The problem with free EMR is that while it may be free from a financial perspective there are always other costs associated with free EMR. Here’s an example of a parts of an email I recently got about a new Free EMR. The company is called Practice Fusion and the following is excerpts from the email I received:

Today we have a press release going out (below) about Practice Fusion releasing a suite of physician applications, including Practice Management, Scheduling, Secure Email and Patient Management that are free and web-based. These are effectively ‘Google Apps’ for doctors - everything a practice needs to run their office, manage and schedule their patients, communicate with other members of the office – all web-based and at no cost.

I really liked the marketing angle that this company is taking. I personally am a devoted google apps user and I absolutely love what google apps is doing for me. Google apps is a completely free application that gives my businesses (EMR and HIPAA included) a whole bunch of business services with my very own branding. Most important of which are Email and Google documents. In return for using this free service, Google puts ads around the various services. A small price to pay for me to receive free email.

Turns out, Practice Fusion is offering a free EMR using the same model as Google Apps. My email described Practice Fusion’s free EMR revenue model as follows:

We generate revenue by embedding advertising, including pharmaceutical products, into our physician tools. We also incur revenue through the sale of anonymized patient data to research groups, pharmaceuticals, and health plans.

Basically, their planning on selling ads around people’s patient information. People are still freaking out about Gmail and Google apps placing targeted ads around their email. Why? Because in order to target the ads properly, that means Google has to search all of your “private” emails. Does this mean that Practice Fusion is going to be searching through all of your patient data?

Being completely honest, I personally don’t have much to hide and so Practice Fusion could have a hey day looking through my health information. However, I’m not sure most patients will share my same view. My guess is that most patients would feel very uncomfortable going to a doctor that is using a service like this. I think they’ll feel like their doctor was selling their information to save a buck. It might be one thing if the patient saved some money too, but that’s not going to happen.

Certainly a doctor using this free emr didn’t have to tell their patients that it was paid for by advertising and getting their information sold. However, could you imagine the backlash that would occur if they didn’t tell their patients and then someone found out. I’m honestly not sure how many doctors would want to take that risk. Sounds like the perfect 11 o’clock (it’s later in Vegas) news story to me. Lead Story: “Doctor Sells Patients Data to Save Money.”

Maybe I’m wrong and people won’t care about this or those that do care won’t find out. If that happens, then it’s hard for a doctor to argue with free. I personally haven’t looked at the feature set to know how it compares to other EMR vendors. However, there’s no arguing some of the benefits described in the email I received:

Practice Fusion offers a unique product to small and medium sized physician practices, which was developed using Adobe® Flex® 3 software for creating Rich Internet Applications (RIAs). Practice Fusion’s solutions are web-based, require no upfront costs, no extra hardware, no large software applications to install and rollout, and no backend databases, which are required by traditional vendors such as Misys and NextGen. Where enterprise solutions may take weeks or even months to implement, Practice Fusion’s services utilizes its exclusive ‘Live in Five’ process to enable physician practices to be deployed and up and running within minutes.

Web Based - Awesome! Certainly the future of almost every software application.
No Upfront Costs - Nothing to lose, but also no motivation to avoid EMR implementation failure either.
No Extra Hardware - Very nice for the doctors. Not so much for the IT support people.
No Large Software Applications to Install and Rollout - I hate managing client applications. This is a big plus.
No Backend databases - This isn’t really true since they certainly have a back end database, but the point being you don’t have to manage the backend database. A nice benefit for most doctors.

Now a word about Practice Fusion’s “exclusive ‘Live in Five’ process.” I’m certain that it is true that they can create an instance of their EMR in 5 minutes. However, don’t be misled to think that you can spend 5 minutes and have a fully functioning and fully configured EMR. It’s just not reasonable to think. It’s a nice marketing angle, but it’s just impossible.

Think about this for a second. Assuming a very small practice of 5 staff. It’s going to take you somewhere around 5 minutes just to gather the information and create the user accounts for your 5 staff members. Now add in the myriad of other configurations you’ll certainly have to do and you start to realize that your EMR won’t be setup and ready to go in 5 minutes. In fact, my experience is that the EMR configuration process is an ongoing process that never ends. Practice Fusion’s free EMR could certainly argue that setting it up is faster than setting up other traditional EMR softare, but don’t be fooled by the “Live in Five” marketing.

