Practice Fusion Blog

Is “cloud computing” right for health IT?

The announcement of Salesforce.com investing and coordinating development efforts with Practice Fusion has brought talk of “cloud computing” to the fore. Salesforce has been known as a leader in cloud computing, and moving healthcare IT to that “cloud” has raised questions by a number of observers. What, exactly, is “cloud computing?” Is it appropriate for health IT? What are the security issues and risks?

“Cloud computing” is a term described as a style of computing in which on-demand resources are provided as a service over the Internet. Software-as-a-service (SaaS) is a type of cloud computing, where users do not need to install or maintain any software themselves – simple Internet access and a browser are all that is needed.  Users do not need to have knowledge of, expertise in, or control over the technology infrastructure in the “cloud” that supports them – the Internet site (e.g. Practice Fusion) provides a unified dashboard to the user, and works out the technical issues of presenting that data in the background.

Is this approach appropriate to health data? One of the greatest advantages of a “cloud” approach is that the network, server and security headaches that exist for locally-installed, legacy client/server systems is eliminated. Cost and poor usability have been cited as the biggest obstacles to adoption of health IT – especially Electronic Health Records (EHR) systems – and has resulted in problematically-low EHR adoption rates. Eliminating this cost, and the IT maintenance burdens that are often beyond the reach of small medical practices, clearly removes these significant roadblocks to EHR adoption.

What about safety? There are several issues around safety of health data which should be separately considered.

1. Data safety in the event of disaster-recovery is better when the data is hosted, in a “cloud.” With local data installation, and certainly with paper records, a local disaster (building fire, tornado, hurricane, etc.) can wipe out local data. The only point of failure in a cloud-based approach is loss of internet access. Redundancy of internet access (hard lines, wireless, cell-phone) is recommended to minimize this risk.
2. Security of the data from the standpoint of malicious hacks. Compared to locally-housed resources, “cloud” services typically improves security because SaaS providers (like Practice Fusion) are able to devote resources to solving security issues that many customers cannot afford. This has been the subject of a recent Practice Fusion blog post. By implementing high-level encryption across connections, as well as housing the data in a dis-aggregated and encrypted structure, the Practice Fusion "cloud" implements all the security requirements resulting from HHS "meaningful use" criteria.
3. Privacy of data. Access to medical data is tightly controlled, and Practice Fusion has devoted much attention to this. Especially in an environment where a patient’s EHR data might be shared between practices taking care of that patient, and where EHR data is shared with a patient-centered Personal Health Record (see here for a discussion of these terms), diligent attention to privacy and permissions must be at the root of a “cloud”-hosted EHR or PHR system.

The approach to EHRs and PHRs that has been charted by Practice Fusion, and is significantly enhanced by Salesforce.com’s expertise and resources, is a tremendously positive step for everyone. Elimination of barriers to EHR adoption, while at the same time ensuring security and privacy of protected health information, are all positive results of using the “cloud” approach. They will move us all toward the true intent of “Meaningful Use” of EHRs – the basis of the federal stimulus around the emerging national health IT policy.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.

How secure is my EHR data?

The benefits of digital medical records are tremendous – both in the improvement of quality of care, as well as in the reduction of unnecessary cost to deliver that care. Measuring healthcare-delivery quality – reporting on items defined by various organizations (PQRI, HEDIS) as well as by the HHS Meaningful Use criteria – simply cannot be done without the availability of electronic health records.

Insuring security and privacy, of course, are critical with any digitized personal information – just like banking information, personal checkbook information backed up online, and many other financial and insurance information available today. In fact, an entire domain of the newly-defined HHS Meaningful Use criteria (which will be used as a basis upon which to certify electronic health record (EHR) systems) is around security and privacy. Standards are being defined for encryption and for disaggregation of health data so that simple hacking into a database yields meaningless results.

The result of all of this is that electronic records which comply with the HHS Meaningful Use criteria are safer than paper. Yes, the scope of potential theft of paper health data is smaller and more local – but easier to do. More aggregated sources of health data are potentially larger targets for thieves, but the locks are better.

