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.

Docs Dig ePromotion

Just 2 years ago, Big Pharma fielded 102,000 sales reps. That number has already dropped to 92,000 and it’s headed to 75,000 by 2012, according to Chris Wright, a principal at ZS Associates.

The cuts will save $3.6 billion for the beleaguered pharmaceutical companies, who are well aware that sales force effectiveness is way down.

Nowadays, only 37% of the drug reps who visit medical practices get to place products in the sample cabinet, and a measly 20% speak directly to a physician. About 25% of physicians belong to a practice that bans reps altogether.

That’s why Big Pharma has become so bullish about ePromotion, a phrase describing 3 techniques by which drug makers communicate with and educate physicians about their product offerings without having to rely on Sid the Drug Rep.

The ePromotion trio includes virtual details, which include audiotapes, videotapes, texts and emails (but no live communication), video details, which involve chat or telephone-assisted Internet sessions in which participants can communicate directly with a representative, and virtual events which include webinars, CME events, conference calls and group discussions.

Big Pharma’s enthusiasm will no doubt be increased by the results of a new survey indicating that physicians’ attitudes toward ePromotion are becoming increasingly positive.

SDI reached these conclusions after performing its Annual Study of ePromotion, the eighth such iteration of the query.

The Study showed that 67% of surveyed physicians expressed a positive overall attitude about ePromotion, up from 62% the previous year.

73% of these physicians felt ePromotion by Big Pharma was equal or superior to face-to-face promotion by drug reps, as compared with 68% the year before.

The average time spent per physician, per ePromotion event was 18 minutes.

With each passing year, “we have seen acceptance toward ePromotion among physicians increase,” said Jason Fox, Associate Director at SDI. “The results of this survey underscore a growing opportunity for the two groups to interact more regularly.”

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

Is there a Doctor in the Mouse?

Prompted by increasingly permissive reimbursement policies, digital office visits--in which patients and physicians use computers to manage clinical issues that traditionally necessitate an office visit--are growing faster than biceps on steroids.

Big Insurers from Aetna to WellPoint are experimenting with such programs, which are a time-savers for everyone and less expensive than a schlep to the doctor’s.

“If…there is payment for it, we will see many more primary-care physicians doing it,” Ted Epperly told the Wall Street Journal. The president of the American Academy of Family Physicians said that at the moment, about 3% of his organization’s members offer digital office visits.

Physicians agree that the new format is best reserved for simple stuff; colds and flu, urinary infections, back pain and sleep disturbances for example.

Even in such instances, some offer the option only to patients they know, mostly as a hedge against malpractice.

And no physician in her right mind would go this route for symptoms that could spell trouble, like chest pain--any kind of pain really--or abdominal symptoms, which are notoriously difficult to diagnose without a physical exam. 

The field is still in shake-out mode, with many formats for the interaction being tried in many venues across the country. The simplest approach is using secure, HIPAA-compliant email . Practice Fusion will support this activity as part of its Patient Health Record scheduled for release in Q1, 2010.

In another format, patients must complete symptom-specific algorithms in advance of the actual interaction. The snazziest approach involves live, online visits using Web video, chat or a phone conversation routed for privacy purposes through a secure computer system.

In a joint experiment of the latter approach, American Well and the Hawaii Medical Service Association combined to offer such services to enrollees, who pay a $10 co-pay for the privilege. 

For non-insured online visits, the going rate around the country seems to be about $20-35 a steal when compared to the cost of the old-fashioned schlep.

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

Big O Bobs, Weaves on Public Plan

During Tuesday’s press frolic, the Big O put some mustard on his pitch for a public option, dismissing as “not logical” suggestions that a government plan would sink Big Insurance faster than the Titanic.

He followed quickly with a favorite refrain, which is that good, old-fashioned competition from a public plan would be an “important tool to discipline insurance companies.”

