In every situation online it seems like at some point someone takes the business model as deep as it goes and then someone just finally says, “Let’s make it free.” Readers of this site will be familiar with the leading Free EHR companies Mitochon and Practice Fusion (both advertisers on this site). They both seem to be doing really well and are working on some really interesting business models.

With my familiarity with the Free EHR business model, I was intrigued when I read about HealthTap’s model for basically providing an online medical visit for free. This was particularly interesting since I knew that HealthTap had received $11.5 million in funding recently.

Andy Oram summarizes what HealthTap is trying to solve really well:

In this digital age, HealthTap asks, why should a patient have to make an appointment and drive to the clinic just to find out whether her symptoms are probably caused by a recent medication? And why should a doctor repeat the same advice for each patient when the patient can go online for it?

Plus, he makes two important observations of what HealthTap has found:
1. Doctors will take the time to post information online for free.
2. Doctors are willing to rate each other.

It’s pretty interesting when you think about how many doctors visits could be saved using something like HealthTap. On face, I’d think that a site like this wouldn’t make much sense. Although, as I think back on my medical experiences I can think of about a dozen or so times where I tapped into my physician friends before going to the doctor. Basically, I wanted to know if going to the doctor would be worth my time or not. In about 90% of those cases I ended up not going to the doctor since the doctor wouldn’t have really been able to do much for me anyway.

As I think through these experiences, I realize that many people aren’t lucky enough to be like me and have lots of physician friends around to ask the casual medical question. I could see how HealthTap could fill that role.

One key to this model is that it doesn’t always replace the visit to the physician. In fact, in a few cases I was told that I’d need an X-ray and that I better go see the doctor. In that case I was more likely to go to the physician since I knew I needed to get something done. I already knew the physician would do something for me when I went so I didn’t have the fear that they just tell me to take some Tylenol and be careful with it.

I’m not quite sure if doctors would be glad to actually have only people that are sick visiting their office or not. Maybe they enjoy the break of the easy patient that doesn’t require any effort on their part.

I think there are still questions about the quality of information that patients will get on HealthTap. This is going to be the most interesting issue to follow. No doubt they’re going to be toeing a fine line called medical advice. However, whether it’s HealthTap or some other online source that someone likely finds through Google, people are going to be looking for this kind of health information online. The idea of a free online medical visit sounds good to me.

Let’s also not be surprised if the Free EHR vendors eventually get into online visits as well. Seems like a natural progression for them to offer this service if they wanted to go that direction. From what I understand they have plenty on their plates right now, but a few years from now it could get pretty interesting.

Last week, I wrote about a conversation with a physician friend on the costs of moving to an EMR. That conversation segued into a discussion of free EMRs and how they can be a good thing for small (definitely a game changer for solo or two-practitioner) practices. This week, I’m analyzing free EMRs from the advertising angle. My friend made a comment during our discussion that gave me pause. He said he didn’t want advertisements distracting him when he was talking to a patient, he’d rather spring for a package that charged him a few dollars a month than one that had ads embedded inside it.

I think the ad question is pertinent to both sides of the equation. As a physician, I don’t want the 15 minutes I spend per patient cut down even more, because I want to get rid of those pesky pharmaceutical ads. As a patient, I don’t want to get the feeling that I’m the third wheel in the space between my doctor and his iPad.

And frankly, the low or no-cost, high volume Walmart strategy doesn’t make much sense to me in the long term. This is not based on some well-pedigreed consumer behavior study but what I’ve generally witnessed, or done myself. I’ve trained myself on the art of selective blocking. When I’m on Google, I studiously avoid looking at the highlighted links on the right, and top of the page. The same way, on eBay, when I’m looking for job opps, I generally skim past the purple highlighted vendors. If you’re a TV junkie, think about when you take your bathroom breaks.

In other words, we all have our own blocking strategies to ignore ads, which is probably not such good news for advertisers. This is not to say that advertisers won’t advertise, or vendors won’t make money.

If doctors already have some amount of natural reticence to ads, how are free EMR vendors going to make money? (I’m not sure if the ad model in free EMR packages is click/pageview driven, or a set price for simply being placed on the page, like magazine ads.) Free EMR vendors might then also offer ad-free versions, for additional dollars a month. At this point, they become just like other EMRs – i.e. when the costs are non-zero, price will not be the only differentiating factor when you’re judging EMR quality.

And yet, if my friend spends $100 a month for an ad-free EMR, as one vendor is offering, he’ll spend only $1200 a year personally for EMR, and be able to avail his Medicare 44K, as opposed to the 80K-100K EMR bids he’s currently getting. Even when ads (or lack of them) are factored out of the EMR pricing, the ad-removal-for-a-price model tends to work better for smaller practices.

