by DAVID C. KIBBE and BRIAN KLEPPER Yesterday we tried to put EHRs into perspective. They're important, and we can't effectively move health care forward without them. But they're only one of many important health IT functions. EHRs and health...

I was invited to join in on a discussion that Ben over at tempdev started with the CEO of Practice Fusion, Dr. Robert Rowley. The guest post by Dr. Rowley essentially began to highlight some advantages of the Practice Fusion SAAS model versus the client server model which NextGen (and most other EHR companies) employs.

Much of Dr. Rowley’s guest post and the comments on it were about whether a hosted one database for multiple practice system facilitates sharing of patient information better than a bunch of disparate client server installs. I’ll leave most of that discussion for the comments on the post, but I will mention that the biggest challenges with sharing information between multiple EHR systems isn’t the technology. The 2 biggest problems I see with sharing patient information between doctors are:

1. Doctors who aren’t using an EHR and won’t give up their paper charts
2. Defining the rules for sharing

Think about what it takes to share information. You have to ensure that the patient has given you permission to share that information, manage how long and which parts of the information can be shared and then go to work to make that happen without sharing more than you should share. Much more could be said about sharing patient records, but my point is that the technology of sharing information isn’t the problem with client server installs. The technology is there, but the policies aren’t.

One final note about sharing using the Practice Fusion model of SAAS EMR is that it still strongly depends on everyone using Practice Fusion. The problem is that there are at least over 400 EHR vendors selling product. This means that ever EHR system will have to learn to talk with each other and can’t just learn to share with itself. At that point, I’d argue that it’s not that much easier for a one database hosted solution to share data with a different EHR software than it is for a client server based EHR to do the same.

Wait, I told you’d I wasn’t going to talk about sharing….so back to some of Dr. Rowley’s other points.

It is true that a client server based system does require a larger up front cost in server and IT support than a hosted solution like Practice Fusion. However, it’s really quite amazing how quickly those costs have dropped. Just today I got a quote for a server for a local doctor’s office that cost under $3k. Prices on servers have become so affordable that it’s not nearly the expense that it was 5-10 years ago.

What wasn’t pointed out by Dr. Rowley is the need to invest in a more reliable and faster internet pipe when using a SAAS EHR. A client server EHR works on your local network which will always be much faster than anything an ISP can provide. Not to mention significantly more reliable. Choosing to go with a hosted EHR can work, but you’ll just have to plan well for when your internet connection goes down.

Hosted EHR companies also love to tout how the software automatically updates as new releases are made. This really can save time compared to in house EHR systems that require you to update an application on each computer (we won’t talk about the in house EHR software that is web based). What they don’t tell you is that you may not want or be ready for the new features. In the client server world, you can test the update and prepare for the changes being made on your schedule. A one database hosted option doesn’t give you that flexibility. If the update breaks something you enjoy, then you’ll have to deal with it until the company can fix it (assuming they think fixing it is a priority).

It’s getting late or I’d keep going about the pros and cons of both the SAAS versus client server models. Don’t get me wrong, I think hosted EHR are certainly a viable option for those implementing an EHR. However, even hosted EHR come with their own list of challenges. Selecting an EHR is more about choosing which challenges you are willing to work around than it is choosing the perfect EHR that does everything exactly the way YOU want it.

I also wanted to talk about Dr. Rowley’s suggestion that “NextGen is an example of one approach, and PracticeFusion is an example of a fundamentally different approach. Rather than seeing them as “a spectrum” of approaches, it might be more appropriate to consider them as different generations of product: EMR 1.0 vs. EMR 2.0″

I think it’s unfair to call NextGen or any other similar EMR as EMR 1.0. Some of the features offered by the client server model blow away PracticeFusion and other web based EHR. The web has come along way (and is continuing to improve), but still can’t compare with some of the UIs client server can offer.

I do agree that they are fundamentally different approaches to solve the same problem. They each have their own benefits and challenges. Pick your poison.

Finally, I was a little surprised that Dr. Rowley didn’t mention the most unique part of his model until the end of his guest post. PracticeFusion’s “free EMR” model that is funded by advertising is what sets it apart from even the various hosted EMR options. This description of PracticeFusion’s business model is its most defining characteristic:

Practice Fusion’s free EMR is an emerging product built on this vision, and has a business model where in-product targeted ads pay for the service. The ads can be traditional vendor ads (pharmaceuticals, devices, billing and transcription services, etc), or can be “counter-detailing” ads, where insurers or local medical groups or IPAs can display their preferred treatment methods for the condition-at-hand.

You can read some of my past thoughts on free EMR by PracticeFusion. I’m still very curious to see how PracticeFusion fairs in the marketplace. One thing is certain, they’ve got a pitch and their selling it to everyone who will listen.

Related posts:

1. Description of a Fax Server in a Doctor’s Office Today I got an email from a doctor asking the...
2. If You Don’t Use a Fax Server With Your EMR You’re Nuts I finally made the time to finish installing a fax...
3. When EMR Software Became Free…Or Does It Cost I’ve been meaning to write about a new Free EMR...

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In case, as I did, you missed the Office of the National Coordinator for Health Information Technology's Oct. 15 town hall on medical identity theft, you can download an MP3 audio recording and a transcript (Microsoft Word document) of the proceedings.

Warning: the MP3 file is a whopping 286 MB. It took me about 7 minutes to download on a typical residential cable Internet connection. It will take you 5 hours and 12 minutes to listen to the whole thing if you're so inclined.

