Annals of Security: Don't Pass the Password

In our year-ender on the biggest data breaches of 2009, we noted that every one of them could be traced to mundane, easily preventable lapses rather than new hacking schemes or attack techniques.

For example, Transportation Security Administration officials failed to e-redact sensitive information about passenger screening protocols from a document they subsequently posted on the Web. And the massive breach of personal health and financial information at Health Net happened when an employee removed a hard drive containing sensitive information for 1.5 million enrollees and placed it in his car so he could work from home. The hard drive was then stolen from his car.

And most recently, a physician at UCSF fell for a spearphishing scam that resulted in the potential exposure of his patients’ personal confidential information. UCSF vowed to re-educate its staff to prevent similar mishaps in the future.

So the good news is that adherence to common-sense security measures can prevent many breaches.

Now for the Bad News
If physicians who must log-on to electronic health records (or billing systems or research data bases) are as lax in selecting passwords as a recent analysis revealed consumers to be, we have a problem.

Security experts have said for years that consumers need to mix-up their passwords as they navigate their connected lives – on Facebook and Amazon, on their Web-mail accounts and cell phones, and of course, their online banking sites.

But most people, it seems, don’t do that.

According to the results of a study by the security firm Trusteer, 73% of Web users use their online banking password on other Web sites. Even when banks enforced strict password controls such as assigning a customer ID, 42% of people used that ID on other sites.

This greatly simplifies things for hackers. While banks (and indeed most medical applications) rely on sophisticated technology and strong password creation requirements to protect password information, such methods can be prohibitively expensive for the local boutique that you shopped at online last week.

So a hacker can break into a poorly defended Web site, steal a cache of passwords and then hit-up an online bank site. Or an EHR. In other words, banking and medical security technology is only as strong as the weakest site where a particular password is used.

“It is sad that such a large portion of users use their banking credentials at other sites,” Amit Klein, Trusteer’s CTO told MSNBC. “It exposes those users to attacks that would otherwise be impossible. I thought people would take banking credentials more seriously."

The Trusteer study confirmed the findings of an earlier one by the Gartner group, yet the director of that study, Avivah Litan warned that even habitual use of multiple passwords won’t thwart sophisticated hackers.

“The truth is criminals steal your passwords lots of ways, such as recording keystrokes,” she told MSNBC. “And if they do that, it doesn't matter whether your password is 15 characters and unique or 7 characters and the same for every site. People have figured this out."

Of course, banks and most medical software providers do more than enforce tough-to-crack user/password combinations to keep your financial information safe, Litan added. One approach is “device fingerprinting,” in which banks identify your computer by analyzing processor speed and time and date settings.

Banks also flag attempts to transfer money to unknown accounts and monitor users that click through their sites at high speed. Such behavior is uncharacteristic of humans who, it turns out, take about 10 seconds before clicking "confirm" during online transactions.

So What Should You Do?
Handle your medical software and banking passwords with care. Don’t share them with anyone, and don’t use these passwords on other Web sites.

Remember that many Web sites—including some social networking sites and e-commerce sites where you have placed critical personal information—do not have high-grade security systems on their back end.

And while it may be impractical to create a unique user/password combination for every site you visit, a practical goal might be to create separate password families for medical software sites, financial sites, sites that store your personal information (e.g. Facebook), and another one for all those blogs you post comments to.

Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs Practice Fusion

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Five Question Friday: EHRs in a Dermatology Practice

This week’s Guest:
Tanya Kormeili, MD
Board Certified Dermatologist
Santa Monica, CA

Dr Kormeili practices with another dermatology colleague. They have 3 employees and are a smaller practice. They use an EMR in their practice – e-ClinicalWorks – and had used paper in other office sites. Prior to this EMR, she had worked with various other systems as part of residency training.

What was your practice’s experience with choosing and implementing your EHR?
I have worked with several EMR's including the Veteran's Administration EHR, and Kaiser. We currently have e-ClinicalWorks at the practice and we have customized it to fit our needs for a dermatology practice.

What was surprising about the process?
It is definitely a learning curve; it slows you down to start with. It is also at times harder because typing is distracting while writing in the chart is acceptable by patients.

What was the biggest challenge? The biggest gain?
Challenge is adjusting to using fixed templates and navigating around the system vs. "scribbling on paper!" Gains: we are paperless. All records and communication is documented; prescriptions are faxed in directly and we know who got what and when. We have great records of our patients. We can present a more professional front because all our notes are typed and neat.

