Chapter 10.Electronic Health Records

This is chapter 10 in my book Health Reform in Perspective.

Prologue: The Obama administration loves the idea that ubiquitous, interoperable, communicating, data-gathering electronic health records in every hospital and every doctor’s office, will save Medicare and health care by rationalizing care, minimizing error, and saving costs. It is not only an idea. It is a $27 billion bet.

EHR “Inevitability” and The Physician "Waiting Game"”

In a recent blog,”EHRs – Size of Physician Market, Number Sold, By Whom, and Comprehensiveness of Systems Sold,” I reprinted a report by Software Advice, Inc, on the state of the EHR market “without editorial comment.”

I shall make that comment now.

Perception of EHR “Inevitability”

The perception persists in all quarters that EHR adoption is inevitable. This perception assumes payers, government and private, health consumers, and the public at large will come to expect and demand EHRs as the standard of care and the exemplar of quality. IT technologies and HITECH information technologies, the theory goes, will dominate. The Internet will reign, and we will all dance to its tune.

But for now the world of EHRs remains split between the conceptual and impatient “true believers” and the behavioral, more patient “late adopters,” who are dragging their feet and playing the “waiting game.”

Among the powerful true believers are,

• Big Government, specifically the Obama administration, who placed $20 billion in the HITECH basket in its February 2009 stimulus package.

• Related government enterprises – The VA, the Department of Defense, Indian Health Services, Community Clinics – all of whom are committed, pledged, and destined to adopt EHRs.

• The EHR industry and its 300 vendors, who foresee and thirst for hundreds of thousands of new jobs, new products, new revenues and the makings of an even vaster enterprise.

• Integrated delivery systems, like Kaiser, who has already poured $3 billion into adopting system-wide interoperable EHRs.

• Large physician organizations and societies – like AAFP, CAP, MGMA, and AMGA – which are committed to EHR adoption by its members.

• IT Giants, like Google, GE, Intel, and Microsoft. Microsoft has been in EHR market for three years now, has three products on the market, and is rumored to be anticipating acquisitions of one or more EHR vendors.

• Young IT savvy physicians, reared on computers and inspired by YouTube, Facebook and Twitter and now I-Pad, who take EHRs as a given and who migrate to groups, hospitals, and other physician employers with existing EHR platforms.

• Organizations like Health 2.0, a consortium of consumer-oriented health IT companies and vendors, who see EHRs and Personal Health Records as transformers of the health care landscape.

The Waiting Game

These are powerful and formidable agents and forces for change but practicing doctors continue to exhibit caution and to play the waiting game. Despite a 6 to 8 year push by government IT aficionados, industry, and Internet gurus, only 1.5% of hospitals and 6% of doctors have “fully functional” EHRs. A full-fledged “interoperable” system remains a pipe-dream, albeit one that continues to evolve and promises to burst into full flower sometime soon.

Reasons to resist change are legend – high installation costs, training and maintenance expenses, drops in clinical productivity, disruption of practice patterns, altered doctor-patient relationships, and little or no return in investment. Understated, but tangible nevertheless, is the feeling that EHRs violate or compromise doctors and patient privacy and confidentiality or will be misused to the detriment of both. To doctors, these are real, and sometimes profound, reinforced by the recession, and calls for cautionary waiting. Waiting for further developments, most doctors believe, at least those on the mean practice streets, is safer than plunging into the maelstrom.

Hospitals, meanwhile, are experiencing lower admission rates, declining revenues, and difficulties accessing capital. Doctors too are having trouble acquiring capital for recruiting new physicians, meeting operating expenses, and dealing with demands for more information infrastructure. It should be no surprise, then, that the AMA and the AHA are saying forced digitization demands are “too much, too soon” and are pushing back against too fast and too much EHR adoption.

We are in a period of watchful waiting for further developments.

• Waiting to see if EHR costs will come down with competition.

• Waiting to see which EHR companies will survive.

• Waiting to see if new “free” EHR business models, such as Practice Fusion, Inc, where advertisers, not doctors, pay for installation and maintenance, are for real.

• Waiting to see if payers, government and private, will demand EHR adoption for participation.

