Practice Fusion Blog

EHR adoption – still slow, but.. is the time now?

The Health Information Technology for Economic and Clinical Health (HITECH) part of the American Recovery and Reinvestment Act (ARRA), signed into law in February 2009, has certainly created a flurry of interest in Electronic Health Record (EHRs). HITECH encourages the adoption of EHRs by offering to reimburse physicians for “meaningful use of certified EHRs” as a supplement to Medicare payments totaling up to $44,000 (paid out over the period from 2011 through 2015).

So, has there been a stampede of physicians rushing to buy EHR systems? No. Why not? Mainly it stems from fear of spending time and money on the “wrong” system. The starting point (the status quo) is a very low level of EHR adoption – according to the landmark study published by the New England Journal of Medicine in 2008, only 4% of physicians report using a fully-functional EHR, and 13% use a basic system. The biggest barrier reported in the study was cost. In addition to cost, poor usability of the EHR products found in the marketplace have made them burdensome, and not worth the effort. The result of these obstacles has been the phenomenon where practices de-install their EHRs once they have used them for a while, despite the incentives to keep them.

A further factor contributing to the “wait and see” attitude seen by physicians currently is the uncertainty about how the federal Health IT process will play out. The Office of the National Coordinator (ONC) for Health IT has commissioned two committees to advise it – the Health IT Policy Committee and the HIT Standards Committee. The Policy Committee has worked out its definition of “meaningful use” after an open process of significant input from multiple stakeholders. The recommendations won’t be official until adopted by CMS (the Centers for Medicare and Medicaid Services) in January 2010. The HIT Standards Committee is still deliberating on the definition of “certified EHR.” It is an arena for continuing debate around linking certification to “meaningful use” and determining the going-forward role of CCHIT (the industry-created legacy certification organization previously designated as the sole source of certification by the government heretofore). The debate over these issues will continue to unfold over the course of the remainder of 2009.

Given these uncertainties, should a physician adopt an EHR now? Or should he/she wait? Practice Fusion represents an emerging technology where the EHR offered is web-based and hosted (therefore eliminating the server-side cost and headaches of a locally-installed system, while maintaining data security and privacy). In addition, Practice Fusion offers its EHR in a way that is free to the physician end-user (subsidized by alternative revenue streams, including ads). Practice Fusion is participating closely in the ongoing discussion on the national stage, in order to ensure that its EHR offering will be “certified” and easy to use in a “meaningful” way. If the risks are removed, getting started with an EHR now makes sense – the sooner that a practice starts to use the electronic tools, and learn how to integrate these tools in ordinary day-to-day workflows, the sooner that the benefits of EHR use can materialize.

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

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.

The Salesforce.com Deal

Earlier today, Practice Fusion and salesforce.com announced a deal that features, among other things, a strategic investment by salesforce.com in Practice Fusion and the late-fall launch of the Practice Fusion PHR on the Force.com cloud computing development platform.

Salesforce.com is the leader in cloud computing. The deal with salesforce.com will help Practice Fusion achieve its potential as a leader in both the EHR and PHR markets.

Salesforce.com has an exceptional record as a service provider for small businesses. In 10 years, it has amassed more than 1.5 million customers. This is significant for health care since, according to an AMA study, nearly 80% of US physicians practice in groups of 9 or less. 

With respect to data security and system reliability and scalability, the salesforce.com alliance gives current and prospective users of Practice Fusion access to the largest HIPAA-compliant infrastructure in the world. In effect, users gain access to $100 million worth of technology infrastructure for free.

That degree of comfort had heretofore been available only to the largest hospitals and physician groups...and at considerable cost, to say the least.

Glenn Laffel MD, PhD, VP Clinical Affairs

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.

"Medical records are an area where IT could make us healthier"

Robert X. Cringley - author, former InfoWorld columnist and tech guru - has an excellent post about medical data up on his blog. He covers the opportunities and concerns surrounding the future of electronic health records. I recommend reading the whole thing, but here's a quick excerpt:

There are lots of advantages to computerizing health records.  A couple of years ago I visited the Mayo Clinic in Rochester, Minnesota, to discuss this very issue.  Mayo has been in the forefront of digitizing all of its six million patient records.  This is a bigger job than most of us realize since it involves not just blood tests and doctor’s notes but also X-Rays and CAT scans.

Mayo, which was a century ago the first clinic in America to standardize the way it kept records in the first place, is also at the forefront in creative ways to use those records once they are in the system.  You see Mayo doesn’t have six million patients, they have six million patient records — many of those being records of people long dead.  But keeping extensive records of dead people creates a powerful database for statistical testing of possible treatments and even drug interactions.  “Surely in those six million records there is something similar to this medical mystery we are trying to solve today.” And often there is.

Figuring out from an analysis of records that combining drugs A, B, and G sometimes kills people can be good to know.

Mayo is taking the process even further to include DNA data for many patients with the goal of being able to statistically identify genetic trends within the population through records analysis.

Click here to read the full text of Cringley's post. His commentary has already sparked another interesting post from an anthropologist, John Hawks on the specific genetic data aspects of electronic health records. Hawks mentions Practice Fusion's recent case study in Chris Anderson's book.

What do you think of Cringley's take on EHR? Share your comments below.

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

EMRs Shown to Improve Care

A treatment program in which nephrologists used an EMR to remotely monitor the care of patients with mild to moderate kidney disease has reduced by two-thirds the number of specialist referrals that took place too late in the course of the disease. 

Brian Lee, a Kaiser nephrologist based in Hawaii, published these findings in the British Medical Journal.

Lee and associates used Kaiser’s HealthConnect system to track progress of patients having elevated serum creatinine levels to assure they received care consistent with evidence-based treatment guidelines.

They suggested referral to a specialist or provided treatment plans for implementation by PCPs as they deemed necessary.

"The goal with kidney disease is to detect it early enough to make changes that will slow the disease down,” Lee told BurrillReport. “Patients who consult with a nephrologist before the onset of kidney failure are less likely to be hospitalized and more likely to survive longer.”

In a separate study funded by the National Cancer Institute, Kaiser’s EMR was found to boost mammography screening rates by 17% among women who should receive them.

Participants were female Kaiser Permanente Northwest HMO members aged 42-49 years old that had not received the breast cancer screening test in at least 20 months.

After identifying eligible patients, the Kaiser system mailed out a “mammogram due soon” postcard to them. This was followed by up to 2 automated phone calls and then a live call for nonresponders.

Before the system was instituted, 63.4% of targeted women completed a mammogram. This number increased to 75.4% during the initial implementation phase of the program, and to 80.6% during a maintenance phase.

The write-up appears in the American Journal of Preventive Medicine.

Glenn Laffel, MD, PhD, Sr. VP Clinical Affairs

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.