What do you wish your system did more easily?
Diagram pictures – to note the location of a biopsy, for example, or to easily add pictures from “before” and “after” treatments with cosmetics

Are you planning for the HITECH incentives? How so?
To be determined

What are your recommendations for other practices?
There are certainly many more choices on the market. Adopt an EHR only if it makes sense, and not because of a "trend."

Which EHR features are most useful to you?
Easy to renew prescriptions; easy to generate a superbill and submit; easy to use templates to keep track of procedures.

***

Want to be interviewed in this series? Have experiences worth sharing with Practice Fusion, or other EHRs? Positive and negative experiences are helpful. If you are interested, contact emily@practicefusion.com

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Meaningful Use and Pediatrics

The American Recovery and Reinvestment Act of 2009 (ARRA) contained a portion (Title XIII of Division A), referred to as HITECH, that is intended to support a broad effort to accelerate the adoption of Health IT and utilization of qualified Electronic Health Records (EHRs).

The main way that HITECH tries to encourage widespread adoption of EHRs is through bonus payments to physicians who are able to demonstrate “meaningful use of a certified EHR.” These payments are to be paid out through the Centers for Medicare and Medicaid Services (CMS) – after all, HITECH incentive moneys are public moneys, and it makes sense to pay them out through the current pubic option of healthcare payments (Medicare and Medicaid). CMS has issued its Meaningful Use “notice of proposed rulemaking” (NPRM), and is currently in the 60-day open comment period before issuing finalized rules.

Physicians can qualify for Meaningful Use incentive payments through one of several avenues. For physicians who participate in Medicare fee-for-service payments, the 2011 incentive payments would be 75% of the total Medicare allowed charges billed by the physician, up to a limit of $18,000. The bonuses diminish each year, and cumulatively add up to $44,000.

Physicians and hospitals who participate in Medicare Advantage programs (Medicare HMOs) can also access Meaningful Use incentive moneys, if their Medicare Advantage (MA) organization (e.g. a risk-taking IPA) submits a request to participate this way. MA organizations must make sure their physicians did not already receive the maximum incentive moneys through the Fee-for-Service pathway already, so as to avoid “double dipping” into the incentive pool.

A third pathway through which physicians can receive Meaningful Use incentives is through Medicaid. States, at their option, can receive HITECH money to encourage physician adoption of EHR technology. The states administer the distribution of these moneys, like they administer the distribution of Medicaid payments at the state level.

To qualify for Meaningful Use incentives through the Medicaid path, a physician needs a minimum threshold Medicaid volume in his/her practice – 30% of all patients served must be Medicaid (during a 90-day reporting period); or if the physician practices in a FQHC or RHC, then 30% of the patient load must be “needy individuals” as defined by those programs. Pediatricians only need to demonstrate 20% of their volume coming from Medicaid, and acute care hospitals only need 10% of their volume to qualify (see table 26, page 288 of the NPRM).

So, where does this leave pediatricians? After all, pediatrics is a major cornerstone of the primary care base of any coordinated health care delivery system. Does this leave pediatrics at a disadvantage?

The nature of pediatric practice is such that Medicare is not a significant part of their practice (except for disabled children), and thus the major thrust of Meaningful Use incentives doesn’t apply here. Therefore, the only avenue left for pediatrics is the Medicaid option – and it only works for practices that have more than 20% of their volume as Medicaid.

Medicaid patients are unevenly distributed among healthcare practitioners, largely owing to low reimbursement and high administrative costs – a study in 2006 showed a growing trend where Medicaid patients are increasingly concentrated among a smaller proportion of physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. The result is that most community pediatricians, not affiliated with these institutions, do not significantly service the Medicaid population – and certainly do not have more than 20% of their practice as Medicaid.

Perhaps this is an unanticipated result from the HITECH Meaningful Use incentive system. Except for the relatively small percentage of “Medicaid doctors,” most pediatricians do not have a pathway for access to Meaningful Use incentives. Yet the intent of ARRA, and of the Office of the National Coordinator for health IT (ONC), is to encourage physicians everywhere to adopt EHRs. For this important pillar of primary care, however, such incentives are effectively cut off. Appreciation of this fact is important, going forward, and hopefully CMS and the ONC will find a way to address it – pediatricians, like all others, need to have access to the same kind of incentives, support and encouragement to adopt and meaningfully use modern EHR technology.


Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.