• Waiting to see if hospitals will offer more financial and technical support for EHRs. .

• Waiting to see if EHRs are as good as promised in reducing errors and improving care – as good in concrete practice as in the abstract theory.

• Waiting so to see if EHRs become more user friendly and functional in clinical use.

• Waiting to see if benefits to insurers and patients outweigh the headaches to doctors.

• Waiting to see if physician transitions and adjustments to new business models – HSAs with high deductibles, cash-only models, concierge practices, hospital employment – offer escapes from having to climb the EHR learning curve.

And so, the EHR waiting game and merry-go round continues. How fast forward it goes, when and where it stops, grinds to halt, or plunges over the cliff to a new nirvana no one knows.

A New Yorker cartoon captures the dilemma of waiting for EHR inevitability. A group of cavemen are keeping count by making vertical slashes in groups of five on the wall and counting with their fingers. The caveman leader explains to a visitor at the mouth of the cave,” It will take longer than we thought to go digital.”
Practice Fusion, Inc - An Innovative Web-Based EHR

When the government passed its $787 billion stimulus in February 2009, it included $20 billion for Health Information Technology and up to $44,000 for each doctor adopting certified EHRs with “meaningful use.”

This government act set off a chain of innovations for EHR companies and physicians.

There's nothing mysterious about successful medical innovation - it is about attracting venture riches, filling niches, adding sons of niches, anticipating physician bitches, and satisfying government hitches.

Practice Fusion, Inc, a San Francisco –based EHR startup had all of these ingredients when it was founded in 2005.

• It attracted venture “riches,” i.e. funding from Band of Angels and Felicis ventures

• It filled “niches” - 1) appealing to primary care doctors and specialists seeking easy-to-use, easy-to-install, free, certified systems to capitalize on the $44,000 federal largess; 2)adding multiple practice management features its management team was familiar with; 3)relying on the Internet, which allowed doctors to off-load all their needs to the Internet using nothing but personal computers and broad band access without installing hardware and software in the office. On top of all those niches, it was free, web-based, and no-risk.

• It added “sons-of-niches” - Those multiple other features such as new speech recognition programs – Dragon Naturally Speaking, MacSpeed Dictating, scanning paper documents, e-prescribing programs, and Personal Health Record programs.

' It anticipated physician "bitches" - complaints such expenses of installing, training, difficulties of data entry, loss of productivity.

• It satisfied “hitches ” for government reimbursement – such as those hard to understand conditions such as what EHRs qualified for “certification” and what constituted “meaningful use.”

And if that were not enough, it could be installed quickly , required no lengthy training or instruction, could be up and running in five minutes, and it had a business model, similar to Google’s Adsense, that allowed it to be “free” for clinicians. The business model is based on advertisements from insurers, suppliers, and drug companies when certain keywords appeared during Practice Fusion use.

Small wonder, then, that Practice Fusion has grown rapidly and now has 30,000 users.

Here is how Ron Howard, CEO of Practice Fusion explains its acceptance.

“Practice Fusion is an electronic health record, which is provided to Physicians at no cost for licensing, hosting, support, and training of the application. Right now we’re the fastest growing physician practice community in the country.”

“Every feature that’s included with the product in any capacity is offered at no cost, so it’s truly free. It’s offered with support, training, and hosting. It’s the only totally free model on the market.”

“ Practice Fusion competes with most major systems in the marketplace. It’s fully-featured. It has everything from front office scheduling to patient management to full-charting templating, prescription writing, lab management, the entire gamut of services. From a major competitor standpoint, we compete with them relatively well, especially over the next few months where we’ll be extending our products to include Quest Lab integration and e-prescribing.”

“Within our product we have a vast template library. We are servicing over 25 specialties today. Templates are created by everyone from our Chief Medical Office to our Physician Advisory Board to our end users. It’s one of the things that’s unique about the product. The product is not only free and web-based, but we have a process called Live in Five. If you go to our website and register, you can actually start using the products within five minutes.”

Is Practice Fusion’s “Free” EHR for Real?