More details of the ONC-sponsored assessment on medical identity theft are at http://www.hhs.gov/healthit/privacy/identytheft.html

ONC promises a full report sometime this winter on issues related to health IT and identity theft, as well as a recommended roadmap for addressing these issues.

Well, looks like one of our 2009 predictions may already be toast. We predicted that despite all the hype, federal funding for healthcare IT would not be forthcoming in 2009.  Our reasoning was simple, there are so many sectors seeking some sort of financial rescue, HIT would not make the cut in 2009 but would see [...]

Noni MacDonald, MD MSc and Amir Attaran, LLB DPhi have an editorial in the current issue of the Canadian Medical Association Journal that addresses the need for apologies when a medical error occurs. The article describes the history of such laws in the U.S. in the 1990’s: [...] Full disclosure to the patient is the ethically and professionally [...]

  John Wesley Hall, Jr. tells us of a recent court decision that I actually agree with: Defendant was charged with child abuse murder in Florida. After the death of her child in Florida, she moved to West Virginia. Defendant was suspected there of child abuse by Munchausen syndrome by proxy, and video surveillance was set up [...]

PharmaNews.eu, an advanced web based news project targeting the European pharmaceutical domain, has been launched. The project was developed to directly connect, promote and disseminate the European Industry and Research pharmaceutical achievements with additional focus on the European Commission (EC) and European Medicines Agency (EMEA) news.

Recently a friend at work sent an email to our workgroup in which he said:

In his weekly radio and video address describing what he called the American Recovery and
Reinvestment Plan, Obama spelled out five main goals. He said his plan proposes to:

-double renewable energy production and make public buildings more energy efficient;
-rebuild crumbling roads, bridges and schools;
-computerize the health care system;
-modernize classrooms, labs and libraries;
-and provide tax breaks to American workers.

So the computerization of our Health Care system
becomes a National Priority.

The implication is that Obama's presidency bodes well for our workgroup, which is devoted to biomedical research informatics. I wanted to share his thought and my reply, which follows:

While I share the enthusiasm for Obama's recovery plan, it may not
have much direct impact on research informatics units like ours, if
any at all. The effort to computerize healthcare was a key goal of the
Bush (W) administration, and while some progress has been made in
terms of determining evaluation criteria for EMR systems, from what I
have seen thus far, little or no interest has been exhibited with
respect to incorporating research informatics in the picture, in spite
of lobbying on several fronts.

The challenge of getting every American's health record computerized
is monumental, conceivably beyond the effort thus far put into space
exploration, and is fraught with contradictory economic and political
interests and motivations. This is not just an academic research
issue. Big Pharma has a stake in the integration of research
informatics into EMR systems (e.g. post-marketing surveillance), and
when Big Pharma's lobbyists can't get much traction, you know the
obstacles are formidable.

That said, another of Obama's campaign promises was to double the
budgets of the NIH and NSF. Let's cross our fingers and hope that
these promises are fulfilled as the massive economic stimulus and
recovery effort gets underway.  If they increased the government's
research agenda by even a fraction of what he promised, it will
benefit us significantly. Biomedical research informatics in
inextricably tied to biomedical research itself; progress in research
will be impossible without significant investments in biomedical
research informatics.

Moreover, all types of translation are becoming increasingly dependent
on informatics. Moving basic science discoveries into clinical
innovations and thence into evidence-based medicine and improvements
in public health can be greatly accelerated by computer and
information science.

All in all there is reason for hope, barring total economic meltdown
and the end of civilization as we know it.

In retrospect, I continue to hope Obama keeps his promise about doubling the NIH and NSF budgets. However, we have thus far in the past few months spent trillions of dollars on bailing out Wall Street, and a few billions on bailing out the auto industry. I wonder how much money will remain once we embark on our New New Deal.

I hope Obama does keep his promise about doubling the NIH and NSF budgets. However, we have thus far in the past few months spent trillions of dollars on bailing out Wall Street, and a few billions on bailing out the auto industry. I wonder how much money will remain once we embark on our New New Deal. Hunscher

Summa Health Network, the physician-hospital organization of Akron, Ohio-based Summa Health System, will offer software to help physicians participate in pay-for-performance programs.

AHIC Successor Inc., a public-private advisory organization, will conduct a public meeting of its board of directors on Jan. 8.

Children's National Medical Center in Washington is subsidizing a portion of the costs for electronic health records for independent pediatricians in the region.

Health Systems Solutions Inc.'s pending acquisition of diagnostic imaging software vendor Emageon Inc. remains on track, says Michael Levine, CFO of New York-based Health Systems.

The federal Agency for Healthcare Research and Quality will hold a conference call on Jan. 13 to explain funding opportunities for up to $50 million in grants to support health information technology initiatives.

Health Data Management is accepting nominations for its fourth annual Nursing Information Technology Innovation Award through Monday, January 5.

Eclipsys Corp., an Atlanta-based health care software company, plans to purchase Premise Corp., which sells patient flow software. Eclipsys announced Dec. 30 that it will pay $38.5 million in cash in a deal expected to close within 15 days.

Two technology vendors and a group practice have met the new CORE standard for electronic administrative data communications. They are: MD On-Line Inc., RealMed Corp. and Summit Medical Group.

The on-again, off-again purchase of medical imaging vendor Emageon Inc. by Health Systems Solutions Inc. is apparently on again

A small survey of hospital CIOs shows that most have not yet heard from their information technology vendors about their plans for complying with new diagnostic code standards.