I’ve been having a number of really interesting conversations with people about Pharma ads appearing in EHR and other clinical software. Most people’s gut reaction is that they don’t want their doctor seeing a pharma ad while he’s ePrescribing. However, most people also agree that there’s too much Pharma money for it not to happen.

In an article at Lab Soft News a few months back, they discuss the challenge and issues surrounding Pharma ads in an EHR:

Very distressing to me, however, is the clear link of the company, and its software, to the pharmaceutical industry. I have blogged on numerous occasions about some of the ethical and legal lapses of some of these companies (see, for example: On the Corrosive Influence of Big Pharma on Academic Physicians; Merck Creates Phony Peer-Reviewed Medical Journal to Dupe Physicians; Details Emerge About Ghost-Written Medical Articles for Wyeth). I have also reluctantly come to the conclusion that even apparently trivial advertising connections to Big Pharma can lead to mischief. I had previously thought that inconspicuous advertisements in EMRs by drug companies might be tolerated if the companies were to bear the costs of these systems. I now believe that allowing these companies even a tangential relationship to physician-office electronic medical records is too risky.

Certainly there are some really great points made. Absolutely there’s a risk that a doctor could be influenced by a pharma ad in an EHR. Will it make them provide a lower quality care because of the ad? I’m not sure it would. Could the care cost more because of the pharma ad? Possibly so. Do we not trust our doctors to do what’s best for us regardless of the other outside influences?

Back to the initial premise, many are concerned with Pharma ads, but they’re bound to happen anyway. So, I ask you the question, is there any way to have Pharma ads without compromising the integrity of the visit? Is there a way to minimize the influence of Pharma while still allowing them a way to talk with the doctor?

No doubt this discussion is going to come up again and again. With Pharma unable to even give a doctor a pen we’re going to see new creative ways for Pharma to be seen by doctors. Advertising Pharma products to patients won’t be enough.

Following on the extremely successful New Media Meetups we’ve held at HIMSS, we decided to do a similar New Media Meetup at MGMA 2011. This time I decided to join up with the great people at HITECH Answers to put the meetup together. Plus, Free EHR vendor, Mitochon Systems, has graciously offered to sponsor the event along with providing the food and drinks.

In case, you’ve missed the previous New Media Meetups we’ve done, this is an event for anyone that participates in new media, is interested in new media, reads new media or just likes hanging out with a bunch of cool people. Yes, that pretty much means that everyone is welcome. Just don’t be surprised if you see people taking pictures and tweeting while at the event.

There’s no specific agenda for the event. Just great networking with interesting people. So, come enjoy some food, drinks and connect with interesting colleagues.

Here are the details for the event:
When: Tuesday, Oct. 25 from 5 – 7 pm
Where: Suite 2169 at Hilton Hotel (right next to Conv Ctr)
RSVP:
Fill out the form embedded below so we know how many to expect:

Or Complete this form to RSVP

About Mitochon Systems
Mitochon’s mEMR system is the first, free, fully certified EHR system. Mitochon uses a free, ad-supported model. Ads are displayed within the workflow of the application. The Mitochon mEMR system, designed by physicians for physicians, is intuitive and easy to install. Most customers are up and running in one day. Mitochon Systems was founded in 2006 by André Vovan, MD, MBA, FCCM, the director of a critical care department at a large California hospital. Information: 877-817-0902 or http://mitochonsystems.com/.

Event hosted by HITECH Answers and HealthcareScene.com

I came across this article on Lab Soft News (he does great work) that talked about some Ethical Questions that related to Epocrates recently launched EHR software and their existing pharmaceutical relationships. Here’s one section from the post:

Very distressing to me, however, is the clear link of the company [Epocrates], and its software, to the pharmaceutical industry. … I have also reluctantly come to the conclusion that even apparently trivial advertising connections to Big Pharma can lead to mischief. I had previously thought that inconspicuous advertisements in EMRs by drug companies might be tolerated if the companies were to bear the costs of these systems. I now believe that allowing these companies even a tangential relationship to physician-office electronic medical records is too risky.

I’ll leave the highly discussed topic of pharmaceutical influence for another post and the comments section. However, when I read this I couldn’t help but wonder why Epocrates isn’t offering a Free EHR.

If you think about most Free EHR models, one of the core revenue paths is through advertising. Let’s not kid ourselves here. When they talk advertising, they’re talking about pharmacy ads. Sure, they might sell some other ads, but the majority of the big dollars for EMR advertising is from pharmaceutical companies.