Based on this, I feel like we’re going to see some steep discounting in EMR prices.

I was talking to a physician friend during the week, and getting his take on EMR implementation. He would dearly like to implement an EMR in his practice. However, the major roadblocks he’s experiencing are in terms of costs. The quotes he has received for EMR implementation runs close to 80K. If he bills patients 500K a year, if he does not implement an EMR solution at all, the differential on the Medicare rebates in the first year would be 1 percent of $500,000, which is $5000, which is a number he says he can live with. If he implements an EMR, his two physician practi ce stands to make $88,000 from Medicare (they don’t see many Medicaid patients). In other words, if he spends 80K for his practice, or shells out 40K personally, he stands to gain $44,000. If on the other hand, he maintains status quo, he loses just $5000. Given the pain of choosing an EMR and EMR implementation, he’s probably better off doing nothing, he believes. And let’s not forget, it’ll be live people working with an EMR system, and productivity will actually take a hit before rising slowly back to pre-EMR levels, as this Feb post by Robert Rowley on Practice Fusion’s blog shows.

In other words, there are monetary incentives but sometimes just don’t make real-world sense.

This same math would look a lot different in a multi-physician practice. The same EMR implementation cost would be spread over a larger base, and more of the incentive money would actually reach the physician.

Which brings us to Practice Fusion. On this blog and elsewhere, Practice Fusion has got a lot of press (Full Disclosure: Practice Fusion is an advertiser on this site), not all of it positive.  Not being a medical practitioner, and never having used any EMR personally, my idea of how Practice Fusion stacks up functionally against other EMRs is pretty much second-hand info gleaned from reviews (John had a recent post on Black Book rankings. It’s interesting to me that Practice Fusion shows up in only the 1-Physician Practice rankings among the top 20.) There are those that caution the model of free. There’s also some debate whether a one-size-fits-all approach will benefit every kind of practice. But just based on its economic model, Practice Fusion is a system I would at least recommend my friend look into.

As most of you know, I don’t often point out individual vendors all that much. However, on occasion I get something sent to me that I think could add to the conversation around various EHR software. I got one of those emails from long time reader, Carl Bergman. He chose to no longer be a Practice Fusion consultant and wanted to share the issues he had with the current Practice Fusion EHR product.

I haven’t had the time lately to be able to dig into Carl’s comments myself, so that I could make an assessment of his comments about the Practice Fusion EHR. However, in the interest of sharing both sides of the story I asked Practice Fusion to comment on Carl’s thoughts on their EHR software. So, below you’ll find Carl and Practice Fusions comments.

As with most things in life, take everything you read in this post with a grain of salt and evaluate what each side says for yourself. Either way, I think it could start a helpful discussion for those considering the Practice Fusion EHR.

Letter sent from Carl Bergman to Practice Fusion:

I have been a certified Practice Fusion Consultant for several months. I’m writing to ask that you remove me as a PF consultant.

I have given this decision a great deal of thought, but I do not believe that I can market PF in good conscious. This is not due in any way to how I have been treated, nor is it any reflection on the support that PF offers to its consultants, which is considerable.

Rather, it is based on what I believe are important, missing product features. This lack of features makes it impossible for me to recommend PF to any of the leads that you have generously shared with me. (Please note, I have not and will not approach any of those leads due to your referral.)

I was initially attracted to PF due to its web basis, ease of use and, simple set up and good support. However, as I went through PF I saw that it was lacking in four important areas: Workflow, Billing, Security and Reporting.

Workflow. Each patient in a medical practice presents a different set of circumstances, attributes and issues. These require that the practice be able to respond in a concerted and orchestrated way. PF lacks this ability. Specifically:

Appointment Type. PF has six fixed appointment types, New, Recurring, etc. They may not be changed, deactivated or added to. Appointment duration is set separately for each appointment. An appointment’s specifics are kept in a note.

Appointments are key to a practice’s workflow. For example, PF has a wellness appointment type. However, there is no ability to link the appointment type to look for outstanding labs before the appointment is set. Nor can appointment type reserve a room or assign a tech to take vitals, etc., as part of an exam. As a result, a practice is left to its own, non traceable, ad hoc methods for preparing for and carrying out the exam.

Shared Task List. When a practitioners decides on a course of treatment, this can set a number of things in motion:
• Labs
• Rx
• Recurring Appointments
• Procedures
• Referrals
• Billing

Each of these also is an assignment to someone else to carry out a portion of the plan. While PF has lists for a patient and individual task lists for each person, it does not have an overall view of pending tasks so a manager can see bottlenecks or assign workloads.