Further, locally-installed EHRs are potentially more susceptible to hacking if the local installation does not have adequate security. Laptops which contain actual personal health data might exist in these scenarios, and could potentially be stolen and used. Many of the traditional, legacy EHRs are built around local installation, and would rely on each local clinic to build their security – this might be expensive and some local installations may simply not do that.

Web-hosted, SaaS-based (software-as-a-service) EHRs have the advantage of having no personal health data housed in local machines. At Practice Fusion, we have placed a great deal of attention to the question of security – housing data in world-class servers with biometric security, multi-geography backups and failover to reduce the risk of data loss in case of a natural disaster. Full compliance with HHS criteria, HIPAA and additional risk reduction beyond these “mandated minimums” has been at our core, so that what is offered to our physicians is the highest level of security available – and it is available to all practice size, even solo practices, as a free service.

With good design, the risks of health-data security can be mitigated. When weighed against the benefits of electronic health data, and the impact of that on improved healthcare, the future outlook is, in fact, quite an optimistic one.

Robert Rowley, MD - Chief Medical Officer, Practice Fusion, Inc.

Why do some physicians abandon their EHR?

With significant stimulus moneys earmarked for physician adoption and “meaningful use” of Electronic Health Records (EHRs) as part of the HITECH (Health Information and Technology for Economic and Clinical Health) act, a component of the ARRA (American Recovery and Reinvestment Act), it is surprising to read that many physicians are actual de-installing their EHRs once they’ve installed it and used it for a while. Why might this be the case?

The recently described trend of de-installation seen in the Phoenix area mirrors an observation reported previously that failure and de-installation of EHRs abound. This is especially seen in solo and small practices, where the decision-making process is more individual and direct (larger groups and staff-model integrated delivery systems function more slowly, by committee). The reasons? Cost and usability, mainly.

Traditional, legacy EHRs have been very expensive, with significant server-end and IT support burdens (often an unexpectedly-large hidden cost). Even with subsidies (e.g. from local hospitals), the cost is significant, and the benefits are not immediately felt. It has been reported that only about 11% of the savings from EHRs go to the physicians – the bulk of the benefit goes to private and public insurers who end up paying for fewer unnecessary tests and the like. So the financial proposition to physicians has largely been one of significant risk – smaller practices, with very tight margins (especially in primary care), are seldom in a position to take on this degree of risk.

The other burden is the issue of usability. Clumsy, antiquated user interfaces (UIs) implemented by some of the larger, older, legacy systems simply get in the way of workflows that have been honed over the years. It is not uncommon to hear anecdotes from physicians who claim a dip in their productivity for a few months while their office got used to a new system, and some never fully recover their previous level of productivity (until they make the decision to abandon their EHR). Usability of EHRs has been the focus of significant study, but this element of EHR design remains problematic.

It would seem evident that the way out of this mess, in order to reverse the trend of frustration and de-installation of EHRs despite federal moneys intended to incentivize it, is to look to newer technologies. Web-based, hosted, SaaS (software-as-a-service)-based EHRs are now emerging, which eliminate the server-end burden and the attendant costs. Many hosted web-based EHRs offer a per-month subscription; Practice Fusion is a web-based EHR that is offered free to physician end-users (subsidized by alternative revenue streams, including advertising).

In addition, Practice Fusion is built with detailed attention to usability. As a web-based product, it can improve and roll-out new enhancements easily without needing any local “upgrades.” The hope is that, as such newer technologies become more widely implemented, practices (especially smaller ones) will find the EHRs tools to be helpful (rather than a hindrance), and will experience the full benefit that sophisticated EHR tools promise to deliver.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.

EHRs, PHRs and Patient Portals – how are they connected?

An increasing amount of attention is being focused on Personal Health Records (PHRs), and how these relate to Electronic Health Records (EHRs). Australia, for example, has set a goal for every citizen to have a PHR by 2012. With a myriad of terms being used in the press around elements of health IT, it might be useful to review what they are, and how they are related.

