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Freenomics and Healthcare IT

Robert.rowley

Electronic medical record (EMR) adoption has remained frustratingly low, despite numerous studies 
showing improvement in health care delivery resulting from EMR use, measured in many different ways (quality, consistency, cost, etc).

The Obama administration has proposed widespread, even universal, EMR implementation over the next 5 years, though how to accomplish it remains to be seen. The Medicare reimbursement “bump” given to physicians this year to use electronic prescribing is a step in this direction, trying to create incentives.

The biggest barrier to EMR adoption has been cost. Traditionally, EMRs
have been very expensive systems designed to be installed and run
locally in a medical office, or some other local network. Thus, in
addition to the cost of the software itself, they are predicated on the
need to have an entire server system and technical support available to
the practice. The business model used by these traditional EMR vendors
has been to expect the physicians themselves to pay for these systems.

Typically an EMR involves start-up costs (thousands or even tens of thousands of dollars per physician), maintenance costs (both of the software and of the underlying server system), upgrade costs, and add-on customized features for additional cost. The result can be an outlay of tens or even hundreds of thousands of dollars to a practice. Sometimes there is financing available (though the credit markets are tight right now), and sometimes local hospitals help underwrite the costs. Not surprisingly, EMR systems have had poor adoption by physicians, and are mostly seen in larger groups or staff-model clinics, or in networks closely affiliated with a local cost-underwriting hospital, and are seen much more rarely in small practices. The new administration has talked about earmarking significant monies to help physicians embrace EMRs, but exactly what this means is as-yet uncertain.

The Practice Fusion approach

Recognizing the importance of EMR adoption, and the challenges in adoption resulting from the business models thus far used, we created an EMR  designed to challenge the basic paradigms of the industry – Practice Fusion. Like with every other full EMR, ours aims to be robust, intuitive, well-designed and able to help physicians move through their workday without slowing anyone down. That is a given for everyone. However, uniquely, the Practice Fusion vision goes further: (1) the data should be hosted, rather than locally installed, so that appropriate and secure clinical data sharing between practitioners taking care of patients becomes easy; and (2) the business model of Freenomics is implemented so that the EMR is free to physician end-users, paid for by other revenue streams.

Freenomics is a term coined in Silicon Valley to describe a free web service paid for by other revenue sources (usually advertising) – Google searches, Yahoo mail, Wiki lookups, YouTube videos are all examples of free services paid for by other revenue sources. Applying this business model to EMRs is groundbreaking. An ad-based EMR that maintains a robust, professional, full-featured offering challenges how we think of the EMR business.

Recognizing the potential for hesitation by physicians using an ad-based model, Practice Fusion allows physicians to opt out and use an ad-free version for a nominal $100/month. This enables a large group to make a rapid decision to implement an EMR across the community without any financial burden, and if an individual physician wants to opt out, the group will know that the price point is negligible.

However, advertising to physicians is a ubiquitous “wind” and physicians have become quite accustomed to it – from in-office detail reps, to pens and notepaper with logos on them, to a myriad of free print journals that contain some modest content and jam-packed advertising. In addition to ads from traditional advertisers (like pharma), ads from service-partners, like billing services, or transcription services, or document scanning services, have also been well received.

An ad server – a sophisticated technology able to populate an ad window with very customized content – can be used in some innovative ways. A public county clinic network, for example, which might have a written policy against any pharmaceutical or device advertising, can utilize the ad service to broadcast its own messages bulletin-board-like to its specific community of clinics and doctors. The potential for organizations who wish to sign-up whole networks of doctors (e.g. IPAs, medical groups, or insurance plans) can use the ad server to render their own custom messages to targeted physicians. The potential is tremendous.

The bottom line is that the traditional model whereby physicians foot the entire bill of an EMR themselves needs to be re-thought – it hasn’t worked! EMR adoption using this approach has been frustratingly low. By contrast, drawing from a business model that has been highly successful in other industries (Freenomics), one can design a business that delivers a web-based, hosted, fully robust EMR to physicians free of charge to them, paid for by alternative revenue streams. The Practice Fusion experience has been a testament to the success of this approach. Further, the impact of this approach in the EMR field must be taken into account when designing EMR-support policy coming from the federal level, as envisioned by the new administration.

Robert Rowley is Chief Medical Officer at Practice Fusion, a San Francisco based company.

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MediTouch EHRjoanScott Shreeve, MDSheree SongerDr Chewy Recent comment authors
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joan
Guest
joan

Hello friends, my name is Frederick, I am a person addicted to Vicodin, as it is a very powerful painkiller for the constant pain I have for the disease, is painful to see how my life is finished and I lose sensitivity, time and Many people do not understand what they feel, I hope you can find a cure for my illness, and thus fail to suffer and also stop making a lot of people who suffer want me, here http://www.findrxonline.com/vicodin.htm may understand our problems and also learn about this disease, so they said they understand people like me because… Read more »

Scott Shreeve, MD
Guest

All, Interesting thread – not sure how I missed this conversation earlier. I was an early critic of Practice Fusion when I first heard of their business model: http://blog.crossoverhealth.com/2007/03/16/adware-within-healthcare-software-free-dumb/ However, I have come around for many of the reasons that Dr. Rowley and Dr. Kibbe mention. In fact, I would suspect that I am the only commenter on this section that has actually used the software in to take care of patients (Crossover Health personal health advisory service). Getting a tool (an EMR) into the hands of providers (much better than paper) who can use it to improve patient care… Read more »