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Notes on a Volatile EHR Market

Right now, the health information technology sector is volatile. Vendors are entering and exiting the sector, and mergers and acquisitions are common. HITECH has driven enormous investment in the sector, and these dollars support innovative companies like Practice Fusion, as well as driving up the share prices of publicly traded HIT companies.

In a recent piece for the Huffington Post Investigative Fund, Emma Schwartz points out that some doctors have been burned by fallout from the volatile environment. Some doctors found it hard for example, to regain access to their patients’ records and recoup monetary losses when they chose to part ways with an EHR vendor.

Here are some thoughts about volatility in HIT:

1) Volatility affects all companies in the sector. Large-sized companies are not immune to volatile economic times as Bear Stearns, Lehman Brothers, AIG, GM and Chrysler recently discovered. And GE—which markets an EHR and has been around a 100 years—had a near-death experience let’s not forget, due to severe underperformance in its financial services division.

And sheer size didn’t protect a Fortune 50 company from losing a “can’t lose” opportunity to a virtual start-up back in 2000, when the National Health Service announced plans to hold an open procurement for a national provider of phone-based nurse triage services (known as NHS Direct).

In that instance, the NHS proposed a service in which all UK citizens could call a toll-free number and speak with an NHS Direct nurse about their medical symptoms. The nurse, using specially-designed clinical algorithms, collected data and recommended an appropriate level of care (e.g. “you should contact your GP right away”).

The Fortune 50 company had established working pilot programs in the UK and was a prohibitive favorite to win the bid. But the small company offered better software and content that could be customized to meet the local standard of care.

The small company partnered with a big UK-based company and the partnership won the bid. In the aftermath, the Fortune 50 company, which had been an unchallenged leader in this particular part of the HIT sector, faded precipitously.

2) Since the sector volatility is in part driven by HITECH, should the government “do something”? Thankfully, the Feds have said no. They have left it to the market to decide. In fact, federal rule making as it relates to HITECH is silent on the matter of the financial performance of EHR vendors. What ONC has done instead is create, through its EHR certification criteria, a vision of a future (and better) state for health care IT, and cleared away as many barriers to the innovators in the sector as they could.

3) So if you are a doctor that wants to begin using an EHR, how do you protect yourself? First, understand that the vendor landscape will appear differently in 5 years than it does now. Some familiar names will be gone. When stock prices of the publicly traded companies settle down, their support and development budgets will likely go down as well. So their service levels and release schedules are as good as they’re going to get right now.

In future posts, we’ll make thorough recommendations about how you might carry out due diligence on EHR vendors before you buy one. But for today, we leave one additional thought:

When you shop for an EHR, ask the vendors if you can get your patient medical records back for any reason, any time you want them. Ask them how soon you’ll get them back, and in what format. And ask if you can get your money back if you are unsatisfied with the EHR for any reason. A company that hasn’t worked these issues out to your satisfaction isn’t doing enough to protect you in this volatile market.

Note: Practice Fusion will provide the entire patient record for every patient in your practice, as either a comma delimited file or an excel spreadsheet, within 24 hours upon request, for free, for any reason, no questions asked. All additional documents like pdfs will be provided in secure format and made accessible to you in secure fashion, for free.

As for the money back part, Practice Fusion is free to begin with.

Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs Practice Fusion

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Should the feds certify EHR Usability?

In an interesting turn, the Commerce Department’s National Institute for Standards and Technology (NIST) is looking to develop standards for evaluating ease-of-use of health IT systems. This raises some questions about the appropriate federal role in guiding the evolution of Electronic Health Records (EHR) systems – should the feds be specifying “usability standards” in the first place?

The NIST notice is currently very preliminary – they are simply looking for companies with expertise in quantifying and measuring Usability in health IT systems. However, the NIST has been charged with developing the specific testing and process documents that will be used (by organizations yet to be selected) to certify EHR systems. The overall policy and specification about Meaningful Use of a Certified EHR, which is needed to access ARRA stimulus moneys available beginning in 2011, have been published for open commentary. However, the specific nuts-and-bolts of certification is being hammered out by the NIST. They have already contracted with Booz Allen Hamilton to help with this process.

