete documentation facilitated by Dragon allows me to now code more at a level 4 as opposed to level 3…” Dr. John Kaschko Primary Care Physician

13. Case Study: University of Rochester Medical Center “An asynchronous process becomes synchronous with Dragon…When I close the note, I’m done, period.” Dr. David Krusch Chief Medical Information Officer URMC “The software works outstandingly. It interfaces smoothly with the EHR. It is affordable, replacing highly expensive transcription services use… Dragon’s success is inevitable.” Dr. Betty Rabinowitz Primary Care Internist URMC Overview: Leading Academic Medical Center 2 Acute Care Hospitals, Primary care network of 100 providers Challenge: Lower Physician Productivity Post EMR Go-Live (Allscripts) Solution: Deploy Dragon Medical 10 Across Primary Care Network Easily Allows Individuals to Create and Modify Templates Lets Physicians Document Unique Narrative per Encounter Seamlessly Integrated with Allscripts EMR – On-Site Training Results: 100% of All Primary Care Physicians Using Dragon Medical An Additional 100 Physicians Have Gone Live Physicians Report Higher Patient and Clinician Satisfaction Saving Over $1 Million Annually in Transcription Costs. Return On Investment in < 3 Months

14. Case Study: Fallon Workflow Impact Study Spring 2008 Fallon Clinic proposed a funded study to evaluate the impact of Dragon Medical V9.5 on: Note quality Provider satisfaction Productivity/cost Real-World Setting Implemented with 10 “diverse” providers: Specialty Computer and typing skills Age and gender Baseline use of dictation 1-2 hours of formal 1-on-1 training Limited customization with macros Limited support as needed 1 Preliminary results.

15. Fallon reported that Dragon Medical generated: 17 % reduction in the average # of minutes after patient left that the visit was closed so bill could be sent (55 minutes  46 minutes, P<0.1) 99% reduction in the average # of minutes after patient left for note to be available in the Epic EMR (3.8 days  46 minutes, P<0.001) 94% reduction in the average % of visits using standard dictation/transcription service (62%  4%, P<0.001) 90% reduction in the average monthly lines of paid transcription/MD (4807  503, P<0.001) 57% improvement in the average provider satisfaction with generating notes (2.8  4.4, on ratings scale, P<0.001) 26% Improvement in the average peer-reviewed medico-legal note quality (3.2  4.1 on ratings scale, P<0.001) 57% Improvement in the variance between what was billed and what could have been billed (P<0.2) Case Study: Fallon Workflow Impact Study

16. Installation Cost for first 3 years: $3,435/MD – License – Annual Maintenance – Professional Tech Support – Professional Training – Handheld Philips Speech Mike Pro USB – 5280 – 2 GB RAM Upgrade 3-Yr Cost of ~8 minutes/day/MD: $25,476 – 0.11 RVUs/minute at CMS rate of $38.09/RVU Total Cost for first 3 years: $28,911/MD Case Study: Fallon Workflow Impact Study Financial Analysis

17. Reduced Transcription Costs for first 3 years: $15,492/MD Increased billing from correct coding for first 3 years: $34,762/MD Total “Hard Savings” for first 3 years: $50,254/MD Net savings of $7,114/year/MD Savings from faster and better communication, as well as happier Physicians. Priceless! Case Study: Fallon Workflow Impact Study Financial Analysis - Savings

18. 20% Accuracy Improvement over Dragon Medical 9 38% More Accurate than Dragon NaturallySpeaking ® Professional in Clinical Settings 50% Faster Response Time than Dragon Medical 9 Regional Accent Support for Non-Native Speakers Contains Medical Vocabularies Covering More Than 75 Disciplines. MyCommands Window – Personal Commands in Browser Configurable PowerMic ® Buttons Announcing Dragon Medical 10 – The Fastest, Most Accurate Dragon Medical Ever

19. Dragon Medical 10 Includes Vocabularies for All Specialties Dragon Medical 10 supports a range of regional accents Powerful Templates and Marcos can be used to optimize workflow – See Demo Quick Voice Formatting – Demo Announcing Dragon Medical 10 Did You Know that…

20. Dragon Medical 10: Increased Number of Medical Specialty Vocabularies Includes Vocabularies for Essentially All Specialties

