By Angel Mehta, Managing Director, Sterling-Hoffman Executive Search
One of the fastest growing software companies in North America thinks it can help solve the healthcare crisis by showing doctors how to run more profitable clinics – and deliver better care to patients at the same time. Angel Mehta, Managing Director of Sterling-Hoffman chats with Sam Chebib, CEO of Nightingale Informatix
(NGH.V), about entrepreneurship, helping doctors save lives, and the exploding market for electronic medical records (EMR) technology.
Angel Mehta: Nightingale seems to have been a regular on
various ‘Fastest Growing Company’ lists over the last 2
years…what’s behind this? Most software companies have been
devastated by the recession…
Sam Chebib: We operate in an under-adopted market and
have high growth potential. Healthcare IT as a market is in its
infant stages…like the DOS days of PCs, before anyone knew what
Windows was. Our success was achieved as a result of a
combination of factors: The clear need from the market for this
kind of technology, our technology leadership, broad suite of
healthcare IT services and having an experienced management team
who is passionate about this business.
Angel Mehta: It’s funny because when we talk about why
Nightingale has done well, you almost sound like going back to
the beginning, you evaluated the opportunity as a venture
capitalist more than as an entrepreneur who was just crazy about
the core intellectual property?
Sam Chebib: Absolutely, and that’s the way to do it now
isn’t it? Return on investment is the primary metric that should
be used to evaluate a business opportunity. Passion certainly
plays a roll…is this going to be fun? Will it be rewarding to
engage in? But we’re very fortunate with Nightingale because it
meets the test of having a strong financial return but also has
an amazingly noble cause…. We’re contributing in an immense way
to providing better healthcare which ultimately…
Angel Mehta: saves lives. I asked a physician friend
about Nightingale recently and started to ask him what he
thought about electronic medical records technology…he just cut
me off and said, ‘There is no way to do medicine over the next
15 years without deploying EMR (Electronic Medical Record)
technology – period.’ He was fanatical about it.
Sam Chebib: Right. And when you are engaged in a business
that has both the amazing potential financial return of
Nightingale and our core product contributes to society in the
way it does…it’s hard not to be excited about what you do every
Angel Mehta: You were not a technologist or software guy
by training…what was different about running a software company
than companies you’d run in the past?
Sam Chebib: I think there are a lot of positives to the
software industry and a lot of negatives. The first negative is
everybody is younger than you are. When you come from an
industry where you’re the young kid on the block and all of a
sudden you’re in the technology world and you start hiring smart
people and realize in the interview that you probably have socks
older than they are…[Laughing]. But I love the margins that come
with the software industry; I love the recurring revenue
component – the benefits that the software as a service (SAAS)
model provides. We are building annuities in a fairly sticky
business. In other industries, you win a contract, and it
probably takes you 2 – 3 years to deliver on the terms of that
contract. But when a customer buys our software, they see the
fruits of their investment in a matter of months, not years. We
add value right away. It’s incredibly rewarding to see that
Angel Mehta: As someone who was new to the software
industry, do you find it challenging liaising with your
development team? Software engineers are a tough bunch to work
with…they’re smarter than everyone, and they usually know it.
Sam Chebib: Oh, always. I mean, as an outsider or
newcomer to the software industry, you tend to think everything
is simple…modifying the product or creating any given module is
doable. You don’t appreciate what the R&D folks have to go
through to make those things happen, no matter how many times or
how frequently they push back and explain how the pieces work
Angel Mehta: So based on those experiences…what advice
would you have for non-technical CEOs who are running technology
Sam Chebib: I go back to this – it’s all about
surrounding yourself with the experts, people smarter than you
are and empowering them to do their job.
Angel Mehta: Let’s talk about Nightingale’s offering
because the EMR market is pretty complex. What is the problem
that you’re solving for customers right now?
Sam Chebib: If you want the story in layman’s terms…let’s
say you bought a GM car – and you decided to take your kids to
Florida and your car runs into problems, you go to any GM
dealer, they punch in the serial number, they can give you a
very detailed, chronological order of everything that happened
to that car from the day it left the factory until today. Then
you can make intelligent decisions on what’s wrong with that car
and how big the problem is and the best way to fix it. That’s
how things work with a car.