So, why would the NIST be interested in evaluating Usability, given that this is not one of the criteria specified in the Certification guidelines? Poor usability has been cited as one of the main impediments to EHR adoption (besides cost), and stimulating EHR adoption is one of the central goals of the Office of the National Coordinator (ONC) for health IT. Historically, CCHIT (the exclusive legacy certification body prior to ARRA) did not include Usability as a certification domain – too difficult to quantify and test. The result has been that many large, legacy health IT systems are so cumbersome – have such poor Usability – that they are prone to mistakes (not from lack of data, but from bad presentation of that data to the end-user).

Iowa Senator Charles Grassley has turned up the heat on legacy vendors for exactly these kinds of failures, sending a letter of inquiry to Cerner Corporation last fall. In a follow-up, Senator Grassley sent letters to 31 hospitals demanding an end to traditional “gag orders” and asked them to report any problems they experience with their EHR systems (or face penalties by 2013). Perhaps it is this kind of pressure that is motivating the NIST to consider developing Usability criteria for EHR certification.

Usability is certainly a factor in the selection of an EHR system – in fact, approaching EHR selection from the standpoint of “Usability, Interoperability, and Affordability” is something we have encouraged all along. However, there is a difference between Usability being something that the market will determine, and Usability being something that is specified by federal certification guidelines. The market moves quickly, and innovation is able to rapidly respond to end-user features and “usability requests” – witness Practice Fusion’s web-based EHR, which can evolve and adapt very quickly.

Granted that some legacy vendors (with a large, established install-base) may take months and millions of dollars to make an important change, but forcing such a change via regulation, as opposed to market competition, is not likely to move the market forward very effectively. Yes, one could argue that rip-and-replace of a poorly-functioning EHR with a better, newer one is more burdensome than getting the existing vendor to make improvements – but this happens all the time in every industry (painful though that process is). Should the feds be a party to such decisions?

It is our opinion that Usability is an important factor in EHR selection, and such selection is determined by the market. Market factors will result in faster development of high-quality EHRs than a process regulated by the feds. The federal rule-making process is susceptible to influence by established well-funded corporations who have an interest in the status quo. While it is interesting that the NIST is considering input from expertise around quantifying Usability, it is uncertain that a federal-regulatory approach will be effective. We will be watching this development with interest.


Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.

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Apple's iPad: No Flash in the Pan

At last week’s media event heralding the release of the iPad, Apple’s new tablet computer, promotional materials suggested that its Safari browser can load Adobe Flash content. But during Steve Jobs’ 8-minute walk-through on the subject, his demo version could not do this.

People were waiting to see how Jobs would deal with Flash in his demo, so they were quick to note the discrepancy. A period of investigation followed, and as a result 2 things became clear: the iPad doesn’t support Flash and probably never will, and Jobs has left Apple open to legal claims alleging false advertising.

The controversy erupted when 9to5Mac’s Seth Weintraub observed that in an 8-minute video whose release was timed to correspond with Jobs’ demo, a section at the 1:15 mark showed a piece of nytimes.com web site known to be supported by Flash. It appeared to load properly.

Around the same time, AppleInsider called attention to an image of the iPad on Apple's web site that displayed Flash-based content from the The New York Times’ "31 Places to Go in 2010" feature (see picture).

But Jobs didn’t mention Flash during his demo (found here). And when when he came to the part in the demo about nytimes.com, his iPad showed not pretty pictures but a pair of queer-looking Blue Legos—the dreaded "broken plug-in" icon.

Jobs’ silence and those Blue Legos spoke volumes. The iPad doesn’t support Flash. It remains unclear whether Apple was trying to manipulate the promotional materials to hide this fact.

Would Flash Make the iPad Better?
Jobs’ decision to display nytimes.com in his iPad demo is ironic. The Times site uses Flash extremely well. In fact Flash is, according to Weintraub, probably the best current alternative “for companies that want to put out interactive content for the web.”

“Without Flash support, iPad users will not be able to access the full range of web content, including over 70% of games and 75% of video on the web” Adobe's Adrian Ludwig explained. "If I want to use the iPad to connect to Disney, Hulu, Miniclip, Farmville, ESPN, Kongregate, or JibJab -- not to mention the millions of other sites on the web -- I'll be out of luck."

“Something that ignores a huge part of the web cannot be the ultimate browsing experience,” added TheFlashBlog's Lee Brimelow. “I love Apple products, especially my iPhone, and that is why I’m passionate about this,” he added.

So why isn’t Flash on the iPad?
Technical considerations probably played a role a few years ago, but no longer. Apple had been using Samsung ARM chips which, some said, delivered a lousy Flash experience and on those grounds alone, the company ignored Flash in developing the iPhone.

