In my recent post about hosted EHR versus client server EHR Dr. Rowley commented on the various scenarios that could occur for sharing a patient record. The comment was so worthwhile that I wanted to make it it’s own blog post and add a few comments of my own. Here’s Dr. Rowley’s comments on data sharing scenarios with various EHR:

Whether you are an enthusiast of free, hosted, web-based EMRs, or an enthusiast of local client/server installations (or a wait-and-see skeptic), the question of data sharing is one that is important to us all.

Maybe the discussion can be best moved forward by considering a real-life scenario and examining how data sharing can occur in different situations. Let’s say that I am the Family Practitioner taking care of Mr. Chest-Hurts, who just was released from the hospital after a heart attack, and you are the cardiologist who saw him there. Mr. Chest-Hurts is in my office for post-hospital follow up, wants a referral to see you as an outpatient, had numerous tests done (which I don’t have in my records when I see him), states that you changed several of his medications on discharge and is confused as to which ones to take (and did not bring them with him for his visit). I just did some lab test and found his cholesterol to be not-quite-at-target. Let us assume that the referral is a simple administrative matter that happens anyway. What is important for patient care here is for us to share our records with each other – we need to reconcile his meds lists, you need the labs I just got, I need the cath report from the hospitalization, etc. Now let’s explore how we share data, given different scenarios:

1. Neither of us have EMRs; we both use paper charts. In this case (the traditional one in medicine), we copy and fax information to each other from our charts. We take each other’s faxes and make them permanent parts of our own separate charts.
2. I have a client/server EMR and you use paper charts. I generate a fax to you from my EMR, which you place in your paper record. You fax records to me, which I scan and import into my EMR.
3. I have Practice Fusion, and you use paper charts. Several options exist here: (a) I can generate a fax to you, like scenario #2 above; or (b) you sign in to Practice Fusion (after all, it’s free, and with “Live in Five” provisioning, you will be able to have access almost immediately). You can then print out what you might need, for inclusion into your own paper chart.
4. We each have client/server EMRs (maybe the same one, or maybe different). Like with paper, we each have separate chart records, and there is no unified patient identifier. A few options exist here: (a) we each have our systems fax out the desired records to each other, and import the data as scanned documents into our separate charts; (b) we each output a Continuity of Care Record (CCR), and somehow push it to each other. There are some efforts (like Relay Health, for example) who are trying to build an infrastructure to be an intermediary for CCRs – I push out a CCR and post it to Relay Health, and you look there and import the CCR directly into your EMR. This need to build a connection between local installs is a challenge (weakness, in my view) of local client/server systems, and will take effort and money to build. There is a lot of activity here.
5. I have Practice Fusion and you have a local client/server EMR. Several options can take place: (a) we each fax our information to each other; (b) we exchange CCRs (like #4 above); (c) I give you access to Mr. Chest-Hurts’ chart (like #3 above), so that you can see the record, and copy-and-paste between the systems if desired.
6. We each have Practice Fusion. We can share the same record on the same patient, and with the right permissions, can see each other’s notes, shared lab values, meds lists, etc. No uploading or downloading of CCRs required. No faxing needed. This is the most compelling scenario.

Pardon my long-windedness here, but my belief is that the discussion of data sharing is very important, and vital to unlocking the true potential of e-tools in improving health care in this country.

I’ll be posting my comments on these scenarios in my next entry.

I’ve recently been rather critical of Practice Fusion’s free EMR offering. I honestly don’t think that any of my feelings have changed about their offering. However, here’s a part of their press release that at least shows they’re getting some traction

Practice Fusion, the leader in free, web-based physician practice applications, announced today the addition of 1,300 medical professionals since its launch in November of 2007 and is currently serving more than a quarter million patients.

That should be a large enough sample size to get some interesting feedback about the product. The question is whether the product is really that good or whether the people at Practice Fusion are just great at marketing. Granted, marketing a free product is easier than getting people to pony up money. It will be interesting to see if their revenue model is sustainable. The problem is that a doctor’s office won’t know if it’s sustainable. I’m still not sure I put my practice on the shoulders of an unproven model. At least not yet.

I’ve been meaning to write about a new Free EMR for a while. One of my most blogged and searched about topics is free EMR. I guess everyone loves to get something free. Why should free EMR be any different?

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.