21. Dragon Medical 10: Improved Regional Accent Performance Nuance has collected data from many speakers and enriched its models. More people will get better accuracy quickly. For the US product: – US regions – “British”, “Indian”, “Australian”, “SE Asian” – “Spanish” New User Wizard offers Accent list – If in doubt, pick “General”. – During Optimization, Dragon may automatically select what accent it identifies as matching your data

22. Dragon Medical 10: More Powerful Macros and Templates Powerful Customized Templates and Macros streamline workflows

23. Dragon Medical 10: Macros and Templates Macros and Template Demo

24. Summary and Review Documenting Care in an EMR is a Challenge Speech-Enabling Your EMR with Dragon Medical is a Proven Solution Dragon Medical’s Value: A Return on Your Investment in 1-2 Months Dragon Medical 10 is the Fastest, More Accurate Speech Recognition Solution Ever: – 20% more accurate than version 9 – 50% faster – Contains Full Range of Specialty Vocabularies – Now Has Regional Accent Wizards to Assist Non-Native US Speakers – Can Be Customized for Greater Efficiency Using Macros and Templates

25. Contact Information Company: Telephone Number: Website:

26. Backup Slides

27. Trends Impacting you Trend 1: Clinical documentation moving to EMR Driving the demand for better patient health documentation via EMR’s US Government 10 year plan for ‘an EMR for every American’ 100% EMR adoption by 2014 Clinical documentation will move from paper files and MS Word documents to centralized EMRs » 25,000 to 30,000 physicians move to EMR per year EMR use requires clinicians to enter structured data in fields and discourages narrative dictation Physicians need to do their own data entry and typing Lower transcription costs, but reduced productivity as the physician starts typing Physicians are less productive

28. Trends Impacting you Trend 2: Remuneration moved from ‘fee for service’ to ‘pay for performance The way physicians are paid has changed dramatically. In the past you were paid by patient contact; now you are paid based on the level of complexity of the patient contact (level 1 to 5). More complex -> higher paid Doctors need to prove service level with documentation. Physicians are paid based on what they document.

29. What Do Physicians Say? “What is a clinical narrative?” “ … A first person "story" written by a clinician that describes a specific clinical event or situation. Writing the narrative allows a clinician to describe and illustrate her/his current clinical practice in a way that can be easily shared and discussed with professional colleagues. In addition, the narrative can help clinicians examine and reflect on their clinical practice or analyze a particular clinical situation.” Describing Practice through Clinical Narratives: Guide for Clinicians, MGH “Narrative allows us to share complex ideas in an efficient and often seemingly effortless manner. Its use in the medical record is extremely important for clinicians because it allows them to synthesize disparate facts and data elements and to paint a picture rich with meaning that is easily interpreted by other clinicians.” Jason S. Shapiro, MD, Department of Bioinformatics, Columbia University Studies have shown that EMRs do not in themselves lead to higher care Template-based systems lack a narrative Patient notes generated by EMRs “all look the same” »

30. Manual Driven EMR - Typing Traditional Dictation + MT Speech driven EMR HIGH COSTLOW COST EMR Increased cost Cost and Time Documentation The Speech Enabled EMR

31. Speech Enable EMR: Increases $/Visit Full freedom to document observations and plans in physician’s own words – not constrained by structure More complete documentation in History, Physical Exam and Medical Decision-Making Aspects of Record At point of charge capture, additional detail gives physician ammunition to code at a higher rate than structured note

32. RBRVS (“Resource-Based Relative Value Scale”) – January 1992 – Fee Schedule Maintained by CMS Input from AMA/Specialty Society RVS Update Committee 23 Medical Specialties Represented – 80+% of Private Insurers Use! Reimbursement Calculation – 5 “Levels of Service” Codes for New / Repeat Patients – Fee = “relative value” of service + amount of resources consumed = amount of Doc Time + Practice Expense + Liability Expense Adjusted by Geographic Practice Cost Index 2008: reimbursement 10% lower than 2007 Reimbursement requires adequate documentation to support level of service billed. Speech Enable EMR: Increases $/Visit

33. The Solution: Speech-Enable Your EMR Using Dragon Medical 10 Dragon Medical is perfectly positioned to solve the problem of: 1.Lower productivity due to EMR data entry 2.Higher documentation costs 3.Loss of reimbursement due to less-complete notes The combination of Dragon Medical + an EMR gives the highest productivity and financial benefits for the hospital and provider. DNSEMR Structured Data input The Speech driven EMR Speech