One final thought before I end this. Let’s go back to my current Google Apps experience. What do I do if Google changes their mind and shuts down their service? There’s not really much you can do. Google’s giving you a free service which they can terminate at any time. Luckily a number of creative IT users have found ways for people to backup their email stored on Google servers.

I finally found a link to this topic buried on the Practice Fusion website. Most of that page talks about how their more reliable than an in house system. Interesting that they didn’t address what happens when your internet goes down and you’re left up a creek without a paddle, but that’s a topic for a different post.

The thing that isn’t addressed by Practice Fusion is what happens if Practice Fusion disappears. Sure, it would be nice to think that Practice Fusion will be around forever and it’s great for them to have that confidence, but it’s just not realistic. What if Practice Fusion sells to another company? What if Practice Fusion goes under? What if the free EMR model doesn’t work and Practice Fusion decides to start charging?

It does alleviate some fear that at the bottom of the linked page Practice Fusion says “It’s your data – always.” However, we’re not talking about a bunch of linear data like email. We’re not talking about something in a standard format that can easily be exported between one software to another. We’re talking about Practice Management, Scheduling, Secure Email, Electronic Medical Record and Patient Management. How do you expect them to provide you a “copy” of this data? Would be an interesting experience to try and see what they provide and how responsive they are to the request.

I’m not trying to be overly critical of Practice Fusion. Maybe they have a great product that’s worth every penny. Wait, of course it’s worth every penny since it’s free. Sorry I couldn’t resist. My point here is that doctors should be careful when evaluating free EMR software. There are certainly benefits to a free hosted EMR solution. Just don’t be blown away by the free tag and make sure you know the challenges of free.

By the way, I hope that Practice Fusion will respond to my various assertions and comments with a response in the comments. They seem like they’re pretty tech savvy. Just the fact that they have a Practice Fusion Blog is enough for me to give them some props (even if they did use typepad and not wordpress). You can expect some future blog posts linking to their blog.

This Friday, July 11, the new Apple iPhone 3G becomes available to the public. The new $199 iPhone 3G will make mobile applications even more accessible to consumers and professionals. Healthcare is one of the most popular topics among consumers, and the iPhone 3G enables consumers to access many new healthcare applications including the free A.D.A.M. Symptom Navigator. According to Harris Interactive, nearly 117 million Americans have searched for health information online. Eighty-five percent of those have searched one or more times per month.

The free Symptom Navigator for the iPhone 3G helps consumers match medical symptoms with relevant assessments and appropriate treatments. Symptom Navigator empowers consumers to make the best use of the healthcare system and understand when self-care or a doctor visit is appropriate. To access the Symptom Navigator on the iPhone 3G, visit http://iphone.adam.com[Don't try to go there in a regular browser]. The tool offers possible causes of the symptom and medical condition, how to self treat, when it is an emergency, when you should call a doctor, and how to prevent it in the future.

Here’s my take on the two questions I posed above:

1. Should patients be diagnosing themselves?
The application described above is a very interesting idea. It’s also true that patients are trying to self diagnose whether we like it or not. I know that when something happens to myself or my kids, I always check what’s online. However, I don’t always trust what’s online. I just take it for what it’s worth and then use that to help me communicate in a more effective way with my doctor.

This iPhone application takes patient diagnosis of problems to the next level. I’m not sure I trust an iPhone to diagnose me. As a consumer, would I really benefit from the information it offers? There’s just something really comforting about calling and talking to someone and hearing someone’s voice tell you that your child is going to be fine and not to worry about it or instructions to take them to the doctor as soon as possible to resolve whatever issue they have. I don’t think I’ll get that same satisfaction out of an iPhone health application. Most likely what I’d see happening is people would check that application and then call the nurse just the same. Something every nurse and doctor in the country loves. Patients trying to diagnose themselves.

