May 14, 2007

Place Your Ad Here
By Selena Chavis
For The Record
Vol. 19 No. 10 P. 26

A fledgling software company supports its free EHR through advertising driven by Google’s AdSense network. Will physicians buy in? Do ads belong on patient records?

San Francisco-based electronic health record (EHR) vendor Practice Fusion hopes to take advantage of two upcoming opportunities: demand created by the nationally mandated push toward an all-inclusive EHR and the pressing need to get thousands of physicians to join the effort.

Steven Waldren, MD, director of the Center for Health Information Technology with the American Academy of Family Physicians, says independent physicians and physician groups—often considered a weak link in the overall effort to transition to an EHR—currently face the greatest obstacles to implementation. “In all of our surveys, well over 80% have made the decision but don’t have the financial resources,” he says.

In March, Practice Fusion announced it was teaming with Google to address this issue by offering an EHR solution at an appealing cost—free.

Subsidized via Google’s AdSense program and the prospect of selling deidentified demographic and healthcare trend data, “Practice Fusion benefits by having the ability to deliver a world-class product to market at no cost, completely lowering the barrier to entry and risk for practices,” says CEO Ryan Howard.

According to 2005 data from the Medical Group Management Association, only 14% of the approximately 880,000 physicians nationwide use database-driven electronic medical record systems. Considering the costs associated with products from larger vendors can run upward of $10,000, Waldren emphasizes that cost continues to be a barrier to widespread EHR adoption by physicians, and lower costs certainly have benefits.

Practice Fusion’s approach to EHRs has turned many heads in the healthcare industry. Opinions vary about whether the venture will prove successful, and many industry experts are taking a cautious “wait-and-see” approach, noting various concerns including expectations that much of the advertising will be bought by pharmaceutical companies.

“Pharmaceutical companies have always searched for new ways to get their product in front of physicians,” says Patricia Wise, HIMSS vice president of healthcare information systems. “The physicians would have to be aware that it is targeted advertising.”

Other concerns stem from how data will be protected and whether interoperability will be a factor. “It is difficult to tell exactly how the system works from the information that has been publicly provided. Will the [EHR] be an internal office system? Will it be a centralized server that several doctors use?” questions Joy Pritts, JD, research associate professor at Georgetown University’s Health Policy Institute. “Different systems raise different concerns. One concern that cuts across systems is that no one will be monitoring the system to ensure they are only pulling out generic data and not capturing patient-identifying information.”

C. Peter Waegemann, CEO of the Medical Records Institute, believes the opportunities far outweigh the concerns. Emphasizing that this venture will potentially bring a public health record to a large segment of the population, he notes, “It’s part of the change we are going through with the patient/provider relationship.”

How It Works
Practice Fusion’s application is available over the Internet, meaning the solution is delivered as a software-as-a-service model. The EHR requires no on-site software installation or licensing. A centralized managed data center houses all servers, software, databases, and files.

Google spokesperson Brandon McCormick says Practice Fusion is one of many healthcare Web sites that use Google AdSense—the unique aspect of the arrangement is that Practice Fusion is offering a free EHR. “Many Web site publishers in all verticals are finding ways to turn their Web sites into revenue-generating opportunities. Google AdSense is enabling these Web site publishers to make money by displaying relevant Google ads on their Web pages,” he says. “Because ads are targeted to the content of the site, publishers are able to provide more helpful information to their visitors and make money every time a visitor clicks on an ad that interests them.”

When a doctor using the service brings up a patient’s record, the AdSense program will recognize certain keywords, such as a diagnosis or condition. Ads related to that condition will appear on the page. According to Practice Fusion, advertising will be unobtrusive and not appear as pop-up ads.

Due to the nature of the offering, Howard says that some fine-tuning had to be done to make the program work. “Practice Fusion does not have a Web site like many other Google AdSense customers—we have an application,” he notes, adding that this meant the company could not simply insert Google’s code onto its Web site. “We also have reservations about this because we wanted complete control over the data that was available to Google, so as to not compromise any physician information and patient personal health record [PHR].”

To accomplish the needed control, Practice Fusion created a custom and secure application programming interface that interacts with AdSense. By utilizing this tool, Howard says the company controls all the physician and patient data transmitted to Google. Physicians who do not wish to view advertising on the EHR may opt to discontinue that part of the service and instead pay a $250 per month fee.

Howard says the Practice Fusion solution also offers free billing with no clearinghouse costs, scheduling, and practice management. “Our EHR will include integrated lab ordering and prescription ordering, along with interoffice messaging and integration into our PHR, which will be released at the end of the year,” he adds.

A Trend in the Making
Whether proponents or skeptics of the venture, many health industry professionals agree that arrangements such as Google and Practice Fusion’s are where the market is heading. “This is something to almost be expected,” Waegemann says. “It was not a surprise.”

Wise and Waldren concur, emphasizing that there will likely be more corporations entering the market through partnerships—Wal-Mart and Google to name two—that are not traditional to the healthcare sector.

“As we see healthcare systems moving to a more consumer-empowered philosophy, you’ll see companies that are traditional consumer companies getting more involved,” Waldren says, adding that he believes opportunities exist through these partnerships. “They are coming from outside of healthcare. They don’t bring the legacy of ‘that’s how healthcare should be delivered.’”