With this understanding, doesn’t that mean that Epocrates relationships with these pharmaceutical companies would be perfectly positioned to execute on the Free EHR model?

I just checked the Epocrates EHR pricing page and it has the pricing as a $359 monthly subscription per seat. It’s also interesting that they’ve chosen to integrate with Nuesoft’s PMS which will cost $200/month per seat. They also require the purchase of the Epocrates EHR Quick Start Package. Not sure the cost on that. Sounds a bit pricey to me, but that’s a topic for another post.

I keep asking myself as I’m writing this post, Epocrates is perfectly positioned to execute the Free EHR Pharma advertising model and yet for some reason they’ve chosen not to do it. Remember, Epocrates has been executing the free software for Pharma advertising for a long time. Why did they choose not to do the same model with their EHR? Do they know something we don’t know?

I don’t know the answer to these questions, but I’m sure to ask them next time I see them. Maybe they’ll be at AHIMA or MGMA.

One of the most fascinating people I met on my recent trip to San Francisco was a doctor named Aaron Blackledge from @CarePractice. We spent a great evening together talking EMR, healthcare and entrepreneurship in general. You may also remember me posting about Aaron drinking the CareCloud EHR kool-aid (See also an opposing view of CareCloud and my thoughts after seeing CareCloud), but I digress.

Dr. Blackledge has posted a thoughtful look at how the EHR cost curve has changed over the past few years. It’s an interesting read for those looking for an interesting take from a physician in Silicon Valley and his idea of the value of a widely adopted platform.

I love the idea of a healthcare/EMR platform. Would you rather be a $100 million EMR company or a billion dollar platform company? Think those numbers are exaggerations? That’s the question that SalesForce.com basically answered. They could have easily become a $100 million CRM company, but instead they’re now a multi billion dollar platform company. I won’t be surprised if we see the same happen for some company in healthcare.

Whether you agree or not on the value of a widely adopted platform, one thing is certain: The Free EHR Model (with Practice Fusion as the first to make the big “free EHR” splash) has absolutely brought the cost of EHR down. I’m sure there were some other forces at play too, but I believe the Free EHR model held everyone else accountable for their pricing.

As Dr. Blackledge says in his post, little by little EHR vendors couldn’t get away with charging $20,000 per user up front for an EHR. I started blogging about EMR when this was the norm. Most clinics would take out a hefty loan to buy their $100,000+ EMR software. It was a scary idea and certainly burnt a lot of physician bridges along the way.

Along came a new pricing model where a doctor could pay a small fee per month. Sure, if you evaluated that amount over 5 years it was still a fair amount of money, but no longer were doctors on the hook for the entire amount even if the EMR software failed to deliver on their promises. Plus, the EMR vendor couldn’t come back later and charge them even more money for future upgrades (that’s right…$20k up front and then amazing upgrade fees).

After that, the Free EHR model made a big splash. While certainly viewed with a fair amount of skepticism (myself included), many other industries are proving this model and doing quite well. We still have a ways to go to see which company is going to be able to execute the Free EHR model, but as I discussed in my recent Pharmacy Ads and Free EHR software post there are a lot of pharmaceutical marketing dollars on the table.

Reminds me of the favorite thing my Dell sales and marketing guy loved to say, “Whether you go with Dell or not, we’re keeping prices low so that everyone else has to offer you lower prices.” I believe Free EHR companies have had that same effect on the EHR industry.

I’ve been writing about Free EHR since I first started this blog in 2005. Initially I was mostly writing about the “free” open source EHR model like I did in this Open Source in Healthcare post in 2006. I still remember when I found out about Free EHR vendor Practice Fusion and wrote this post in 2008 about Free EHR Software and Some of the Hidden Costs. I think it’s fair to say that I was a bit more skeptical of the Free EHR model then than I am now. Practice Fusion and Mitochon Systems are both Free EHR vendors that advertise on this site (Full Disclosure). So, I’ve had a chance to talk at length with both companies. I must admit that the more I talk with them, the more intrigued I am with the Free EHR model.

However, there are still challenges that are faced by the Free EHR model. This struck home quite strongly when I saw the relatively recent news about Free accounting software vendor, Outright, changing from a free model to a paid model. Funny thing is that I was really close to using Outright for my accounting, but then opted to go instead for the Free open source software Gnucash. However, this change in direction made me pause and wonder what would happen if a Free EHR vendor chose to switch from the free model to a paid model.