Then, in a denouement worthy of at least runner up at a Harvard Law Debate Club, he triple-dog-dared anyone to come up with a better plan that met his 2 etched-in-stone requirements. “Reform has to control costs and it has to provide relief to people who don’t have health insurance or are underinsured,” he said.

Big Insurance, destined in this match to play Smokin’ Joe to the Big O’s Ali, released a wild haymaker of its own 2 hours before the Big O even showed up.

“We do not believe it is possible to create a government plan that could operate on a level playing field,” quoth Karen Ignagni, president of America’s Health Insurance Plans, and Scott Serota, president of the Blue Cross and Blue Shield Association in an open letter to the Senate.

“Regardless of how it is initially structured, a government plan would use its built-in advantages to take over the health insurance market,” the letter continued.

No doubt the Big O smirked when he read that.

Meanwhile, Kent Conrad, the intrepid Senator from North Dakota has created a stir with his suggestion that nonprofit consumer-owned cooperatives could be an alternative to the government plan. He foresees the Feds forking over $3-4 billion to jumpstart the co-ops, after which time they would sink or swim on premiums and investment income, just like Big Insurance.

The Big O knows he can live with this or any approach that covers most everybody without breaking the bank, but this day he was on offense.

“If private insurers say that the marketplace provides the best quality health care, if they tell us that they’re offering a good deal, then why is it that the government — which they say can’t run anything — suddenly is going to drive them out of business?” Obama asked.

Dr. Spock himself couldn’t have asked a more logical question.

Glenn Laffel, MD, PhD, SVP Clinical Affairs

Practice Fusion participates in the Free! Summit 2009

Practice Fusion was one of several participants in the Free! Summit, which looked at different examples and business models around offering free products and services. Unlike many such businesses which offer a free "basic" or "introductory" product, and monetize by driving customers to purchase "premium" upgrades (sometimes referred to as a "freemium" model), Practice Fusion offers a free, fully-functional, high-end SaaS-based (software-as-a-service) EHR to all physician end-users, subsidized by alternative revenue streams.

A review of this conference can be found here.

Follow Practice Fusion on Twitter: #practicefusion

Interview with our CEO - Ryan Howard by David Williams of Med Pharma

Our CEO Ryan Howard was recently interviewed by David Williams co founder of Med Pharma Partners:

http://www.healthbusinessblog.com/?p=2252

Enjoy!

Practice Fusion Support Team

Hill medical group invests in IT, hurting net income

The San Francisco Business Times is running a great article about how Hill Physicians Medical Group's NextGen implementation is impacting the organization's revenues.  Here's the entire story:

Hill Physicians Medical Group, one of the few medical groups or IPAs to publicly divulge its financial results, generated $428 million in revenue and $5.3 million in net income last year, according to preliminary figures from the San Ramon-based group. Its formal annual report is expected by early June.

Dan Robinson, vice president of corporate services for 2,600-doctor Hill and its PriMed Management Consulting Services management group, said 2006 revenue increased 3.4 percent over the prior year. Net income fell 31 percent, from $7.7 million in 2005, due to a steep increase in funds invested in implementing its electronic medical record system and increased performance-based pay for its doctors.
Hill spent $5.89 million on its EMR implementation last year, 78 percent more than 2005's $3.3 million, Robinson said; meanwhile, performance-based pay jumped 23 percent, from $26 million two years ago to $32 million in 2006.

PriMed's administrative costs remained low, he said, at 10.8 percent, "whereas other similar groups generally run in the 13 percent to 14 percent range."

Hill, run by longtime CEO Steve McDermott, is considered one of the best-run IPAs in California, if not the nation, and is one of the very few to provide any public accounting of its financial results. "Bottom line, financial performance remained strong again," Robinson said of the preliminary results. "We're continuing to invest aggressively but judiciously in clinical and technical support services that support our physicians' practices."

-Ryan Howard
CEO, Practice Fusion

Intel/Cisco Dossia Initiative

I recently wrote a commentary that was featured in today's Modern Healthcare about Intel's and Cisco's Dossia initiative, which can be read here.