As I was writing three recent blogs, I kept pondering these questions: Is Practice Fusion, Inc, a San Francisco-based company offering a “free” EHR to physicians an example of “disruptive innovation”? After all, its EHR appears to be simpler, more convenient, more affordable, and intuitively easier to use than other EHRs– the criteria usually applied to disruptive innovations. Does it signal a “breakthrough” towards a decentralized technology deployable at the site of care? How can Practice Fusion offer its EHR for “free”? What triggered this “breakthrough”?

When all is said and done, I believe this “breakthrough,” if it is that, is not attributable to new EHR software or hardware, but to a new revenue model. Or you might say, it is a “fusion” of all three of these elements.

Here is how Ryan Howard, CEO of Practice Fusion, explains this model,

‘Our revenue model works in a few different ways. We monetize transactions from our partners. We do some lead generation. So if the doctors are looking for a billing service, for example, we have a billing service that they can use. We do some advertising to the physicians: different health care services, insurance companies, device manufactures and pharmaceuticals as well.”

If you think about it, Practice Fusion has adopted and modified the revenue model that has made Google so successful, namely gathering revenues from online advertising and lead generation tied to “free” access by users. It does not require physicians to install new hardware and software, but to off-load what they need in an EHR to the Internet using their existing office computers.

The beauty of it is, of course, is that you can use your own computer and somebody else – people and businesses who want access to physicians to sell them products – pays the freight for the EHR.

In other words, someone else, not physicians, is paying the bill. According to Howard,

“The product is provided to physicians fully subsidized. It’s not a “take now, pay later” or get half of the product now and then pays for the rest of it. Every feature that’s included with the product in any capacity is offered at no cost, so it’s truly free. It’s offered with support, training, and hosting. It’s the only totally free model on the market.”

Back to my recent posts for context.

• On May 22, in “Will Innovation Save America’s Health Care?” I wondered out load whether innovations from largely web-based technologies and systems would save us from Europe’s fate- the crushing cost and ensuing debt of unsustainable social welfare programs.

• On May 21, in “EHR ‘Inevitability’ and the Physician ‘Waiting Game,’“ I questioned whether EHR systems were ready for prime time, and I implied physicians were right in waiting for useful, affordable, and intuitively and clinical compatible systems.

• On May 20, in “EHRs – Size of Physician Market, Numbers Sold, By Whom, Comprehensiveness of Systems,” I reprinted an article by Chris Thorman of Software Advice, on the scope, players, and nature of the EHR market.

In the May 20 blog, I shared a chart showing EHR vendors and number of physician users.

Vendor Physician Users Practices Served

Epic 45,000
AllScripts 40,000
eClinicalWorks 40,000
GE Centricity 35,000
NextGen 35,000
SOAPWare 30,000
Practice Fusion 18,500
Eclipsys 11,000
Sage Health 10,000 .
Greenway Medical 6,000

On May 21, I received the following email from Emily Peters, Director of Communications for Practice Fusion,

“Hi Dr. Reece,

“I’ve been closely following your blog coverage this week about market share, innovation and Practice Fusion.”

“We do see some element of the “waiting game” that you described with physicians, but much less than even just six months ago. Practice Fusion now serves about 40,000 users and 2 million patients across the country – making us, not only the fastest growing EMR community, but also one of the largest. “

Before that on May 13, I had read a podcast interview with Ryan Howard, CEO of Practice Fusion, in which he said, “We just broke 15,000 users.”

I have no reason to question or challenge these physician user figures, which bespeak of explosive growth. But I can ask: how could one EHR company grow so fast?

Maybe it’s simply a matter of timing, namely, the physician market is primed and ready to get into the EHR game. Maybe it’s the marketing magic of the word “free.” Maybe it’s because Practice Fusion has the only “free” EHR on the market. Maybe it’s word getting around among physician users that this EHR really works. Maybe it’s because the Practice Fusion model profits physician users because it qualifies them as “meaningful users” and therefore qualifies them for federal reimbursement. Maybe it’s because most physicians now have broad band Internet access in their offices and can put this EHR to work in a short time frame without elaborate training and installation preparation.

Or maybe Practice Fusion is not what it’s cracked up to be and is too good to be true. There are no perfect systems in the EHR world, all are evolving, and there is always room for skepticism, or as one pessimistic wag with a weakness for puns observed, there is always gloom for improvement.