No doubt that any change in Free EHR business model would likely be similar to Outright where they provide a fair amount of time for users to remain on the free model. They’d also have to provide some way to get your data out of the EHR or else their paid model would not likely survive. The bad will that would be created from holding the practice’s data for “ransom” would be terrible for a company. Although, switching from a free EHR model to a paid one would be even more detrimental I think.

Of course, the EHR company could easily argue that at some point they’re faced with only a couple options: close the company or switch from the free to a paid EHR model. Faced with those options, would you rather have your EHR company go under or be able to pay them for the services you’re receiving? Although, as I’ve discussed in other Free EHR posts, just closing the company down completely wouldn’t likely be an option. Instead, the company would instead be acquired for some discounted rate by another EHR vendor. So, the real options would be to switch EHR companies since the acquiring company would likely want you to switch to their EHR or start paying for the EHR services. I think in most cases, EHR users would prefer to start paying for the EHR services. Even if deep down they’d feel like it was wrong and unfair.

As I argued in the post above, the real problem with all of this is that transferring EMR and EHR data isn’t as simple as even accounting data (like the Outright example above). Moving from one EHR to another is a pretty intense process and leaves much to be desired. Although, it’s not like Free EHR software are the only EHR companies that could go under, be bought out, be merged, etc. Everyone says that EHR company consolidation has to happen and so the transfer of data from one EMR and EHR company to another could happen for all sorts of EMR companies large (see Misys) and small.

Also, I think one other difference between the Free EHR companies and the Outright example above is that Free EHR companies aren’t just an ad only business model like Outright. For example, there’s a lot more value in aggregate healthcare data than there is in aggregate accounting data. Even anonymous healthcare data is incredibly valuable if done right. Not to mention a number of other possible business models that could be placed on top of a Free EHR offering.

As always, I’m not trying to scare people away from the Free EHR model or drive people to that model either. My point is to just bring to light all of the possibilities of what can happen if someone should choose to go with the Free EHR model. I’m sure there are even more angles to this which will be brought up in the comments. I look forward to the discussion.

I also sent an email to my contacts at Practice Fusion and Mitochon Systems saying I was going to write an article about this and asked them for a response. Here are their responses and I’m quite sure they’ll join us in the comments as well.

Practice Fusion’s response:
It’s hard to see a young company like Outright struggle with their pricing, but the truth is that being a free, web-based business is not for everyone. Practice Fusion does not succeed by being free alone. Our dedication to delivering the easiest to use product, our phenomenal support team, the support of 80,000 healthcare providers across the country, our sustainable platform – these are the elements that have made us the largest EHR community in the country. We are 100% committed to bringing free EHR technology to every doctor in the country and that will never, ever change.

Mitochon System’s response
There are two key differences between Mitochon’s free EHR model and the small software service company you cited, Outright.

First, Outright offers its services directly to individual consumers. There is no third-party payer involved and the service does not provide value-added for anyone but the individual purchaser. In contrast, healthcare is often compared to a three-legged stool: patients, providers (physicians, hospitals) and payers (health plans, employers). When a physician provides care to a patient, a third-party usually picks up all or part of the bill. Free EHRs can potentially add value for all three parties involved. Our experience has been that both payers and providers are willing to subsidize or support free EHRs through paid clinical messaging (ads, health message reminders).

Second, it appears that Outright tried the ad-supported model and it failed for them. Although the article does not state exactly why the advertisers were dissatisfied, it might be that the user demographic was poor. Perhaps the Outright users just didn’t buy enough of the advertised products.

In contrast, physicians are major purchasers of goods and services for their patients and their organizations. According to Dr. John Eisenberg, a leading medical economist, physicians’ professional fees alone represent about 20% of all health care expenditures and they are responsible for decisions that govern how 90% of each health care dollar is allocated. With annual health care expenditures in the U.S. now topping $2.5 trillion, clearly physicians are a highly desirable audience for paid messaging delivered by many different organizations.

In conclusion, we know for a fact that the free EHR model works now and we believe it will grow and expand dramatically in the future.

Many of you that I saw at HIMSS were aware that I participated in a Free HD TV Giveaway contest with fellow blogger: Dr. Joseph Kim. The giveaway was sponsored by Free EHR vendor Practice Fusion.

I’m really happy to say that @WesBates picture with me won him a 42″ HD TV and thanks in large part to those who attended the New Media Meetup I was able to beat out Dr. Kim as well. I just got the TV yesterday and it’s awesome. Thanks Practice Fusion!