Now consider the same for something of greater importance. You
are the patient, and you walk into any clinic and ask for a
diagnosis of what your problem is, with no real understanding of
your own body’s history and of course, as a patient, no real
understanding of medical issues. Well then you cross the street
from your GP to your specialist. And chances are they have no
clue what your medical history is. They have no clue if any
tests have been completed, what medication you’re on, what your
family’s genetic tendencies are, what you’re allergic to. In the
absence of properly documented clinical information, the
specialist will have to consider what you tell them. And what
you tell them is pretty much your subjective view of your
condition, untrained observations about your situation. There is
no place to just punch in a social security number or some
unique identifier and obtain your medical history. It’s not a
big issue if you’re young, but as you grow older…and the number
of medications you’re on (or have been on) grow…it makes a huge
difference. People die because there’s no access to real time
clinical information through an information highway for
healthcare – especially in North America.
The main reason that there’s no such information highway for
healthcare is because in North America, 80% of the clinical
information collected by the doctor or a nurse is done in an
Angel Mehta: With a pen and a paper…?
Sam Chebib: Exactly. Hospitals tend to be a little better
in terms of automation and documenting your personal history,
but this is a small fraction of our medical history. But the
majority of the medical information is not stored anywhere that
is easy to access for any given physician that may need that
history to offer you the best treatment. That’s what we’re
trying to solve. Our mission is to try and get physicians to
document what happens to patients electronically so that
ultimately, the patient receives better healthcare, the
physician becomes more efficient and our overall cost of
healthcare is lowered.
Thankfully, various government policymakers understand this
problem and the overall costs to society of not having
electronic medical records. They’re determined to do something
about it. For the first time in any industry, governments in the
United States and Canada are encouraging physicians through
programs or incentives to adopt EMR technology. Governments have
realized that EMR can provide better quality care and reduce the
overall cost of healthcare to the system, freeing up dollars for
investment in additional facilities.
Angel Mehta: Can you quantify that? I mean, why is it the
best investment a physician will ever make?
Sam Chebib: There are studies that suggest that for every
dollar spent in healthcare and in delivering healthcare, 25¢ is
waste and redundancy. I’ll give you an example on how that may
happen. If you were to go today to your GP and you complain of
anything, they may send you to get some blood work done or an
EKG. You can go back a day later to another clinician for a
second opinion or maybe a specialist who doesn’t have access to
the results of that blood work or EKG. So what happens? The
exact same lab work needs to be done again. The same principle
may apply for prescription drugs. It’s all about access to real
They can’t rely on what you tell them because as a patient, you
don’t have the qualifications to give them the detailed
information they need. So they need to do those same tests over
Physicians operate in a quasi information vacuum since the
information they need may already exist but they don’t have
access to it. I’ll give you another example related to
efficiency at the physician level: When Vioxx was recalled from
the market a few years ago, because of certain perceived risks.
Word got out that you have to immediately tell your patients to
stop taking Vioxx or at least what the risks were. The average
physician has 2,000 charts. The amount of effort required by
each physician to go through these 2,000 charts to figure out
which patients have been prescribed Vioxx is quite laborious…the
sheer number of hours involved…no physician can possibly do that
by hand. Yet it’s a 30-second exercise with EMR technology to
just scan the data, pull up a report and spit out letters or
send e-mails to everybody who is on that drug to stop taking it.
That’s the power of digitizing medical records. See what I mean?
Angel Mehta: Yes, but that seems so obvious…. Why is
there such a giant delta between the technology that’s available
and the number of doctors that have implemented it? It’s almost
like healthcare, an industry full of really smart people, is
behind every other industry when it comes to the deployment of
really basic technology. Is that true?
Sam Chebib: In North America, yes. But in the UK, the
adoption for Electronic Medical Records technology is near 100%.
In the Netherlands it’s 100%. Scandinavia it’s 100%.
Angel Mehta: So why is it taking so long?
Sam Chebib: There are valid reasons for why it is taking
so long. Number one – there is a behavioural change required by
the physician. That’s our biggest obstacle. Some physicians are
not convinced on the return on investment from implementing an
EMR to justify dropping their paper pads and pick up a tablet.
I think there is a demographic issue as well – physicians tend
to practice way beyond the average age of retirement so we have
a good chunk of physicians in their 60s and 70s that may not
necessarily be open to changing their behaviour. I think what’s
happening right now is the younger generations of physicians are
changing the landscape: They know that EMR is critical, and they
won’t run their practice without it. Government subsidies are
making a huge difference. I think in about three or four years
from now, it won’t be an option anymore – every medical clinic,
every hospital, will either have EMR technology, or be on the
path to getting one. You can’t do business without email today,
and in the future you won’t practice medicine without EMR
Angel Mehta: Are government subsidies from the Obama
stimulus helping Nightingale’s cause?