I also wonder what’s going to happen when the iPhone application misdiagnoses a person and tells them to stay home when they should be rushed to the hospital. Can you imagine the liability this company will have if someone dies because their iPhone told them not to worry about it? Makes me wonder how this company got investment. Now, I’m sick of liability ruining innovation, but you just have to wonder when we’re talking about life and death.

I should also mention that I’m a nerd by profession. If I, being a nerd, don’t think I’d use a service like this I wonder how many less computer literate people will be interested in this application.

2. Should EMR companies provide an EMR interface on the iPhone?
The first person I ever saw with an iPhone was actually a doctor I know. I wonder if he’s ever tried to access his EMR using his iPhone. The above email made me wonder how useful would it be to have an iPhone interface for doctors to access their EMR.

Of course, there’s no arguing the portability of the iPhone and the latest iPhone’s 3G technology means that it should have the bandwidth necessary to accomplish such a task. However, the iPhone is much like Dragon Naturally Speaking (DNS). DNS can pretty much work with any EMR. However, there are deep integrations that can be done with DNS that take DNS from a pure data entry application into something much more powerful. The iPhone can pretty much work with any web based EMR that works with the safari web browser. However, without an EMR interface designed for the iPhone, a doctor won’t benefit from all of the cool user interface and touch screen features the iPhone offers. Does this mean that EMR companies should build a special iPhone interface for doctors?

This is an important question for almost every EMR company. Even client server based EMR products need to ask themselves if they should build a special web based interface for the iPhone. Just because your a client server based EMR doesn’t mean that you can’t build another interface using web based technology. The question is should you?

The answer to the question becomes rather clear when you think about what advantages a doctor receives by being able to access their EMR on an iPhone. Most doctors have NEVER accessed their EMR on their phone. Those doctors I know that have accessed their EMR on their phone fall into one of the following two camps:
1. Tired of scrolling
The first category of EMR users said that accessing their EMR on a phone was painstaking because the scrolling was a constant annoyance. I think we’re all getting spoiled with big 19″ monitors. I know I’ve connected to some of my servers using a phone and scrolling was the biggest problem for me. So much so that I never tried it again. A number of companies are working on roll up screens, but until that happens scrolling seems apart of an internet phone experience. Certainly some could argue that with the iPhone you have an easier method of scrolling. This is certainly true, but it still only slightly diminishes the pains of scrolling in my book.
2. Just meds and allergies
This group seems sensible. What if an EMR vendor offered a small subset of the EMR that was available on the iPhone (or any cellular phone for that matter). Knowing someone’s medications and allergies would be nice to have available on your phone when your visiting a hospital. Why not be able to browse your EMR’s schedule of appointments on your iPhone. Many people probably do that now, but I’m not talking about synching your phone with your calendar. I’m talking about a true real time view of your appointments for that day. Would certainly be a nice way to prevent the doctor getting upset with someone from the front desk because his calendar wasn’t up to date with what was stored in the EMR.

It’s easy to see the advantages of offering a subset of your EMR information on the phone. There’s a lot of things that are useful that won’t ever happen. Unfortunately, I think this is one of those features. At least for now, I don’t know many doctors who are asking for phone integration as part of the EMR RFP process. EMR vendors are in the business of selling EMR software. If their users aren’t demanding it, then I don’t see many EMR vendors providing it.

No, I won’t be surprised if some EMR vendor comes out with an iPhone interface. Some EMR companies could do it rather quickly because of the way their EMR is designed and they might as well enjoy a little bit of PR benefit from having an iPhone application. I’ll be excited to see what that company provides, but don’t count on many EMR vendors to follow suit. It just wouldn’t be smart business for most.

One final thought. The iPhone has been a real internet darling that has garnered lots of good press. It’s what Steve Jobs is great at doing and the iPhone is no exception. The problem is that the last time I checked, the iPhone was less than 2% of all the phones sold in the US. The incredible user interface of the iPhone can’t be argued. The problem is that software companies very rarely want to develop software for 2% of the market. Until iPhone establishes user interface standards that other companies adopt, don’t expect EMR companies to start developing software for the iPhone.