It was pretty interesting wearing a Practice Fusion shirt around the HIMSS exhibit hall. Many of the people that I talked to asked about the shirt. However, I was a bit surprised that I didn’t get more people riping the Free EHR business model. Instead, it seemed like most people were familiar with it.

The 3 questions I did get asked the most about Practice Fusion was about their long term viability, how they make money offering a Free EHR, and whether a Free EHR is as good as the other EHR that you pay a lot of money to get. I asked Emily from Practice Fusion these questions and here were her responses:

1. Viability – We had 500% user growth in 2010 and doubled our team. The company has been very successful in attracting advertisers, partners (Dell, DeVry, Microsoft) and investors. We have 70,000 users serving 8 million patients today. And we bring on 300 more each day (compared to AthenaHealth brining on 600 docs in Q4). There’s a lot of strength in our numbers. Happy to answer any specific questions here.

2. How does Practice Fusion make money – Our favorite question! Practice Fusion is ad-supported, just like the radio, Gmail and EMR & HIPAA. Our discrete advertising allows the EHR to be available entirely free for any doctor in the US.

3. Quality – We were so honored when Black Book Rankings announced we were voted #1 EHR for 2011 primary care in January. Practice Fusion was up against EHRs that cost tens of thousands and still came away with the most #1 awards for categories including reliability, support, best-of-breed technology and delivery excellence. Forget “you get what you pay for” – that report proved that a free EHR could definitely be the best EHR.

To expand on all three of these: one thing that’s core to Practice Fusion is our alignment with our users. Since we’re an ad-supported product, we only succeed if doctors actually use the product. Our focus is on support, training and continuous product enhancement because of this. You saw it yourself when we completely re-did the getting started process inside the EHR over the end of the year. Keeping our users happy is fundamental to our growth. It seems simple, but surprising rare in the health IT sector.

It was fun to take pictures with so many cool people. Unfortunately, I did a poor job of keeping track of all the pictures. However, here’s a few of them that I did get to give you a flavor for the cool people I met:

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

It’s going to take a couple weeks to really process all that I saw and heard at HIMSS 2011. In fact, there’s no doubt that much of the content I publish over the next month or two will be things I learned from the people I learned from at HIMSS or influenced by what I saw and heard. However, after a good night’s sleep in my own bed I’m really happy with my experience at HIMSS. The energy and passion for healthcare IT that was found at HIMSS was really powerful and wonderful to be apart of.

I think those people out there that are asking if we’re in a healthcare IT bubble right now are on the mark. There’s very little doubt in my mind that we’re in a healthcare IT bubble. It’s a feature of $36+ billion in EHR incentive money being given out by the government. I can’t remember the size of the EMR market numbers off the top of my head, but $36 billion in money coming into what is a relatively small market is going to change things dramatically. So, it makes sense that this type of infusion of money would create a bubble of sorts.

One person in their comments that we’re in a healthcare IT bubble asked if the bubble would pop before HIMSS 12 in Las Vegas. I believe we have at least one or two more years before the healthcare IT bubble pops. In fact, if you thought that HIMSS 11 in Orlando was big, I predict that HIMSS 2012 in Las Vegas will be even bigger. The EHR incentive money will have started flowing and the trench battles will be in full swing as the 300+ EMR vendors battle each other for customers.

EMR software was obviously my focus at the conference and despite my comments about the lack of innovation by EMR vendors and the future of EMR, I think there are a ton of really interesting EMR approaches that in aggregate are going to impact the EMR world in really dramatic ways. Here’s some examples:

• Azzly described a meeting of EHR vendors they attended with ONC. The question was asked which EHR vendors in the room started development after the HITECH act was announced. Azzly was the only one to raise their hand. I’m sure there’s other EHR vendors in that same boat, but it will be interesting to see an Azzly EHR that was built post incentive go up against the legacy EHR software.
• ClearPractice was the first native iPad EMR (called Nimble) that I’d seen and there’s no doubt they’ve made a big play in that space. Will that combined with the backing of John Doerr and their internet driven sales change EMR as we know it?
• Will larger companies like Greenway and Sage continue to gain market share as they go after the EMR market while maintaining their customer experience? Or will they head the way of the Misys of the world and be bought up by other EMR vendors?
• What about NaviNet‘s entrance into the EMR world? Can they leverage their existing connections with so many providers to be a major player in not just interoperability but in EMR as well?
• Even the big behemoth of a company, GE surprised me when I visited with them. There was a polish and a professionalism that I loved about my visit with GE and GE’s Centricity Advance people. I think there’s a fair comparison with Microsoft. Something about the nature of the US loves the underdog and hates the big name player. Yet, the big company just keeps executing their vision and many doctors are going to happily buy and use their products.
• What about Ingenix‘s multiple EMR offering strategy? Will it just be confusing to clinicians or will they effectively differentiate their various offerings while providing a backbone for interoperability as well? Is the future large EMR vendor one that aggregates a bunch of niche specific EMR companies?
• What impact will the transcription based EMR vendors have on the market? I wrote about the change from transcription company to EMR vendor earlier this week. Watch for the names MD-IT, FutureNet, Intivia, and MxSecure.
• Many people probably don’t recognize the name MedPlus. However, everyone knows the company behind the MedPlus Care360 EMR: Quest Diagnostics. There’s something powerful about being able to turn on an EMR in a medical practice with basically the flip of an electronic switch. That’s what MedPlus can do since Care360 is already being used in so many clinics that use Quest for their lab work. Add in their existing lab sales staff that already have relationships with large numbers of clinics and they’re going to be a very interesting player in the EMR space.
• Free EMR is a really compelling marketing tool. There’s a reason that Practice Fusion and Mitochon Systems free EMR offerings get so much press and so many doctors evaluating their EMR offerings. While many might disagree with their model or even believe that it will fail, these companies have and will have an interesting impact on the EMR landscape.
• MicroMD offers an interesting approach. First, because of their existing LONG term practice management clients. Second, because of the interesting integration with the supply side of their company. Not to mention, the executives that I met with were some of the most realistic people and well thought out people I met at HIMSS.
• Props to EMR company MIE that could use a fake EMR company (Extormity) to launch themselves into the EMR discussion while also helping to open up the discussion as well.  If I were a doctor, I’d want to demo their EMR just so I could see if I could find any Extormity features in their EMR.  Although, maybe that’s just the blogger in me.

I could keep going on, but that gives you a bit of flavor of some interesting EMR vendors and their market approaches. Plus, this is just 16 of the 300+ EMR companies that are working in this space. Each one with their own interesting story.

The most exciting thing for an EMR nerd like myself is that we’re really only at the beginning. Wait until we get beyond 15-25% adoption and reach 50% adoption. Then, the fun really begins.

Full Disclosure: Practice Fusion, MD-IT, MxSecure, and Mitochon Systems are all advertisers on this site. EMRandHIPAA.com’s HIMSS11 coverage was also sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

It must have been a couple years ago when I first heard about a Free EMR called Practice Fusion. Shortly after hearing about this Free EMR, I got a note saying that Practice Fusion had a Live in Five program that would get a practice live on the Practice Fusion EMR in 5 minutes. Check out my initial reaction to the Practice Fusion Live in Five program from early 2009.

Since that point, I’d wanted to try out this Live in Five challenge to see really how much I could get started in Five minutes with Practice Fusion. I still have the email from 9/15/09 when I first wanted to try this. Suffice it to say that I’ve been sufficiently busy with all the talk of the EMR stimulus that I hadn’t taken the chance to try it out myself. Plus, when I did it, I wanted to do a good job. Especially since I knew it would take more than 5 minutes.

Well, tomorrow I’m heading to the Practice Fusion user group meeting to meet with the people at Practice Fusion and to do some interviews for the XM Radio station ReachMD. That should be fun and you’ll certainly hear more about the interviews later. Since I was going to the Practice Fusion user group, I figured it was time to try the Live in Five challenge and see what I could do. So, that’s what I did.

Signing Up
I started at their standard Practice Fusion EMR sign up page. It’s free so I filled out their simple forms. I think the whole sign up process only took me 2-3 minutes. Granted, I’m pretty fast with computers and online forms. I was a little disappointed that they didn’t let me choose my own username and my own PracticeID. I’m not sure there reasoning with this, but likely it would take people longer to come up with their own. It’s just hard for me to remember the username jlynn677. Plus, it takes me back to the days of AOL, and that’s not pretty. Although, this wasn’t a huge problem for me since I was only using one computer and it remembered the info for me.

As any good system would do, it made me use a more complex password. Yes, I deliberately used an easy one to see what it would do. Good thing it asked me to make it more complex. Annoying for many users, but definitely necessary. I also specified myself as a doctor so I could test the doctor interface.