According to Howard, Practice Fusion approached Google after considering various strategies for lowering the cost of the company’s offering, as well as diminishing barriers to physician entry. “We worked with healthcare attorneys Davis Wright Tremaine to ensure that the legalities of the models were HIPAA compliant since this was a new model for the market,” he says.

Waldren believes this new model presents opportunities for the healthcare sector to learn about the successes large consumer-focused companies such as Google have had in the areas of interoperability, which remains a challenge to the healthcare sector. “They can bring their successes with innovation and connecting consumers to healthcare,” he notes, adding that when consumers are seeking information, they typically seek out companies such as Google or Yahoo. “And they can bring the consumer along … something healthcare has not done very well.”

While interoperability remains a challenge to the healthcare sector, Howard stresses it is an important aspect in the evolution of the Practice Fusion EHR. “We are currently enabling e-prescribing functionality in our offering, but this is not the definition of interoperability as I understand it,” he says, adding that e-prescribing is the parameter for interoperability that the Certification Commission for Healthcare Information Technology has chosen to impose. “True interoperability is the ability to share patient data, such as existing conditions, diagnoses, and treatments, between practitioners at the point of care. Practice Fusion will have the ability to do this for users on our system when our [EHR] becomes available.”

According to Waegemann, the movement toward more consumer-empowered healthcare via PHR availability will get stronger. “The Google partnership is the first to address the larger market [outside the scope of a sponsoring organization],” he notes, adding that 80% of PHRs are currently sponsored by some type of umbrella organization, whether it be an employer or an entity such as the American Association of Retired Persons. “The genie’s out of the bottle—it will never go back. The patient has the power to be a partner in healthcare.”

The Point of Decision Making
Of particular concern to many in the healthcare industry is the impact that the advertising aspect of Practice Fusion’s EHR model will have on physicians, particularly as it relates to expectations that it will be heavily weighted toward the pharmaceutical industry.

Acknowledging that physicians are currently bombarded with pharmaceutical advertising placed in other mediums, Waldren points out that this venture is the first to place ads “at the point of decision making.”

“Is it going to ‘buy’ us [physicians] more than the current models? That’s a good question,” he says.

Wise agrees, adding that the impact is unknown at this time. “Until we have research that dictates how that impacts [physicians], I guess I would be very cautious,” she warns.

While it is not yet known exactly how the advertising will appear on a particular page of the Practice Fusion EHR, Wise sees the potential for confusion, especially if the EHR offers clinical decision support, a tool offered by many EHR solutions on the market. With clinical decision support, indicators relevant to a particular patient—such as allergies or drug contraindications—appear on screen as reminders when a record is pulled up.

Wise believes that the clinical decision support tool could potentially be confused with advertising, and doctors may quickly close the screen before they recognize the needed information.

And What About the Data?
Questions have been raised regarding how information is identified for the purposes of displaying appropriate advertising. According to Practice Fusion, keywords are limited to a patient's condition, diagnosis, or treatment.

As long as data is deidentified, Wise does not see major privacy issues. “If they are in compliance with HIPAA, there is no reason why any of us should be concerned,” she says.

Waldren agrees, saying, “If I were a patient, I wouldn’t be concerned about the ads in terms of them being associated with a certain condition.”

Where many questions currently lie is how the data will be used. “I think most Americans would be surprised as to how well-used their healthcare data is,” Wise says, emphasizing that the selling of healthcare data is certainly not a new business model. “Secondary use of medical data has been a practice for a while in the United States.”

Allen Wenner, vice president of clinical applications design for South Carolina-based Primetime Medical Software, believes the Practice Fusion-Google initiative will open the door for further temptation.

“There is a lot of data in an EHR. Do they [Google] get the deidentified stuff by configuration, or do the doctors sell that information to them?” he questions. “I think doctors are in so much trouble financially that allowing disease-specific advertisements to patients and physicians is a given. But the day the malpractice bill and the house mortgage are both due may be different. I fear offers will be made.”

Is the Market Ready?
Skeptics of the initiative are quick to note that “free” doesn’t necessarily make the solution a success. “We have demonstrated in the marketplace that just giving away technology is not necessarily successful; it has to offer significant value,” says Waldren.

Citing examples of free offerings that didn’t quite meet marketshare expectations—including the VistA system offered by the U.S. Department of Veterans Affairs and a past venture by BurroughsWellcome—Wenner points out the issue of EHR adoption is “not about software, it’s about change.”

Wenner believes the Practice Fusion proposal reflects a lack of understanding of the physician market because doctors have had years of experience in writing prescriptions and no experience with software. “Technologically, most physicians are behind the general public in use of computers,” he emphasizes. “This is reflected by e-mail communication between doctors and patients. For example ... 68% of patients want it, and 9% of physicians do it. Doctors do not have the information infrastructure or the workflow adaptation to do e-mail.”

Wenner says the issues of EHR adoption are more about workflow changes, and physicians need to be educated about technology implementation, not offered the technology. “Free is too expensive for doctors,” he says. “Taking a paper-based medical practice to a paperless environment is difficult and requires far, far more than software.”

According to Waldren, EHR solutions will only work in physician environments if there is a solid training program, ease of documentation, and some level of interoperability with labs and pharmaceutical information.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.