Another item to note is that Cisco, Adobe, Cadence, NEC and Oracle worked with RelayHealth on a similar project in 2001 to enable their employees to message their physicians. While this is not an exact apples to apples comparison, the resulting low adoption reflects the trends of physicians and patients today.

Even when these products are subsidized by a third party (ex. Blue Cross), physicians and patients are not using them. Again, the problem is that these solutions are not integrated into the typical physician's practice management and EMR systems, thus not part of the physician's current business process flow within their practice. Thus, when patients login to these systems, there is no medical record, billing, or prescription information. 

Another issue with these solutions is that since all of this patient information (appointments, billing, prescription and possibly chart data) is residing in the practice management/emr solution, users within in the office (including nurses, office administrators and practice managers) must attempt to work between multiple solutions to utilize these applications, making their data entry workload significantly higher.

-Ryan Howard, CEO, Practice Fusion

 

Problems Facing the CCHIT and RHIO Groups Leveraging Today's Technologies

Today, everyone seems to know that the majority of practitioners are not connected to each other and to their patients - but why?  The problem lies in current healthcare IT vendors’ inability to embrace new technologies and their continued use of enterprise client-server product models. The following details the problems with existing models which are being used today.

 

Implementation, Support and Maintenance

Enterprise-based solutions that are installed in physicians’ offices have extremely long deployments, which take many months, if not years to implement - Kaiser is a case in point. Generally, consultants go on-site to each practice to install the software (Practice Management/EMR), databases, and enable connectivity to insurance payers. In addition, each physician will likely need replace their existing hardware to run these new applications.

 

When there are thousands of these types of installations and a there is a bug in the product or a change in privacy or compliance laws, patches or a new release of the application need to be installed.  When you multiply these factors by the hundreds of thousands of potential installations in the US, it becomes extremely human resource intensive to deploy and maintain, if not impossible. This situation happened to WebMD in 2004 when they failed to bring the physician community utilizing their enterprise practice management solutions to HIPAA.

 

Security

Most organizations believe their data is secure onsite, but statistics show most data breaches occur as the result of a disgruntled employee, a laptop stolen (for example, the VA), or hacker. In addition there are hard drive failures, viruses, malware, spyware, power failures and break-ins and more.

 

Making traditional enterprise systems secure is a complicated and expensive endeavor that gets exceedingly complex for each practitioner deployed. This is supported by new articles seemingly written every week about a computer stolen with confidential patient data. This is because in an enterprise model, patient records reside in the on site database with each practitioner, which astronomically increases the changes of a data theft. For example, the computers stolen in just one incident from San Jose Medical Group contained 185,000 patient records. Two more recent incidents can be found here: Computers with health data stolen from cancer program and Security advisory issued about stolen laptop 

 

Interoperability

The enterprise model will never work well in a large interoperable community environment. Kaiser is experiencing major issues with their installation, and keep in mind that this is a controlled environment. In a large, real world community where there is no central administration, record aggregation, record locator service and record synchronization the enterprise model will never work.

 

Since the CCHIT and RHIO groups have not started any type of interoperability standardization, it is my prediction that any physician group investing in an enterprise EMR today will be unpleasantly surprised when they find out that their product, which they have invested millions of dollars into, cannot connect to the masses outside of their enterprise. To date the CCHIT has only addressed mundane security features in available applications. This is a hoop vendors just through to get the stamp of approval. Buyers don’t seem to realize that an entirely new generation of applications will be need to achieve the pinnacle of interoperability. I discuss more about interoperability here.

 

Cost

Last, but not least, enterprise solutions are expensive. The typical practice cannot afford the six figure price tag the typical practice management/EMR offering costs, nor can physician groups afford multi million dollar price tags. In addition to the cost of software, these solutions are riddled with additional charges including consulting, training, support and maintenance, which combined often triple the original price over a five year period.

-Ryan Howard, CEO, Practice Fusion