When I started the job 3 years ago, I took advantage of working at the University and started classes for my Masters in Information Systems. Happily I completed my Masters a few weeks ago. With the completion of my Masters degree, I’ve decided to start looking around for other job opportunities. I already have a few leads, but I thought I’d post my availability to my blog in case any of my readers have potential job openings.

To be completely honest, I’m really jack of all trades when it comes to technology. I’ve done everything from server and database administration to workstation rollouts. I enjoy optimizing processes and analyzing how to revamp a process using technology. I don’t want to be a programmer and will probably avoid doing any hard core system or database administration, but those things are fine as a small part of my job. I much prefer working in a strategic position where I can plan and organize in a way that the company is well positioned for the future.

If anyone has some potential job openings in the EMR or Healthcare IT field, then I’d love to hear about the opportunity and I’ll have my resume handy. You can either leave me a comment or send me an email at john [at] emrandhipaa {.} com

Thanks to Medical Software Associates and emrexperts for advertising on EMR and HIPAA. I really appreciate your financial support of this blog and my wife appreciates it even more.

If there are any other advertisers interested in advertising on EMR and HIPAA, please leave a comment on this post or email john [at] emrandhipaa {.} com Visitors to this site stay an average of 4 minutes and 40 seconds and visitors are almost exclusively interested in EMR and health care related topics. A very nice targeted market for EMR vendors, EHR vendors or I would think it would work really well for pharmaceutical companies too.

Reminiscing aside, I find Mike Leavitt’s blog completely captivating. He currently has been writing about his trip to China. For some reason I’ve always had an inner itch whenever I heard about China. I don’t know what it is, but I find the place completely fascinating. So, you can imagine my fascination with the HHS secretary’s interaction with the Chinese government. Plus, these posts about HHS and China give Mike a real personal quality that I find real and interesting.

Of course, I couldn’t begin to read the HHS Secretary’s blog without making sure to find some post about EHR or EMR. I quickly found a post entitled Value-Driven Health Care Interoperability which I think could more aptly be entitled “Electronic Health Records (EHR) Progress Report.” Of course, he is in government so that explains the title.

I’m grateful that the HHS Secretary is willing to engage the public in a discussion about EHR and EHR adoption, but unfortunately the post I found is so filled with political rhetoric. It sounds really good, but really has very little substance.

First, I’ll start with the good.

Three years ago, there were 200 vendors selling electronic health record systems but there was no assurance that the systems would ever be able to share privacy protected data in interoperable formats.

I think the concept of a certification for interoperability is good. It just makes sense that every EMR software vendor should be able to interact with another. Establishing a quality standard for this interoperability is valuable and even worth certifying.

Unfortunately, I think the HHS Secretary has been getting bad information when he says the following:

Since then, we have made remarkable progress.

An EHR standards process is now in place, and we are marching steadily towards interoperability. We created the CCHIT process to certify products using the national standards and it is functioning well. More than 75% of the products being sold today carry the certification.

Where to begin? First, Mike has suggested that there were 200 vendors selling EHR systems 3 years ago (It’s probably a few more than 200 EHR, but we’ll let this one slide). Mike asserts that “75% of the products being sold today carry the certification.” If that’s the case, then simple math tells us that there should be 150 certified EHR software, no?

If you look at the 2006 CCHIT Certified Ambulatory EHR list I count 92 EHR software products. Let’s see, that’s only 46% of EHR products that are certified. Plus, my count of 92 EHR counts some of the software multiple times since a number of the EHR software vendors certified multiple versions of their product. That sounds like less than 75% of EHR products sold to me.

Of course, Mike Leavitt certainly could say that 75% represents a percentage of actual products sold. Certainly the certified eMD’s has a lot more installs than any of the free open source EMR products out there. However, I think it’s a bit deceptive to say 200 EHR and then 75% of products sold if they aren’t the same thing.

I also love how it says 75% of products sold. I think we’re all aware of the outrageous failure rates of so many of the EHR products out there. It’s unfortunate that we don’t have a percentage of products installed. Then, you’d have a much better idea of how many doctor’s offices really have the possibility of interoperability.