Perhaps readers of this blog will give me insight into what they think of Practice Fusion? Is it for real, or does it have blemishes that I do not see? Please feel free to comment one way or another.

“Meaningful Use” of EHRs: Clinical Useful or Data Boilerplate?

People who use the word “meaningful” put my mind of edge. They rings alarm bells in my head. When they utter “meaningful,” they usually convey the impression that what they have to say is socially significant. It captures the big picture, is beyond the pale of ordinary mortals, improves the lot of humankind, or, in the case of health reform, advances the overall cause.

That was how I reacted when I heard David Blumethal, MD, national coordinator for health information technology at the Department of Health and Human Services, announce the “The “Meaningful Use” Regulation for Electronic Health Records.” He did so with fanfare, “The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.”

Here is how the WSJ Health Blog announced the news,

“The final regulations — all 864 pages of them –on what will constitute “meaningful use” of electronic medical records are now here. And the changes they include make it easier for hospitals and doctors to qualify next year for the first round of incentive payments for adopting EMRs.

As part of the stimulus package passed last year, up to $27 billion will be paid out by the Centers for Medicare and Medicaid Services over 10 years to providers that meet a series of requirements for EMR use.

Rather than having to meet 23 or 25 different objectives (for hospitals and doctors respectively), providers will now have to meet just 14 or 15 “core” requirements dealing with EMR basics, such as being able to enter patient data and use a computer-based system to record medical orders.

Then they can pick an additional five objectives from a menu of ten options. Those include incorporating some lab tests results into records and providing a summary of care record for patients transferring to another facility.”

Blumenthal lists these “core set” and “menu set” of meaningful objectives along criteria for payment by CMS.

Core set.

1. Record patient demographics.
2. Record vital signs
3. Maintain up-to-date problem list of current and active diagnoses.
4. Maintain active medication lists.
5. Maintain active allergy lists.
6. Provide patients with clinical summary after each office visit.
7. On request, provide patients with electronic copy of their health information.
8. Generate and transmit prescriptions electronically.
9. Computer Provider Order Entry (CPOE) for medical orders.
10. Implement capability to electronically exchange key clinical information among providerd and patient-authorized entities.
11. Implement systems to protect privacy and security of patient data into EHR.
12. Report clincail quality measures to CMS or state

Menu set

1. Implement formulary checks.
2. Incorporate clinical laboratory test results into EHRs as structured data.
3. Generate lists of patients by specific condition for use for quality improvements, reduction of disparities, research, and outcomes.
4. Use EHR technology to identifiy patient-specific education resources and provide these to patients as appropriate.
5. Perform medication reconciliation between care settings.
6. Provide summary of care record for patient referral l or transition to another provider setting.
7. Submit electronic immunization data to immunization registries or immunization information systems.
8. Submit electronic syndromic surveillance data to public health.

What does this all mean? What does it not man? And how it likely to play out among practicing doctors?

• It means that nothing is dearer and nearer to the heart of federal bureaucrats and technocrats than a “meaningful” national ubiquitous interoperable EHR system that allows doctors and hospitals to communicate with each, with patients, and with the federal government, which will have mountains of data to play with.

• It means that government will have to create new bureaucracies to make sure EHRs systems are standardized, credentialed. monitored, regulated, and implemented.

• It means that within five years, the government, through payment incentives and support systems, hopes to have most clinicians on board the EHR train.

• It does not mean, however, that clinicians will find EHRs as useful clinical information for communicating information. Many clinicians tell me that current EHRs are simply data boilerplate and do not convey why a patient was referred, contain narrative information on clinical status.

• It does not mean that this transition from paper to electronics will happen without pain.

Keep in mind that less than 10% of doctors and 5% of hospitals currently have fully functioning EHR systems, and many of these do not talk to each other.

Keep in mind that many doctors, especially those in small groups, or solo specialists, will opt to pay the penalty for non-use of EHRs.

Keep in mind that many doctors may drop Medicare and Medicaid patients rather than follow the CMS-Piper.

And keep in mind, that the $27 billion devoted to meaningful EHR use could turn into a massive federal boondoggle that neither patients or doctors appreciate.