Well, I was quickly logged in and the first thing I see after logging in is the Practice Fusion training page. I must admit that I was touch overwhelmed by all the training videos. Although, I also was glad there was so many and that I could train at my own rate on whichever features I wanted to train on.

I had to get a taste for the videos and so I clicked the first one to see what they were like. The pace of the video was a bit slow for me, but I could see how this would be extremely beneficial to a new user of the system. The only problem is that the video was cutting into my 5 minute test very quickly. So, I clicked off the video to go and click around the system on my own. I figured the videos would be there later if I couldn’t figure something out myself.

First Impressions
Once I started clicking around I saw this layer of tabs to choose from. As I clicked on each one I was a little confused why these prominent tabs were all for things like To Do List (which was empty of course), Community, Forums, Activity Feed, etc. I was looking for schedule, patients, and charts. Took me a minute to realize that the other buttons above those tabs would get me where I really wanted to go. I guess I’m just so use to tabs being the navigation.

I did notice a prominent button that I thought would be very useful. It was a link to a Live Chat with a support specialist. I’m kind of arrogant like that and wasn’t sure I wanted to ask for help, but I was glad to know it was there in case I needed help of some sort.

Appointment Scheduler
Of course, this was well past the five minute mark. I certainly had been logged in and provisioned on the Practice Fusion EMR in well under five minutes, but as I expected it would take longer than five minutes for me to do a good walk through of their EMR.

I then proceeded to check out the Schedule section. It took me to a “Daily Calendar” section which was of course empty. I started to look around for a button to add an appointment (since I assumed there weren’t any). I even right clicked on the grid to try and add an appointment. The right click revealed the all too familiar Flash Player options. Something that I would see multiple times as I tested the system. I guess I’m just too used to right clicking.

I decided the Daily Calendar didn’t have the option to add an appointment and so I clicked on the Weekly Calendar tab and it worked as expected for scheduling an appointment. I would have loved to have a quick patient creation area when creating the appointment, but overall it was pretty easy to schedule an appointment. It was funny when I was trying to select the patient for the appointment, I went to the bottom right corner of the screen to click the OK (or in this case Select) button. Turns out, I almost clicked on the ad that had a button like image on it. Then, I realized that the Select button I wanted was at the top instead of the bottom.

I also tried to drag and drop the appointment to a new time, but sadly no dice there. I guess Flash doesn’t support drag and drop like that very well? I did like how the patient had a space for an email so it could send an email reminder. I wonder if text message reminders are next.

I then played a bit more with the schedule and found it pretty straightforward. After going back to the Daily Schedule (which now had the appointment I made) I saw a drop down for status. I marked my patient as Arrived and the Status drop down box changed to a new set of statuses. I thought this was really cool, because it only presented you the statuses that you would need. I’m not sure how you’d go back if you changed the status on the wrong one though.

Patient Chart
Now with an appointment scheduled it was time to check out the chart for that patient and start a note. I clicked on the hyper-linked name of the patient in my “Daily Schedule” and was taken to the chart. I was a little confused by where it sent me. It was basically a history page of what had been done on the patient. I saw a lot of other options to click, but I was surprised this was the page I got clicking into the patient chart.

I later realized that I should have clicked on the hyper-linked date and it would have taken me to the note in the chart for that day. Although, since I didn’t I must admit that I was searching for a little while to find out where I could create a note for the patient. I finally found the note listed under the title “Events” with today’s date. That felt a little awkward to me.

Before finding the note, I did see a bunch of history items like PMH, Dx History, Rx list, Allergies, etc. I did find the allergies a bit confusing since it was under the PMH (free text) and then there was a separate tab for Allergies (very specific) and they weren’t tied together in any way. If I have a medical history of allergies shouldn’t that go under my allergies? I think they showed both at other places in the chart, but deciding where to add the allergies and how to add them would be important.

Turns out the Allergies were confusing, but there was a link that said “Learn to add allergies” and so I clicked it and it took me to a training video for allergies. Only problem was the training video was for the allergies tab and I was on the PMH tab. So, it took me a minute to figure out that there were the 2 places. Although, the video introduced me to the other area. Balancing free text entry of allergies with specific allergies are a challenge for every EMR. Not to mention even harder with the Rx list. For example, I didn’t see a way in Practice Fusion to enter some Chinese Herbal Medication in the list. One that’s not likely in the database. Let alone if the patient says, I’m taking the pink pill. I’m not sure how I’d have documented that in the Rx List in Practice Fusion.