Wait a minute! I was being extra generous above when I said that there were 92 Ambulatory EHR CCHIT certified. Why? Because it was 92 EHR certified with the 2006 CCHIT Certification. Correct me if I’m wrong, but I think that interoperability was taken out of the 2006 CCHIT Certification (along with the joke of the pediatric requirements). I’m pretty confident about this, because I work on one of the 2006 CCHIT Certified EHR and I have no way of sending a chart to another clinic other than manually going through the product and printing out the chart.

What does all this mean? That means that instead of 92 interoperable CCHIT certified EHR, there are only 31 EHR CCHIT certified in 2007. That represents 15.5% (not 75%) of the 200 EHR products on the market today are interoperable according to number of certified EHR.

I’m not really blaming Mike Leavitt for this. I’m sure him or his office was given a nice executive report with a bunch of data and they made it look as nice as possible. Reminds me a lot of what I call EMR sales miscommunications. Sometimes the data just gets lost in translation. Let’s just hope my trackback to Mike Leavitt’s blog gets read.

You thought I was done. Nope. Still plenty more to say and I’m just hitting the major points.

In addition, a National Health Information Network will start testing data exchange by the end of the year and go into production with real data transmission the year after.

This concept I really find intriguing. I look forward to seeing this go public and I’m glad it’s on the agenda. However, I fear that this isn’t more than political hyperbole. I’d love to see how they plan to address any of the following: unique identifier, the ultimate hacker’s health information paradise, economic model, motivational model and that’s just the list off the top of my head.

The primary reasons for low adoption rates among small practices are predictable: economics and the burden of change.

I’m glad you pointed out the obvious. If this was so obvious, then why did you support the implementation of a certification that costs so much money that EHR will inevitably raise the cost a small practice pays for an EHR? That doesn’t make much economic sense. Not to mention you missed what I think is the biggest factor in lack of implementation: fear. Not fear of change. Not fear of the expense. Certainly those are two major factors, but I believe that adoption rates by small practices are so low because most doctors have seen too many of their colleagues fail at implementing an EHR.

Let’s start waving the CCHIT certification flag again. Many will be willing to make the case that CCHIT certification helps supplant a doctor’s fear that their EHR implementation will fail. It may even supplant some fear, but what it doesn’t do is decrease the number of failed EHR implementations. It’s a problem I’ve discussed many times on this blog. Certifications don’t certify usability. They never have and never will.

I actually have a thought about what should have been done instead of CCHIT, but I think I’ll save that for a future post.

Thanks Mike for opening up the lines of communication with your blog. Now it will be interesting to see if Mike Leavitt and HHS have really embraced new social media and participate in the discussion they started. I’m certain that Mike’s blog is going to become one of my favorite reads.

The biggest benefit is that it almost forces doctors, nurses, front desk staff, lab, pharmacy, etc to sit down and think about our EMR, how it could be made better and which parts of the EMR are just causing them pains, problems, frustrations, or other discomfort. We tried to make sure that each EMR meeting went over: our current EMR challenges, features of the EMR that we aren’t using and finally discuss ideas for enhancements to the EMR software.

We’re lucky that we selected a smaller EMR vendor that’s completely focused on the college health EMR market. That means that we have a strong relationship with the EMR company. In our final meeting the EMR “trainer” said that they really are our “partner” in not just the EMR, but they’re willing to support us beyond just software. The nice thing is that our EMR vendor really does try to do this. They don’t always succeed at it, but they certainly are sincere in their effort.

Another major benefit of having someone from the EMR vendor do a site visit is that they are looking at your clinic with fresh eyes. They can see things about the way your process works that you may not see. Plus, they have usually been to hundreds of other EMR installs and so they are aware of how other clinics are using the EMR software.

Of course, you can’t expect someone from your EMR vendor to come and work miracles. In fact, many of the ideas they have just may not work for the way you practice medicine. It takes a solid filter to be able to see the benefits, problems, and workarounds that will work best for your standards of care, legal regulations, and clinical organization. The biggest problems that an EMR vendor faces is that it’s really hard to build a one size fits all EMR. Different practices act differently. However, there’s something really valuable about discussing the various options of an EMR.