The terms EMR (Electronic Medical Records) and EHR are often used synonymously, but many define EMR as just the physician interface, and EHR includes both a physician and a patient interface. The main idea here is that EMRs/EHRs serve as tools designed for physicians, and attempts to replace the use of traditional paper charts in a medical office. A well-designed EMR system will work harmoniously with workflows in a physician office, and will ease the time and burden involved in medico-legal documentation of patient encounters. An EMR may interface with a Practice Management (PM) system, which carries out billing. PM systems, sometimes housed in-house and sometimes housed in outsourced billing agencies, are responsible for packaging billing information, sending out bills to insurers (via paper or electronically), posting payments, and sending out patient bills. Often, PM systems are stand-alone, and sometimes are part of an EMR-PM integrated system.

As EMRs have matured, many have offered Patient Portals – web-based ways in which patients can view some of the information contained in their physician’s EMR. When a Patient Portal is added to an EMR, it is often then called an EHR. Patient Portals are populated by EMR data, and not updatable by the patient directly. Kaiser’s KP Online is an example of such an offering. Such Patient Portals may contain ways by which patients can communicate via secure email/messaging with their physicians, receive lab results, request appointments or pay their bills.

Patient-centered documentation has grown in parallel to EMRs. Though the precise definition has undergone evolution, a PHR has come to imply a computerized application that stores an individual’s personal health information (like allergies and adverse drug reactions, medications, illnesses and hospitalizations, surgeries and other procedures, vaccinations, lab test results, and family history). The idea is that a PHR is portable, controlled by the patient, and serves as a repository of data that can be referred to when encountering the healthcare system in a variety of settings (like going to a new doctor, or a hospital, or an emergency department).

Traditionally, PHRs began as simple, empty shells, and relied on patients to enter all their information themselves. Not surprisingly, such efforts were only taken up by a few “early adopter” enthusiasts, and failed to gain widespread usage. More recently, a newer generation of PHRs have emerged (Google Health and Microsoft Health Vault), which offer the ability to fill PHR data from outside data-source feeds, such as lab results. Unfortunately, much of the available data imported by these PHRs had come from health-plan data, based on billing (not clinical) information, which was found to be significantly inaccurate.

What is the future of these trends? PHRs and EHRs have been converging, and this will continue to evolve. EHR Patient Portals have the limitation of being only about what is contained in a given practitioner’s system (what happens to your Kaiser Patient Portal when you leave the Kaiser system?), though they have the advantage of being pre-populated by the clinicians’ EMR data. PHRs, more portable and centered around the patient (regardless of where healthcare is sought), have tried to be more connected, and filled by EHR data where possible. The ideal is to create a PHR that is filled by data drawn from each EHR system used by the various clinicians involved, allowing patient feedback and involvement – and done in a way that is secure and protects privacy.

The federal government is building a Nationwide Health Information Network with this goal in mind. Some traditional EHR vendors are building their own infrastructure to help in this effort around Health Information Exchange (HIE). Practice Fusion is moving in that direction as well – by building the ability for clinicians to share charts across different practices, the Patient Portal under construction will in fact be a PHR pre-populated by the EHR data from all the clinicians involved in care, and available securely via a web connection – and, importantly, available as a free service facilitated by the underlying Practice Fusion business model.
 
Robert Rowley, MD – Chief Medical Officer, Practice Fusion Inc.

Does a free EHR level the playing field on quality?

As the measurement of clinical quality has evolved, an observation has emerged that practice size matters. In an article published by the AMA in November, 2007, the multiple pros and cons of large group practice vs. smaller or solo practice are discussed. However, according to a study reported in the Annals of Internal Medicine in 2006, larger groups outperformed smaller practices on a number of clinical quality metrics.

 Why is this the case? Looking into the details of these reports, the key seems to be access to electronic tools (EHRs) which are able to present prompting for wellness and disease management to the clinician. Such systems historically have been more available to larger groups – mainly due to cost, the adoption of EHRs has been higher among larger practices than among smaller ones.

So what would be the outcome if small practices had equivalent access to sophisticated EHR tools with prompting and decision-support at the point of care? If the cost barrier were eliminated – which is what Practice Fusion offers – and physician practices (regardless of practice size) were able to move along the adoption curve toward true meaningful use, it is quite conceivable that the differences in quality metrics seen historically will disappear.