But then, Android phones featuring ARM Cortex A8 processors were released. They supported Flash. Subsequently Apple began using the A4 ARM Cortex A9, a chip that should “provide a good experience, especially with Adobe working with ARM on optimizing the experience for their architecture,” said Weinstein.

So now, “it isn't about speed,” Weinstein concluded. “The iPad's processor can handle Flash.”

What it is about, is business. In November 2008, Wired.com predicted that Apple would probably never support Flash on the iPhone. “Allowing Flash would open doors to content that competes with apps in the App Store,” Wired reasoned. It would, “be in Apple’s interest to shy away from the platform.” The same reasoning applies to Apple's new iPad.

So, “instead of being able to watch the Daily Show and the Colbert Report free with ads (on Hulu), my only (reasonable) option is to buy them on iTunes,” explained Weinstein.

Apple has not responded to several requests for a comment about Flash or the false advertising complaint.

Late Breaking Developments
-->Over the weekend, Paul Threatt, a graphic designer at Jackson Walker design group, filed a complaint to the FTC alleging that Apple engaged in false advertising during last week’s media event. It reads as follows:

On the Apple iPad, iPhone, and iPod Touch devices, Apple provides a proprietary web browser named Safari. On these electronic devices, Apple computer does not support the web browser extension commonly referred to as “Flash”. The Adobe Flash extension is a popular browser plug-in that has gained wide popularity due to its ability to easily display video and image based slideshows on the web.

In several advertisements and images representing the Apple products in question, Apple has purposefully elected to show these devices correctly displaying content that necessitates the Adobe Flash plug-in. This is not possible on the actual devices, and Apple is very aware of that fact.”

“Despite the controversial lack of support for Adobe Flash on these devices, Apple has elected to depict these correctly utilizing the Flash plug-in. This constitutes willful false advertising and Apple’s advertising practices for the iPhone, iPod Touch, and the new iPad should be forcibly changed,” Threatt claimed.

-->On Friday Apple removed the image of the iPad showing nytimes.com content from its home page. It also revised the video to show the blue legos where appropriate on the nytimes.com site.


-->Also Friday, Weintraub said: “We’ve just got word from our source at Chiat/Day Media Arts Lab that they make fake optimized web pages for all of Apple’s commercials — which load faster. In this case they made optimized images to take the place of Flash and are redoing them as we speak.”

-->Meanwhile MacRumors has sources at The New York Times telling it that the Times itself “generated high-resolution images of several of its pages, including Flash, in order to improve the look of the pages for Apple's use in iPad marketing materials.”

Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs, Practice Fusion

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Five Question Friday: My Experience with Practice Fusion's EHR

This Week's Guest:
Chad Costley, MD

Chad in his own words:
I'm a Family Physician by training but have limited my practice to teenagers and adults. I went to medical school and completed residency at the University of Michigan and worked with two large medical centers before journeying last year into solo practice. I launched Ponce Primary Care (Decatur, Georgia) as an escape from the hamster-wheel that has become too common in primary care. With the help of Practice Fusion and other efficient IT systems I'm able to practice with a single employee and very little other overhead. I strive to provide accessible, comprehensive, evidence-based and coordinated care to my patients. In addition to my medical career, I hold a MBA from Emory University and am involved with a number of start-up technology companies. My wife, LeighAnn, and I have two boys ages 5 and 9. I'm a distance runner, tennis player and mediocre but striving cook.

Thank you Dr. Costley, for agreeing to participate in our series about electronic health records (EHRs) and their impact on health care professionals. We want an honest appraisal of our EHR, and value advice that helps us improve it. So here’s my first question:

-- When did you begin using the Practice Fusion EHR?
I began using the Practice Fusion EHR a year ago when I opened my new solo practice. I was on the verge of buying an "internet-based" version of a popular EMR for thousands of dollars when some red flags went up. I'm not overly technical, and perhaps that was an advantage when the company started talking about VPNs to connect remote computers and limits on which operating system I needed to use. The simple question of "Why can't I use this wherever I have an internet connection?" was met with really fuzzy answers.

The second and largest flag was the mandatory three-day "training" I was required to purchase. "If the system is so easy to use, why do I need to pay your consultants to sleep in a hotel here in Atlanta for three days to teach me how to use it?" I asked. Fuzzy answers.