Sheree Songer
Guest
Sheree Songer

This is what disturbs me about this model; do you want a company that focuses its technologies on delivering ads or on creating a truly usable EMR? One can’t help but think that behind closed doors there is more talk about how to increase ad revenue than how to solve the Doctors problems. I would prefer to work with a company that wants to get to know my business and helps me understand how to do it better than one that just wants to sell me something in a call-out box…

Dr Chewy
Guest
Dr Chewy

Dr Rowley, I found your article quite interesting, interesting enough for me to spend a few minutes signing up for the service to see what it was all about. Can you please explain how you get to your number of 13,000 subscribers? Although I have little intention of using the service and certainly have not used it yet, do I count as a provider on your platform? Reading some other literature on your site and running some quick math it appears that you are being quite liberal in your counting of subscribers. Can you elaborate on the trigger to count… Read more »

Robert Rowley, MD
Guest

Many of the comments on this thread have been quite good. In particular, David Kibbe asks many of the central questions on all of our minds with respect to this approach to deploying EMRs. And I certainly understand the dire circumstances faced by primary care physicians, and the dangerous attrition in the primary care workforce that results from this – I am a practicing primary care physician (Family Practice) in a region with high managed-care presence, and have seen the challenge posed by the expense of EMR adoption. Wearing another hat, I have also served as a medical director of… Read more »

John Irvine
Guest

Bev – I’m chiming in here, because I’m the editor responsible for making the call to run Dr. Rowley’s piece. You may disagree with his firm’s business model (and I’d certainly expect you to), but I think the goal is for THCb to be the forum where these issues are discussed. There are some good questions here for us all to think about – many of which Dr. Kibbe raised in his reply. How are physicians reacting to this offering? Equally importantly: how are pharma companies reacting? Are they participating? One might think they’d jump on the opportunity, but you… Read more »

bev M.D.
Guest
bev M.D.

Matthew;
I know this is just a side issue, but compare this “commercial” to a doctor posting about a drug or medical device made by a company with which he has a relationship, paid or unpaid. Do we think that doctor will be as objective as one with no relationship? I don’t think so.
I would rather have seen a post from a user. But – your blog, your call; no hard feelings!

Matthew Holt
Guest

Bev. It’s not a commercial for two reasons. One, it’s Robert’s opinion about something that has been in the news a fair amount (and one for which we had him work on several rewrites) and two, we didn’t get paid!
Of course, you are absolutely welcome to express your opinion about the validity of Practice Fusions model (which I too have several reservations about).

spike
Guest
spike

I agree with 99% of this. A hosted system in a web-enabled Software as a Service model is the only way a small provider group is going to go to an EMR. athenahealth is on the right track here. I also think that asking the provider to pay for it might not be the best approach. But why ads making up the difference? Ethical issues abound and is it even realistic? If the ads work, that’s a problem almost in itself. When I go to a doctor using one of these systems, I’ll have even more questions about why I’m… Read more »

bev M.D.
Guest
bev M.D.

Why is this post not just a commercial? Matthew?

maggiemae,PhD
Guest
maggiemae,PhD

Here is an idea…Why don’t all of you declare yourselves 501(C) 6 organizations and claim your income as Tax Exempt. This is what Lieber does at HIMSS.org, the so called HIT leader. They’ve made over $100 million in the last 10 years and haven’t paid a dime in taxes. Some people go to medical school thinking they will become millionaires and really could care less about helping people, I feel badly for those who truly care about the patients and are having a hard time with it. But the reality is the other extreme, the guys that carry the cash… Read more »

Margalit Gur-Arie
Guest

endofline: This is so true. I don’t know why people keep ignoring this very stark reality: primary care physicians, particularly in small offices, but in large ones too, are increasingly unable to practice. I speak to primary care docs almost every day and in the last month or so, I’ve heard stories that should be of concern to anybody that is remotely interested in transforming healthcare. Doctors are shutting down established clinics and becoming hospitalists; others are considering selling and just moving on. The ones that stay are trying to restructure and salvage something. There are always those that do… Read more »

Stephen Motew, MD
Guest

Clearly innovative approaches such as ad-based services will be required to spur broad adoption of EHRs. Our surgical specialty practice has seen our EMR/PM overhead skyrocket during the implementation, maintenance and upgrade phases and despite the huge per provider cost we are LIGHTYEARS behind using the most important and cost-containing features. Frankly, with declining contractual reimbursement and recent lower procedural volume, this expense is a major concern and limiting factor for practice growth, including recruitment. The use of off-site data clearinghouses, protected data farms, and implementation of ‘cloud’ computing, and web-based applications are obvious means to tie together the vast… Read more »

Jaan Sidorov
Guest

Electronic medical record (EMR) adoption has remained low, because numerous studies have also failed to show improvement in health care delivery resulting from EMR use, measured in many different ways (quality, consistency, cost, etc.)
And the idea of having ads on an EHR screen while I’m seeing patients could only be hatched on Planet Silicon.

David C. Kibbe, MD MBA
Guest
David C. Kibbe, MD MBA

Dear Robert and others: I commend the folks at Practice Fusion for entering this forum, which last time I looked was still an open and welcoming place for innovative thinking, products, and business models. The fact is that cost has consistently been a barrier to use of EMRs by physicians — not the only barrier, of course, but a significant one. It seems inevitable to me that someone would try out an ad-based EMR/EHR product at some time, and I’m very interested in the results of the experiment. Will physicians use the product? Will only physicians in very small medical… Read more »