Certainly, one can argue that there is more to clinical quality performance than simply having enabling technology. Having the tools and using the tools effectively are not the same thing. It may be that the team approach to care will be better able to carry out the recommendations offered-up by the EHR technology. Such a team approach is more feasible in (though not intrinsic to) larger groups – and certainly the emergence of Patient-Centered Medical Home models of care implies teams working collaboratively. Only time and experience will tell. But, at the very least, making sophisticated next-generation low-cost (or free) EHR tools available to every clinician – regardless of practice size or setting – will tremendously enable improvement in health care. It will “level the playing field” and allow smaller practices to “move up the quality ladder” and achieve outcomes previously out of reach.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion

The conversion from paper to EHR – how much does it REALLY need to cost?

The topic of converting medical practice from paper to electronics seems to appear daily in news, blogs, radio, and seemingly everywhere. Earlier this week, NPR's Marketplace had a segment about the costs of implementing an EHR.

Several factors have brought this question to light: ARRA stimulus money set aside to encourage physicians to take on e-adoption (up to $44,000 cumulatively from 2011 to 2015, as an add-on to Medicare payments): the emergence of a national Health IT policy that defines goals, objectives and “meaningful use;” and the debate around federal health reform – all these factors add juice to adoption of EHRs.

 

One of the presumptions in the discussion has been that EHRs are expensive. Several studies have shown that the biggest barriers to EHR adoption historically have been (1) cost, and (2) usability (or the lack of it). Traditional EHR vendors have offered very large, self-contained, locally-installed client/server systems – and these systems have been very costly. Not only is there the cost of the EHR software itself, but there is the cost and burden of establishing a server, with data backups, security, connectivity and the like. This is something beyond the resources available to smaller practices, and therefore (not surprisingly) such EHRs have been implemented in larger organizations: hospital-based systems, large medical groups, staff-model organization like Kaiser, etc.

 

But how much does an EHR need to cost, really? Firstly, a locally-installed client/server system involves server-end costs. Even if that EHR software were given away free, the server costs remain – and this is considerable. Again, a major challenge to small practices. However, web-based, hosted EHRs completely remove this layer of burden from the practice. No longer are there server-maintenance, data backup, security, and network connectivity issues – all you need is an internet-connected computer and a browser.

 

Even beyond the benefits of a hosted, web-based “software as a service” (SaaS), there is also the question of paying for the service. Some SaaS-based EHR vendors charge a monthly use fee, sometimes per-MD and sometimes per-user. Practice Fusion has developed a unique business model that allows the SaaS service to be offered for free to all end-users. Revenues come from ads, and other alternative revenue sources.

 

By eliminating the cost barrier of EHR adoption, Practice Fusion can focus on the issues that are truly significant – usability, flexibility, portability, connectivity to other data sources, and true establishment of “meaningful use.”

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

The debate over EHR certification

As the national Health IT Policy committee continues to develop a policy around “meaningful use,” the debate on what criteria should be used to deem an EHR as “certified” has been heating up. The Certification/Adoption workgroup held hearings on July 14 and 15, and testimony there illustrated significant debate on the role that CCHIT (the legacy certification body for EHRs) should play in the new era.

 

CCHIT developed certification criteria in a national policy vacuum, and (not surprisingly) created criteria that were largely feature-focused. Large legacy EHR vendors, via their trade organization (HIMSS), created and spun off CCHIT, and developed a criteria-set in 3 domains: functionality (what specific features were included in the software), interoperability (which was about fairly low-level data exchange capabilities between systems) and security (a superset of HIPAA). It did not address anything about usability, or outcomes.

 

In the current era, where ARRA moneys are earmarked for health IT adoption (HITECH), the Office of the National Coordinator for Health IT (ONCHIT, or ONC for short) has developed policy focused on results – on “meaningful use” of technology. In its July 16 meeting, the HIT Policy Committee has defined its views around certification a little more. They propose a new term: “HHS Certification,” which is to mean a system that is able to achieve government requirements for security, privacy and interoperability, and would enable the Meaningful Use results that the government expects. Certification should flow from the Meaningful Use criteria, and be carried out in a way that is much more flexible than has occurred in the past. 