-- So what happened then?
Fortunately, a friend who was more savvy than me found Practice Fusion through an internet search. I spent about 30 minutes trying it out with imaginary patients and documented my first patient the next day. It was great - easy to use, intuitive, unburdened by the often useless bells and whistles that plague really complex EMRs.

In my previous, large practice life, I endured the launch of an EMR project for a large health system. It was torture primarily because the system was clearly designed to support billing rather than patient care. The doctors passively and actively resisted the EMR implementation because the system didn't help them take better care of their patients. I believe Practice Fusion is different in that respect because its logic inherently follows the natural flow of a doctor-patient visit.

-- How did the first couple of days go, when you started using the Practice Fusion EHR?
Our "transition" was naturally easy as we were starting from scratch with the practice and Practice Fusion. We use it every day now for all of our medical documentation.

-- How are you using the system now?
We have a truly paperless office. FAXes arrive in .pdf format and are loaded into Practice Fusion without being printed. Any paper our patients bring in from other offices is scanned and either given back to them or shredded before I see it in electronic format within Practice Fusion. We are close to fanatical about not allowing paper to survive in our building; paper is the enemy of exceptional, well-documented, and efficient care.

We use LabCorp so do have the extra step of having to access lab results in another system and load those .pdf documents into Practice Fusion. We also don't use the calendar as everyone here operates on iPhones and needs to be able to see each other’s calendars easily when away from the practice. For example, my patients have my cell phone number. When I speak to a patient by phone I can give them an available appointment immediately via the Google calendar we all use. It would be a meaningful improvement to Practice Fusion to have it link with an outside calendar/email system such as Google (noted by interviewer; we are seeing increasing demand for this feature).

-- What’s your take on the Practice Fusion EHR? Which features do like? Dislike?
Some of this is answered above. However, I love the new e-prescribing functionality. It's so easy to use and we've had zero problems with it since its recent launch. I tend to not use templates very much as I can type quickly and find that I write more nuanced notes than templates typically allow. Having said that, I've been experimenting a bit more with the templates in Practice Fusion lately and like the ease of template creation and customization.

-- What’s missing from the Practice Fusion EHR?
The biggest missing pieces in Practice Fusion for me at this point are a secure patient communication tool within the Patient Portal and integration with LabCorp (noted by interviewer. Discussion to follow on www.ehrbloggers.com). Allowing patients access to med lists, diagnosis lists etc. is fine - but most patients don't really need that. The option of making appointments would be useful if we used the PF calendar, but we don't. What would really take the system to a new level would be the ability to communicate securely with a patient about lab results, lifestyle change check-ins, etc. directly from the system (coming soon, stay tuned!). We use LabCorp nearly exclusively so are obviously anxious for that integration.

-- How has it impacted workflow in your office?
My personal workflow has changed significantly in using Practice Fusion. I now do my documentation in front of the patient most of the time. I've never liked the approach of typing while patients are speaking - eye contact matters in primary care:) However, my patients really like it when I say at the end of the visit "I'm going to document our visit now." I literally read what I'm typing to the patient as I document. It summarizes the visit for them, leads to a clearly agreed upon plan which I often print for them. This has significantly limited the number of emails and phone calls after visits from patients who were confused about medications, referral recommendations, etc.

When I leave an exam room after a visit - my documentation is done 90% of the time. I can't imagine returning to the days of a pile of paper charts on my desk at 5:30 pm waiting for notes or the similar situation of a pile of paper "encounter forms" that need to be translated into a bulky EMR. The quality of my notes has gone way up as even a few busy hours can cloud the precise memory of exactly what happened in a visit.

-- What about support and updates from Practice Fusion?
I had a few phone interactions with Practice Fusion early on as I moved my brain away from the notion that I needed a $15,000 system :) Other than that, I've relied upon the training videos somewhat but frankly find most functions to be so intuitive that they teach themselves.

-- What advice can you give to Practice Fusion?
At the small practice level, I do think Practice Fusion needs to overcome the impression of some that if you're not charging them for use, you must be doing something shady with their patient data. I'm on a couple of list-serves where doctors have expressed this concern along these lines. "Sure it's free, but I don't really want Big Pharma having access to my patients' information. I'm not a sell-out." Being more explicit about your business model would help alleviate concerns that something that seems too good to be true usually is. (Noted. This subject is profoundly important to us. We have no right to distribute patient confidential information and we will not do that.)

This is terrific feedback, Chad. Thank you!

Interviewed by Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs, Practice Fusion

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