Charting
I like how simple and easy to use the SOAP note was in Practice Fusion. It was really straight forward to go in and chart items. Not to mention how easy it was to add your own templates to any section of the SOAP note. I did wonder if any of the vital signs section could be adjusted, added to or modified. It certainly has the base needs, but I know in the clinic I worked in we had a pretty customized intake process for collecting vital signs. For example, our intake asked questions based on the gender (ie. last pap smear for females). I didn’t see any sort of advanced templating like this in the documentation areas. Maybe I just missed it.

I did like the way the dxn sections worked and the integrated ePrescribing. In fact, even with my 30 minutes in, I prescribed a drug and sent it to ePrescribing. Yeah, I had to see what would happen if I tried to ePrescribe since it gave me the option. The system then told me that I needed to fax in a form to get ePrescribing set up and I had a link to download the form (which I think was already filled in with my info). I was glad that it wouldn’t let me ePrescribe, and it was pretty slick to prompt me to sign up for ePrescribing that way.

I also found the script printing page to work really well. You had options to add or remove the signature section or header section of the script. This is a good feature if you prefer to use a stamp or are printing on letterhead already.

The signing of the note was easy and straightforward. I of course wondered how and if I’d be able to make corrections to the note after it was signed. At first I couldn’t find anything, but then in a bit of an obscure location, I found an “Addendum” button that allowed me to add a comment to a signed note.

I did wonder how I’d chart a note for that patient for say a phone call. I didn’t see an easy way in the chart to create a simple note like this. I’m guessing it must be done from some other screen, but I didn’t see a way.

Document Management
I liked the Document Management functions built into Practice Fusion. They were quite slick and I love the way that you can sign off documents. The upload process was easy. On my first upload I completely missed the section to assign the uploaded document to a patient. So, later I had to figure out how to assign it after upload. Not a big deal once I figured out where I missed it.

I was missing the Fax Management section. I’d seen a button to Fax a referral earlier and so I wondered how they dealt with faxes. I knew there had to be an answer so I clicked that “Live Help” button to get an answer to my question. Plus, I must admit that I wondered how quickly they would respond and how the Live Help would work.

After a minute or two I got a live person who told me that they only do outgoing Fax Referrals. They didn’t have any feature for incoming faxes yet. That’s too bad since it would have been a killer feature. Although, a fax server is still killer and easy to set up in an office. I also asked the support person about bulk upload of documents and they said I could only upload one at a time. Not a horrible thing, but I could see bulk upload being a useful feature. Then, just assign them after the bulk upload.

Multiple Logins
One problem with the chat with the Live Support person was that the chat took over my whole Practice Fusion browser session and I couldn’t do anything while we were chatting. The tech person that I am, I decided to open up a new Practice Fusion window on my other monitor. Plus, that would be a good test if I wanted to have 2 windows open at the same time.

Only problem was that once I logged into the new window, the old window logged out. Yep, I guess you can only have one browser session logged in at a time. I even tried to lock the browser session (which is a nice feature) and then log into another browser window. Once I logged back into the locked browser session, I was kicked out again since I had opened the other session. So much for having 2 windows open with Practice Fusion.

Second Login Configuration
I did find it really interesting what happened the second time I logged into Practice Fusion. It gave me a series of screens to configure. Simple things like address, phone, etc of my location. It also asked about any lab interfaces I might need. Definitely a good idea to wait until the second time I logged in to ask me these things.

I also wanted to see what kind of configuration options were available. I thought that it would be utterly overwhelming, but it really wasn’t. Pretty straightforward stuff and easy to add new users, new payers, new facilities, etc. If anything, I wonder if it might need more options.

Overall Thoughts on Practice Fusion EMR
About an hour and twenty minutes later I completed my perusal of Practice Fusion’s EHR. A little longer than the 5 minutes, but that was to be expected. An hour and twenty minutes on my own to go through an EMR is pretty good. I think I could log in right now and easily schedule a patient, chart a note and get them their scripts, referrals etc with no problem. I’d say that’s a pretty simple design.

I do wonder if I’d hit a wall when it came to how simple it is. I wonder if there are other features I’d be wishing they had that they don’t yet have implemented. I’ll be asking some of the doctors that I meet tomorrow this question.

I’m sure this is very purposeful on Practice Fusion’s part, but the EMR is pretty much void of billing. I think I saw one button that said “Send Superbill.” So, I’m mostly evaluating it on the EMR basis and not the billing portion. My understanding is that they work with a Practice Management System for this. I’ll find out more on this tomorrow as well.