 

At Practice Fusion, we applaud the direction being charted by ONCHIT. The emerging certification criteria, focused around achieving Meaningful Use, gives us an opportunity to build systems that have true value. This year presents a unique window of opportunity to “get it right” and create tools that can actually facilitate a transformed healthcare delivery system.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

“Computerized Physician Order Entry” – what does it all mean?

“Computerized Physician Order Entry” (CPOE) has become a bit of a buzz-word in Heath IT circles, stemming from a focus on this in the emerging national Health IT policy. One of the areas of “meaningful use” described in the health IT Meaningful Use Matrix encourages the use of CPOE. Exactly how to measure usage, however, is a bit problematic – how can you determine the percentage of “orders” which could have been done electronically that were, in fact, done that way? How do you capture a denominator, given that “orders” not done electronically were presumably done via paper or other manual methods, and would not be available to be counted by electronic systems.

 

Much of the desire to have CPOE be a national “meaningful use” criteria stems from a study in the journal Radiology which show that CPOE, when combined with Decision Support (DS) significantly reduces the growth in utilization of high-end imaging (MRIs and PET scans). The data is quite compelling that such systems make a real difference.

Further complicating this issue is that Computerized Physician Order Entry means different things in an inpatient vs. outpatient setting. Filling out a “physician’s orders” sheet is a familiar workflow in an inpatient setting, where a ward clerk takes entries from the order sheet and turns them into directives for care (imaging, pharmacy, nursing, etc.) – replacing this workflow with a CPOE system is an easy transition, mimicking traditional workflows. It also creates a framework where decision support (DS) can be introduced, and data-driven “standing order sets” for specific situations can be called upon.

 

In an outpatient setting however, there is no equivalent of a “physician’s order” sheet. Instead, physician directives are handled through a variety of messages. A messaging system serves as the platform for response to incoming messages (e.g. handling patient incoming phone calls, or incoming requests for refills from pharmacies), as well as outbound work-orders (e.g. follow-up appointment scheduling, ordering imaging studies, ordering lab tests, issuing prescriptions [de novo or refills], nursing orders, referrals). 

Therefore, when defining “CPOE” for an ambulatory EHR, specific order types (message types) should be defined in the certification criteria – radiology/imaging requests, lab order requests, electronic prescribing, referral generation, follow-up scheduling, etc. Additional message types in an ambulatory setting (e.g. responding back to patient phone calls or emails) may also exist, though not strictly “CPOE” in this sense. Such a messaging platform can subsequently serve as the place where decision support (DS) can be introduced.

 

This field, motivated by powerful incentives and compelling data, is evolving as the Health IT Policy Committee starts translating “meaningful use” into certification criteria, and defining exactly what and how CPOE is to be measured. The window of opportunity for input into this process is certainly here, and Practice Fusion will remain an active participant in this discussion.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

The emergence of a national health IT policy

The American Recovery and Reinvestment Act (ARRA) creates  the framework for a national health IT policy. Such a policy has never previously existed. In order to develop such a policy, a new set of federal advisory committees has been convened – the Health IT Policy Committee has now met and has reported its findings to date here.

 

In a short amount of time, the Health IT Policy Committee has developed a very positive framework that helps IT developers (such as Practice Fusion) gear their efforts in a consistently meaningful direction. The HIT policy started with an “ultimate vision to enable significant and measurable improvements in population health through a transformed health care delivery system.” Adapted from the National Priorities Partnership, several overall goals have been identified: (1) improve quality, safety and efficiency; (2) engage patients and their families; (3) improve care coordination; (4) improve population and public health, and reduce disparities; and (5) ensure privacy and security protection. This overall vision is described in a “meaningful use preamble” document.

 

For each of these Health Outcomes Policy Priorities, a series of Care Goals have been defined in a “meaningful use matrix.” And for each of these Care Goals, a series of Objectives for 2011, 2103 and 2015 have been proposed, as well as Measures associated with these Objectives by which to determine “meaningful use.”

