Electronic medical records (EMR) are to health care professionals what world peace is to humanity-everyone wants it, but not everyone agrees how to go about it.
Explore This IssueJuly 2008
One EMR company, however, San Francisco-based Practice Fusion, is quickly finding success with physicians of all types. Undoubtedly, one of Practice Fusion’s draws is that it’s free to use. The catch-and the factor that agitates naysayers-is that the product is sprinkled with advertisements that are based on the content of the medical records. Practice Fusion launched its revamped EMR and Practice Management suite in October 2007 and, by the beginning of April 2008, had at least 500 users. Adoption has been phenomenal, said Ryan Howard, Chairman and Chief Executive Officer of Practice Fusion. The growth is unprecedented right now.
Free, and Then Some
The cost-or rather, the lack thereof-of Practice Fusion is a selling point that sets it apart from other health information technology products. There’s obviously a federal mandate, said Mr. Howard, referring to the nationwide goal of implementing EMR by 2015, as presented by President Bush in April 2004. But the low adoption is directly attributed to the very inflated costs of solutions today, the intrusiveness of implementing a solution, as well as the time needed to get the system implemented and users trained on the system.
With these challenges in mind, Mr. Howard and his colleagues developed the free, browser-based EMR product that can be implemented in five minutes and for which training takes one hour. Within 24 hours, patient data will have been extracted from a practice’s billing system and imported into the EMR and practice management system.
From there, physicians can create chart notes of visits and calls, manage medication allergies and immunizations, track appointments and patients, send nursing orders and billing messages, among other features.
With a Catch
As proud as he is of Practice Fusion, Mr. Howard is forthright about the catch: The product is direct-to-physician message-supported-there’s advertising in the product, to cut to the chase. He added, But the advertising is not intrusive. It’s completely private. There are no pop-ups. There’s no obligation to click on the advertising.
These aren’t ordinary, random ads. Ads, powered by Google’s AdSense and similar programs, are generated by keywords found in patients’ information. Anyone familiar with Google’s Gmail has already experienced how these programs work.
Previously, Practice Fusion, too, carried a fee, but its executives discovered that any price was too high for these doctors, said Mr. Howard. So we decided to come up with a novel way to subsidize the cost of the solution.
Commercialism and Bias
As one might expect, there has been some alarm among both physicians and the public about the interplay of commercialism and medicine with Practice Fusion and similar products. For example, a recent article in the New York Times (http://bits.blogs.nytimes.com/2008/03/03/this-blood-test-is-brought-to-you-by/ ) and readers’ comments following it expressed concern about the possibility that these ads could influence a physician’s decisions in treating patients.
Michael S. Benninger, MD, Chair of the Head and Neck Institute at the Cleveland Clinic in Ohio, shared these concerns. If I’m utilizing a tool to take care of individual patients, where there are biases being introduced, and those biases are largely financially driven, not necessarily qualitatively driven, and there’s no true editorial censorship, to me, that raises major ethical issues, he said.
Dr. Benninger doesn’t take issue with advertisements in general. He views advertisements that accompany Internet pages when he specifically searches for certain conditions or treatments as acceptable. In addition, ads appeared in Otolaryngology-Head and Neck Surgery, for which he served as editor from 2000 through 2006. We had no trouble with advertisements, he explained.
However, Otolaryngology-Head and Neck Surgery created policies that stated that no advertisements could be within a certain number of pages of an article of the same content. For example, he explained that if there were an article on allergic rhinitis on one page, accompanied by an advertisement for allergy medication, whether it’s an indirect or direct affect, it biases individuals. Dr. Benninger stated simply, The article should be independent from any advertisement.
Regarding Practice Fusion, Dr. Benninger stands firm about the separation of commercialism and medicine: Industry trying to bias providers in the context of a medical exchange for an individual patient is absolutely inappropriate.
Pharma and Privacy
Another, more specific concern both professionals and laypeople have seems to be the ever-encroaching presence of pharmaceutical companies. Mr. Howard does not dismiss these as trivial. It’s kind of a double-edged sword for physicians today. Our chief medical officer, if he were in this conversation, would argue that the advertising is much less intrusive than actually having a pharma rep come onsite, he said.
For the record, at the time of the interview, there were no pharmaceutical advertisements in Practice Fusion, according to Mr. Howard: A lot of our partnerships are dictation, transcription, and billing services. To which Dr. Benninger responded, But how do we know those are the best services?
Beyond this, privacy matters-always a hot topic in health care, especially with HIPAA and with the boom of health information technology-continue to cause anxiety. Mr. Howard assured, All the ads are triggered off physician demographics and specialties, very nonprivate pieces of information.
He explained that Practice Fusion never sells any private patient or physician information. This is to protect the patients, the physicians, and themselves: The reality is if we compromise that, we’ll compromise our model, and we’ll be out of business. You haven’t heard about [breaches in privacy] because it hasn’t happened [with Practice Fusion].
At the end of the day, at least for now, it seems that Practice Fusion, a proposed solution to the looming question of how to establish electronic medical records, conjures up at least as many questions as it does answers.
On one hand, there’s the ethics of the situation. Dr. Benninger explained, I personally feel that industry relationships are appropriate to move forward the science of medicine-the docs can’t do without the industry, and the industry can’t do without the docs. The stickiness of the situation lies in defining the boundaries between industry and practice.
On the other hand, there’s the feasibility of a solution. As Mr. Howard discovered, EMR systems without advertisements might be available, but often at a high price-and often at a price too high for independent medical practices. So while some systems are feasible in terms of financing and infrastructure for certain groups, such as institutional powerhouses such as the Cleveland Clinic, they are logistically out of reach for many who choose to practice privately, like many of Practice Fusion’s users.
It seems there’s only one definitive axiom in the midst of this period of changing technologies: The patient should come first. According to Dr. Benninger, Physicians’ decisions should be motivated by the best option for the patient, not pressure from various external sources.
Google, Cleveland Clinic Partner to Test Personal Health Record System
Google has recently released Google Health, a free, Cleveland Clinic-tested, Web-based personal health record (PHR) program.
The core goal of Google Health is to give patients the ability to manage their own health information as well as share information with multiple physicians, health care providers, and pharmacies at their discretion
Currently, more than 100,000 Cleveland Clinic patients use Cleveland Clinic MyChart, which allows them to view their test results and current medications, as well as schedule appointments and receive health reminders. More than 1500 volunteer MyChart users evaluated Google Health’s features and security. Google Health enables users to add new data; connect to articles, discussion groups, and other resources; and access MyChart, even outside the Cleveland Clinic’s system. The program is password-protected, and Google announced that personal health information would be stored on separate hardware from the company’s other endeavors in order to add another layer of security.
The portability of the system is one of its strengths, according to Cleveland Clinic and Google representatives. For example, people who reside in Ohio for part of the year and in a different state for another part of the year will now be able to share their health data with providers in both states with ease.
In addition to the Cleveland Clinic, partners include Allscripts, CVS, Longs Drug Stores, Quest Diagnostics, and Walgreens.
©2008 The Triological Society