As far as the ads, they really weren’t that intrusive. It was fun to see who they had advertising. I saw a few Dell ads along with what looks like an IT consultant that specializes in supporting Practice Fusion implementations. Not to mention a number of pharmaceutical ads and an ad for their user conference tomorrow.

Overall, I found Practice Fusion simple and intuitive to use. There is certainly room for improvement in usability in some aspects of the design, but I didn’t find anything that was too hard to figure out. The fact that it’s a SaaS based EHR bodes well for future development of features and usability as well. Plus, for the price (Free), it’s definitely worth an hour and 20 minute test drive to see for yourself.

Full Disclosure: Practice Fusion is an advertiser on this site and is paying for my flight and hotel to attend their user group meeting as a moderator and for the ReachMD interviews. Although, they didn’t pay me to do this review.

I’ve had a number of people ask me my thoughts on this Wall Street Journal article which talks about open source EHR and in particular the open source EHR developed by the VA hospitals called Vista.

I must admit that I’ve been enamored by the concept of free EMR. One of my most popular blog posts was this guest post about Free EMR by Medicare. Turns out that Vista is one of those open source (free) emr software that keeps popping up. I imagine it will continue to pop up for a long time to come.

Let me offer three points that I keep hearing over and over when I hear people talk about open source Vista.

1. (We’ll start with the good) Those that go to the VA are quite happy that no matter what VA hospital they go to, they have their information available. I’ve heard this on multiple occasions. I’m not sure if people are saying this because they’ve actually experienced it (which is likely considering the transient nature of veterans) or because they’ve had the concept drilled into their head. Either way, this is the major perception and considering it’s all one nice package I’m inclined to think it’s a huge advantage of Vista in the VA hospitals. I’d love to hear someone address how this “EHR interoperability” using Vista would work in commercial hospitals.

2. The users of Vista really don’t like using the program. It’s clunky, unwieldy and not the friend of the user. I’ve heard this multiple places and not just from doctors, but also from nurses and the IT people supporting the software.

3. The “database” that Vista uses, MUMPS, is a piece of junk and a major anchor on what could be an otherwise interesting open source project. I’m sure there’s some really interesting history behind the VA’s decision to use this MUMPS “database” system instead of one of the current SQL based database systems. Unfortunately, I’ve seen numerous people talking about the pains of MUMPS and the problem it creates for the future of open source EHR Vista.

I’ll admit that I’m not an expert on Vista, but I’m just telling you about the common themes I’ve read over and over again. Any other ones we should know about or other perspectives on Vista EHR?

I’m a major proponent of the open source software movement. In fact, pretty much everything that I use to run this website is open source (WordPress, Linux, MySQL, PHP, Apache, etc). Wow, I didn’t even include all the software tools I use to publish EMR and HIPAA. Anyway, I’m a firm believer in what open source can accomplish. You may have read my previous posts about the Free and Open Source in Healthcare Un-conference this summer or possibly what I think is the right open source EMR model. I’ve also cautioned about whether “free EMR” is really free. Ok, I could go on for a while covering all the posts I’ve done, but here’s 2 links to all my free EMR posts and my open source EMR posts.

My point is that I believe in open source can do and I think it could have a major impact in health care. In fact, I sincerely hope that it will have an impact. The problem is that if HHS decides to use CCHIT as the certification criteria for the EHR stimulus, then the HITECH act will basically be excluding open source EHR and EMR packages from being part of the “certified EHR.”

Sure, I guess a community of users behind an open source EHR could pool together enough money to pay for CCHIT certification, but realistically I don’t see this happening. In fact, the thought of paying so much money to CCHIT is almost counter to the open source movement. I just don’t see why any open source EHR would make CCHIT a priority in their development life cycle.

Yes, I do know that HITECH includes a provision (if that’s the right term) that allows HHS to provide an open source package. Does that also mean that HHS will provide an exception for the government provided open source EHR package? Will users of that open source EHR be able to get the medicare and medicaid bonuses? I’m not sure that HHS even has the authority to do this. However, even more important is that they’d still be excluding the dozen of other open source EHR software programs out there.

This is just one more reason why HHS should not use CCHIT and should consider creating their own set of certification criteria. Looking at my recent CCHIT As The HITECH Certification Criteria Poll it looks like at least the majority of my readers would prefer a different certification criteria as well.