Monday, March 19, 2007

"Free" EHRs: A Faustian bargain on patient privacy?

One of the biggest barriers to wider adoption of electronic health records (EHRs) is affordability. Regardless of whether you "rent" (ie, pay a monthly fee for access to a web-based product) or "buy" (ie, purchase a license to put the software on your own computer), the first-year costs for a respectable system are $15K-$25K per clinician. It was inevitable, therefore, that some "free" products would enter the market. As it turns out, there's no such thing as a free lunch.

First came a non-commercial alternative, VistA-Office, which the government has already paid for. VistA-Office is the office-based version of the VistA system that has been so successfully deployed in the US Department of Veterans' Administration, and it can be downloaded without charge from a non-profit, government-sanctioned vendor called WorldVistA. Of course, there's more to the cost of an EHR than just the software, so though the license is free, a potential user would still have to pay for hardware, implementation, training, support, and maintenance. Nevertheless, it's always great, and economically efficient, when the government is able to create commercial spin-offs from work it's already funded.

If VistA-Office can be thought of as a non-commercial approach to "free" EHRs, Practice Fusion, a San-Francisco-based startup is its hyper-commercial opposite. Launched last August, the company's original plan was to offer their EHR without charge in return for access to the deidentified clinical data generated by users, which the company would sell to pharma companies, insurers, and researchers. If that isn't controversial enough, the company announced last Friday that they'll be partnering with Google's advertising arm, AdSense, to put context-sensitive ads on the EHR in real-time. As described in the San Francisco Chronicle: "When a doctor using the service calls up a patient's health record, AdSense will recognize certain keywords -- such as "diabetes" -- and ads related to that condition will appear on the page."

I assume that all of this is HIPAA-compliant, though it would take some convincing that no places or dates of service are being compromised when ads are being delivered to a physician's EHR in real-time based on what they type into the system. And we haven't event talked about state laws yet.

Regardless of whether it's legal, this approach does pose issues for physician-patient trust. For example, does a physician really know what they're getting into? The slippery slope has already been demonstrated. In August, the story was:
The “completely hosted, community-based model” EHR will be subsidized on the back end by selling de-identified data to insurance groups, clinical researchers and pharmaceutical companies, said CEO Ryan Howard.
Now, seven months later, it's clear that selling data isn't going to generate enough revenue.

Practice Fusion's deal with Google is what makes a free medical records system possible. Google's AdSense program will generate ads that will be displayed as the records system is used.
What's next if that doesn't work? If I'm already using the product, do I get a say in how it's expanded? If I don't like that, is my only option to leave, with all of the switching costs that that would entail?

Practice Fusion claims that health insurers will be eager to get into this action as well. Insurers have a hard enough time trying to keep patients on their formularies. How much harder will that be when drug ads are being inserted into the physicians' thought process at the point-of-care?

Purely on a user-interaction level, I'm not sure how many physicians will like having ads on their screen (actually, I am sure but I don't have any data to back me up). It's already a challenge to figure out how to present meaningful medical information on a screen without overloading the user. Dynamic ads won't help that.

Finally, but most important, how will patients feel about this? The first time a patient sees a Paxil ad pop up on his physician's screen, the questions will start flying. And the physician will be in the awkward position of saying that those ads don't affect his/her decision-making, that the company generating those ads is Google, but not to worry, through the magic of technology, Google has no access to private medical records (and the physician will be crossing his/her fingers hoping that that's true).

Practice Fusion's CEO says that "he does not expect data-sharing will be a concern to physicians who accept the free EHR." If that's true, it's only because they haven't asked their patients yet.

6 comments:

David Harlow said...

In addition to the HIPAA and ethical issues raised by AdSense-funded EHRs, there's an anti-kickback question as well. As I blogged yesterday:

With a tip of the hat to John Christiansen, one must ask: if a physician who opts for the ad-subsidized version orders a federally-reimbursed service or product whose ad pops up next to a patient's EHR, are we in anti-kickback territory?

Bill Donahue said...

Dr. T raises some great points here. But I think even before we reach the very sensitive patient confidentiality and physician influence issues, what if we just step back and see what potential impact this "offer" could have on physician EMR adoption? Here in Hawaii we are very familiar with the VISTA or free software offer. To my knowledge, only a very few doctors are actually using the software and are not really paperless. Like Micky points out, this software is free but it's not cheap. By the way, what about integration with practice management and billing? The Veterans Administration doesn't do a lot of billing.

In any event, the impact of the VISTA offering, to the extent that it has had any real impact, has been to slow physician adoption of EMRs, not accelerate it. By throwing something "free" into the marketplace that is not part of a whole program of adoption, like MAeCH, VISTA simply freezes in place those doctors who are thinking about putting money out of pocket for an EMR. Granted, doctors who take the time to really investigate eventually abandon the idea that they are going to get something for nothing. But my experience has been that the vast majority of doctors who are only thinking about EMRs and hear that there is a free one ("The government is going to give us one") take that opportunity to stay on the fence when it comes to adoption.

Steven said...

I am a physician and member of the MAeHC Board, but writing here with my own personal opinions.

There is evidence from a variety of directions that supports the notion that advertising influences how physicians practice. Soumerai and Avorn developed "academic detailing" in response to the powerful influence of the pharmaceutical industry's "detailing" efforts to get physicians to prescribe preferred medications. The more than $5 billion that the phamaceutical industry spends annually on advertising -- targeted both to physicians directly and to patients -- underscores the point that advertising/marketing drives prescribing behavior. If it didn't, large pharmaceutical companies wouldn't invest in it. Organizations such as Consumers Union and the attorneys general of the 50 states will no doubt monitor this issue carefully. I personally would like to think that physicians will not allow any advertising to exist on their EHRs. On the other hand, with financially strapped practices barely getting by and simultaneously feeling the need to invest in HIT, "free EHRs" will be very appealing, even if they come with a "harmless" banner ad or pop-up.

Steven R. Simon, MD, MPH, FACP said...

I am a physician and member of the MAeHC Board, but writing here with my own personal opinions.

There is evidence from a variety of directions that supports the notion that advertising influences how physicians practice. Soumerai and Avorn developed "academic detailing" in response to the powerful influence of the pharmaceutical industry's "detailing" efforts to get physicians to prescribe preferred medications. The more than $5 billion that the phamaceutical industry spends annually on advertising -- targeted both to physicians directly and to patients -- underscores the point that advertising/marketing drives prescribing behavior. If it didn't, large pharmaceutical companies wouldn't invest in it. Organizations such as Consumers Union and the attorneys general of the 50 states will no doubt monitor this issue carefully. I personally would like to think that physicians will not allow any advertising to exist on their EHRs. On the other hand, with financially strapped practices barely getting by and simultaneously feeling the need to invest in HIT, "free EHRs" will be very appealing, even if they come with a "harmless" banner ad or pop-up.

David E. Williams of the Health Business Blog said...

Micky,

Haven't heard from you in a while. Did Blogspot (a Google subsidiary) silence you for writing this post?

Anonymous said...

Hey, while searching for widgets for my blog, I stumbled upon www.widgetmate.com and wow! I found what I wanted. A cool news widget. My blog is now showing latest news with title, description and images. Took just few minutes to add. Awesome!