I highly recommend this type of collaborative approach to working with your EMR vendor. I believe it’s paid amazing dividends for our clinic. In the end, your EMR company better be a good partner or you’ll pay the price later.

As I was looking through the statistics for this blog, I decided to do a quick back of the napkin excel formula calculation of how much time people have spent reading my EMR and HIPAA articles. Here’s how I broke it down using statistics over the past year:

Number of Visits: 50,000
Average Time Spent on EMR and HIPAA: 2:04 minutes

Then, I took the above 2 numbers to calculate how many hours people have spent reading about EMR and HIPAA on this site and came up with the following:
1722 hours
or
71.75 days

Hopefully that was a well spent 71.75 days that helped improve a doctors use of EMR.

It’s been a long time coming and so it will be interesting to finally take a look under the hood. I haven’t personally had enough time to do a full analysis of Google Health myself, but techcrunch posted the announcement live and an initial review.

I think that techcrunch summed up a major part of Google Health and its meaning for EHR software in the following:

Google is planning to open up APIs to Google health to make it easy for other partners to tap into its health platform. And make no mistake about it. That is what this is: a platform. Health apps anyone?

Sure does make for some interesting thinking about how an EMR or EHR could integrate with Google Health. Depending on how my next couple days go, I may see if Google Health has given any sort of specifications for importing a patient record into Google Health from an EMR or EHR software program. In my previous posts it was said to use some form of CCR to integrate Google Health with EMR and EHR software. I hope this is the case. If it is, I think I’ll try to be the first to integrate Google Health with my EMR. I don’t think most of it would be that difficult.

We worked for an entire year testing, making requests, testing, more requests and more testing before we were able to launch an interface between our lab and EMR, but it’s been one of the best things we’ve done. The reason it took so long is the topic of another post, but it was for good reason.

One of the best advantages to a lab interface with your EMR is that you don’t have to worry about what to do with all those paper labs that you’ve signed. Inevitably all those signed paper labs will have to be scanned and attached to a patient in your EMR.

Really, that’s why a lab interface is so much better. The interface inserts the lab info right into your EMR so you don’t have to worry about:
1. Losing your lab results (before or after you sign it)
2. No need to scan your signed lab results into your EMR
3. You can run really cool reports on the data from those labs in your EMR (ie. blood sugar change over time)
4. Most EMR will notify you that there are lab results to read, so there’s no more waiting for the paper to somehow make it to you

In our EMR, a lab result gets easily signed off with the click of a check mark. Actually our labs our grouped into batches according to labs that were ordered at the same time. This makes it so all our lab results appear on one nice lab report as opposed to one lab report per lab. All doctors have to do is highlight all the labs and click “Mark as Read” and that whole batch of lab results are signed electronically in the EMR.

Of course, many of you will probably ask how we handle abnormal results. Well, I guess you’ll just have to wait to learn about that.

My job is to implement this EMR the best way possible. That’s what I do. It doesn’t matter if it’s good bad or ugly. It’s counter productive for me to rate how good my EMR is. It is what it is. I haven’t been assigned the task of selecting an EMR. I’m not paid right now to see what other EMR vendors might be better than the one I have. I’m paid to do my very best at implementing the EMR that was chosen.

I don’t want to sound harsh here, but I think that many of the EMR failures are due to people worrying too much about what other EMR software can do and not enough about what their EMR software can do. The question shouldn’t ever be, can our EMR software do this? Instead you should ask, “how can we do this with the EMR software we’ve chosen?” This is two very different perspectives that reap very different results.

I’m not talking about someone who is in the process of selecting an EMR. I’m talking about someone who has already selected an EMR. It reminds me about one of my favorite quotes about marriage that says, “When you’re dating keep both eyes wide open, when you get married keep them closed.” You could just as easily say, “When selecting an EMR keep both eyes wide open, but once you’ve chosen an EMR keep both eyes closed and make the most of it.”

Of course, one thing I can’t help doing is answering people’s questions about EMR. I’ve had dozens of people call me about my EMR and I just love talking to them about the benefits, challenges and hassles of my EMR.