Sam Chebib: They will, I believe in a major way, as they
will force mainstream market to occur. But as of now, the Obama
dollars have not started to flow yet. The criteria have not yet
been defined for what makes a physician qualify for some of the
subsidies available. But in Canada, the subsidy programs are a
lot more mature, and we started to see some pent up demand and a
lot of positive signs in the market place
Angel Mehta: How does Nightingale’s offering compete with
the other EMR products on the market? In essence, why should a
physician buy from Nightingale and not someone else?
Sam Chebib: Good question.
While we realized that the ultimate customer is a single
physician, and the product has to satisfy their specific
interest, we also saw a shift in the buying behaviour, where it
is done at the Enterprise level on behalf of many physicians. So
we built a function rich, enterprise grade product for large
scale roll-outs We sell at the enterprise level to hospitals and
buying groups, but they have the capability to roll the product
out to hundreds or thousands of physicians under their pyramid
if they wish and the product was built with the physician’s
needs in mind.
The way to do it was to leverage the internet and deliver our
products and services as an ASP model, eliminating the need for
our clients to invest in servers and IT infrastructure. It is a
total outsourcing model.
This has proved to be the most efficient model for optimum
Angel Mehta: What are the biggest misconceptions that
physicians and customers have about Nightingale or EMR
technology in general? Is there a gap between what customers
perceive and what the reality is?
Sam Chebib: Yes, and its simple – just technology
Unfortunately, physicians get attracted to simplicity. They are
probably justified in their thought. The problem lies in the
fact that extreme simplicity defeats the purpose of being able
to capture clinical data in discreet fields, reducing the user’s
ability to report properly on the data and defeats the purpose
of being able to aggregate the data to create the clinical
information highway. I believe that the various certifying
bodies have realized this problem and are tightening the
specification for approving products
Angel Mehta: What are some of the most exciting
transitions that Nightingale has gone through in terms of its
product offering and its ability to help physicians run their
Sam Chebib: One major transition that we went through
about a year ago where we came to realize that at the end of the
day our user’s interest is in the output, not in the input. So
the first thing we did was bundle a traditional medical
transcription service with the offering, so those physicians who
like picking up the Dictaphone and having someone else
transcribe their notes can now dictate directly into their EMR.
So essentially, doctors can use our technology without changing
their behavior or workflow. Doctor’s love being able to do that.
The other major transition is what we call natural language
processing, where we can take the input in text format, and
through complex algorithms extract reportable discreet fields.
This helps in providing easy input methodology with intelligent
Angel Mehta: Let’s switch gears for a bit and talk about
entrepreneurship and the CEO experience…I’ve always wondered if
there is a formula we can use to predict whether someone will
become a CEO or entrepreneur. Do you think there is a
correlation between growing up in a business family and becoming
a business leader? Be it as a formal CEO or just an
Sam Chebib: I don’t think so. I think there are numerous
examples of siblings who grew up in the same household that
ended up on the two opposing extremes of the business spectrum.
I believe that you’ll find that there are two types of CEOs –
those who follow a well defined plan of moving up the corporate
ladder…those are the ones that inherently do not take a lot of
risk, so it takes them relatively longer to become leaders.
Then there are those who take larger risks very early on in
their lives….Some fail as we all know, and a few of them
actually make it big.
I was in the former category; I moved up the corporate ladder,
doing it the safe way…and didn’t become an entrepreneur until I
Angel Mehta: If you had a chance to go back and do it
again, would you have taken more risk early on?
Sam Chebib: I guess I would have. I mean it’s a big
mistake to take it later on in your life; you’ve got to do it
before you have kids because your priorities change when you’ve
got a family to care for and rightfully so. I would have missed
out on a lot of the leanings that I acquired being with large
organizations, but it may have balanced itself out.
Angel Mehta: So what finally drove you to finally take
the entrepreneurial risk later on in life?
Sam Chebib: I think there are a number of factors. I
think you have more confidence as you mature as a business
executive, you’re a lot more confident in your ability to take
the deep dive and take some risk. After so many years, it’s not
necessarily intuition, it’s not a gut feeling of what may or may
not succeed, it’s a properly thought out approach that come with
age and maturity and you can see a clear path in front of you.