 

Actual detailed Certification Criteria are currently being defined, and will be derived from the Objectives. Practice Fusion has been engaged in this process and has submitted commentary to the committee.

 

The traditional certification criteria for EHRs has come from CCHIT, a non-profit agency that grew out of an EHR vendor trade organization (HIMSS), but was spun-off as an independent agency. CCHIT had been designated as the sole certification pathway for EHRs prior to ARRA. However, the certification criteria developed by CCHIT since 2006 were developed in the absence of a guiding national health IT policy. Such criteria could be characterized as being more product-centric than results-oriented.

 

The newly created Meaningful Use Objectives, from which new certification criteria will be derived, commendably is more focused on results than any particular “functionality” characteristics of the software. It is as yet unclear how the certification process will be carried out, and what role CCHIT will play in this process, but what is becoming clear is this: in order for EHRs to be examples of “enabling technology” that will truly transform healthcare, “what counts are results.” Practice Fusion remains committed to engaging this process and developing products that will satisfy all the “meaningful use” criteria and truly help enable a transformed healthcare system.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

Follow us on Twitter: #practicefusion

“Meaningful use” and what it means to physicians

The Obama administration’s massive stimulus package (known as ARRA) contains a section pertaining to the adoption of electronic health records (known as HITECH), and earmarks substantial money (up to $44K per physician over the next 5 years) for physicians who can demonstrate “meaningful use of certified EHRs.” Defining what exactly is meant by “meaningful use” has been the focus of intensive debate as the newly-created government bodies charged with oversight of this have begun deliberation. The exact definition of “meaningful use” should be hammered out by the end of 2009, with incentives beginning to become available to physicians in the subsequent years.

 

“Certification” has similarly been a subject of much debate. Traditionally, CCHIT has been the sole certifying body for EHRs, emerging as a non-profit agency spun off from a government-industry collaborative. Many have assumed that CCHIT will remain as the going-forward certification body, but others have questioned this and propose that alternatives to certification are appropriate. They argue that, besides the $30K certification price tag, CCHIT developed its criteria in an era when large, self-contained client/server EHR systems were emerging, and that such criteria lose relevance in a web-based, distributed, cloud-oriented environment – such as the one that Practice Fusion has emerged in. CCHIT wants to modernize its criteria, but it may lag behind technological innovation.

 

Regardless of how certification will emerge, it is clear that “certified EHR” and “meaningful use” will be closely linked. In order to qualify for “meaningful use,” an EHR should be able to do the following:

1.     Electronic prescribing, both out-bound e-prescribing of new, de novo prescriptions, as well as responding to prescription refill requests originated by pharmacies

2.     Achieve interoperability, meaning that summary data (diagnoses, medications, allergies, etc.) can be easily exchanged with others using different EHRs. There is a standard type of document, called a Continuity of Care Document (CCD) which needs to be able to be created and exported, as well as imported.

3.     Generate quality reporting and metrics. The criteria set has yet to be determined, but is likely to be either the HEDIS set of metrics (used by insurers in the private domain) or the larger PQRI set (used by Medicare, and which encompasses the HEDIS criteria plus many more)

4.     Point of care decision support. This will be a technology that evolves, starting with simple things like prompting for wellness and chronic-disease management prompts, but evolving into presenting physicians with evidence-based guidelines for the diagnosis at-hand.

5.     Routine, secure, electronic communications between patients and caregivers. This can include prevention and screening reminders, and numerous other ways of supporting patients in their own management of their own health.

 

The specifics of all of this, of course, will be hammered out in the debate process this year. Practice Fusion is keeping a very close eye on all of this, and is rapidly building features in each of these categories. Our goal is to offer physicians a robust EHR that is not only free to use, but also will qualify everyone for “meaningful use” as this definition becomes clearer. Whether CCHIT remains the sole certifying channel, or whether it becomes one of several avenues towards certification, Practice Fusion intends to achieve “certification” as ultimately is defined by HITECH.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

Follow us on Twitter: #practicefusion