You know, with some degree of certainty, how you’re going to get
from here to there. Another element that comes into play is that
if you’re a bit older, perhaps you’ve built some financial
security; so your tolerance for failure becomes a bit higher.
Angel Mehta: Bill Gates used to keep a memo called “The
Ten Great Mistakes of Microsoft” and update it every year…I
always coach the CEOs I’m working with to keep that type of
list, as a way of having a log/formal history of bad decisions
so that they can avoid similar mistakes in the future. Have you
ever kept an inventory like that? Perhaps of early mistakes made
in your career…things that you wished you had done differently?
Sam Chebib: This is a good practice, that maybe I should
adopt. I wouldn’t say there is one flagrant mistake that I made,
but there are a number of smaller mistakes that haunt me now and
then. But if I were to pick the biggest one, it would be the
tendency to be impatient and lose focus. When you’re an
entrepreneur, you start working on something interesting and
exciting and pretty soon you’re off chasing a brand new idea,
falsely assuming that the core business will look after itself.
So a lack of discipline is a key weakness for many
entrepreneurs, and it was certainly one of mine early on.
Fortunately I’ve learned to curb that vice.
Angel Mehta: Was the ability to curb that vice, as you
say, a function of having been a fairly senior executive prior
to becoming an entrepreneur?
Sam Chebib: Partially, yes. That training gives you a
sense for the importance of using metrics and trends and numbers
to evaluate your actions. If the trends and the metrics are
going the wrong way, then there is something wrong with what
– beyond the excuses you give yourself.
But I have to give credit to close friends and business
associates that have my best interest in mind.
Angel Mehta: Entrepreneurs who get started early will
inevitably be surprised at every turn as they encounter the
challenges of running a business for the first time. But you
were obviously quite seasoned by the time you became an
entrepreneur….so what surprised you, if anything?
Sam Chebib: I think the biggest surprise for me, and
probably for a lot of entrepreneurs, is that ‘if you build it,
they will come’ fallacy. As an entrepreneur, you inevitably
believe in what it is it you’re offering – more so than anyone
else. And you just assume that with the amazing value
proposition you have, customers will come. But it rarely works
that way… I have spoken to many entrepreneurs, very few of them
saw their early plans unfold as they have anticipated. But with
focus and perseverance, it works itself out couple of years into
Angel Mehta: Unless you’re EBAY or Google…
Sam Chebib: Sure disruptive technologies with viral
marketing element…but 90% of the time, customers have to be
shepherded…they have to be lead into buying. It never happens as
quickly as you want it to and it never happens as easily as you
want it to. The more you dive into the business, the more you
find that there are others that are just as smart or probably
smarter than you are that have figured out a lot of the
questions that you’ve been struggling with for a long time. And
they’re struggling to get customers just like you are.
Angel Mehta: What was the best advice you’ve ever
received from an early mentor that is still relevant today?
Sam Chebib: I had a number of great bosses and mentors.
The one that stands out, is my boss two jobs ago, who I would
like to think is probably one of the greater minds in Canadian
business. While I don’t think he verbalized his advice, but
rather articulated it by setting an example through his everyday
conduct. It was this: Establish your core values, live them and
let them dictate your behavior and surround yourself by
likeminded people who share those values. Everything else will
look after itself.
Sam Chebib is President and CEO of Nightingale Informatix
Corporation, one of the fastest growing health care service and
software companies in North America. Prior to founding
Nightingale, he was the President and COO of MedcomSoft Inc., a
public healthcare information company listed on the TSX
specializing in physician practice management systems for the
Canadian, United States and Australian markets. Sam held a
number of positions with Toromont Industries Ltd., a public
company listed on the TSX specializing in construction
equipment, energy and industrial equipment. He instrumented the
acquisition of the medical and dental assets of Medifirst, a
private healthcare delivery company, as part of a family
business. For interview feedback, please contact Sam at
Angel Mehta is Managing Director of
Sterling-Hoffman, a retained executive search firm focused on VP
Sales, VP Marketing and CEO searches for enterprise software
companies and lead investor in
www.softwaresalesjobs.com, the #1 site for software sales
jobs. Angel can be reached for feedback at
Disclosure: Angel Mehta owns shares of Nightingale Informatix.