Security. PF has four fixed levels of security: Staff, Nurse, NP/PA and PA. Users are assigned to one or more of these levels and optionally as administrators. As with appointment types, the categories may not have their attributes modified or may new ones be added.
I found a definition of the categories in the Support Forum/Getting Started, which defines different user’s edit rights. It is silent about how, if at all, access is limited. Apparently, any user may view all parts of a record. Allowing any user to view anything in an EMR is a dangerous policy because it allows confidential information, such as an AIDS test result, to be known by those who have no need to know it.
Billing. PF includes elements, such as insurance plans, copays, etc., that are usually associated with practice management and billing systems, so it is surprising that it does not include billing as well. Instead, it integrates with third party billing systems, such as Karo.

I have long been biased against systems that tie an EMR from one vendor with billing from another. No matter how well designed, the attempt to integrate two different data structures just doesn’t work well. While PF states that is it fully integrated with Karo, an on line subscription based billing system, but neither site has much detail on the integration much less a data model. I think a user should also know what, if any, terms, relationship, contract, etc., exist between PF and Karo or other billing services.

Aside from detracting from the free nature of PF, the question of the degree of integration is major. For example, who is responsible for the interface’s operation PF or Karo?

Is a demographic change in either reflected in the other? From what I read in the PF Community Forum, the answer is no. I would like to know whose reporting module, if either, can access the combined data from the two systems?

Also, if I use Karo, does that mean I have to set up a separate security system. To look at billing do I have to go from PF and log into Karo?

Reporting. A major advantage of an EMR over a manual system is not only the ability to find and retrieve a specific record, but also the ability to find and report on a selected set as well. For example, if the FDA notifies physicians that they should review all cases of Crone’s disease that are more than three years old who are on a specific dose of a particular antibiotic, PF could not do this.

PF’s reports are limited to searching and reporting on specific topics. In this, it compares unfavorably to a host of other EMRs on the market. If it did have a well developed reporting function, it could make up for some of its lack of workflow abilities, but it does not. This lack of reporting ability when combined with the lack of an internal billing function is a deal killer.

I regard each of the issues that I’ve listed to be a major problem any one of which would cause me to be skeptical of a product. Taken as a whole, and I am aware of the wide adoption of PF, I find that I cannot recommend PF as an EMR.

Carl Bergman
President
SilverSoft, Inc.

And Practice Fusion’s response:

Here’s some notes back. In general, Carl doesn’t seem to have a very deep understanding of the product. A failure on our part, perhaps, but these answers are easily given from our support team:

- Appointment type: EHR accounts come with six default appointment types, but any Admin level user is free to create their own to match their workflow. This setting is under the “admin” tab in the EHR.

- Task list: Each practice manages the passing back and forth of tasks a little bit differently. Most use the secure message feature to send follow-up, billing, lab messages, etc. A practice manager could review these messages or, more easily, could use the Live Activity Feed to see where there are bottlenecks. Since most of our practices are small (under 10 doctors) this doesn’t seem to be a big issue.

- Security: Each user has just one level of permission inside the EHR. Their individual login dictates the level of access they have. It is certainly not true than any user has the same access rights to any record. Plus, our activity feed gives an added level of transparency where you can see exactly who has accessed what, any actions they’ve taken, etc. That’s a unique Practice Fusion feature. However, it is a great suggestion to add more customization to these edit levels, that’s a popular request from our users as well and we have it on our development roadmap.

- Billing: We have the opposite bias from Carl here. We believe that being billing agnostic gives Practice Fusion users a great deal more flexibility in how they choose to manage their billing and an easier transition to EHR since they don’t have to change their billing process at the same time. Kareo is just one option that we provide our users, they are free to use whichever biller then would like. Their low-cost, integrated billing software is popular with our users. The integration today is fairly light, but we are working on ways to make it a more robust connection.

- Reporting: Practice Fusion does have some basic reporting features built in to the EHR today. For example, the reporting feature has assisted doctors with managing the Darvocet recall and with identifying H1N1 high-risk patients. The Crohn’s (note the spelling) disease example he gives would actually be fairly easy to run within PF. You would just do a report on ICD-9 code 555.9 with the date range set and then filter the resulting patients based on prescription (or run a second Rx report and merge). I don’t have any Crohn’s patients in my test account, so I ran a report on chronic migraine instead, below. However, we are in the process of upgrading the reporting feature for both Meaningful Use and our own planned enhancements.

There you have it. I’ll let you be the judge for yourself. Plus, I’m interested to hear what other Practice Fusion users have to say about the various opinions stated in this post. One thing that Practice Fusion has going for them is they at least don’t charge anything for their EHR. So, it’s not like a doctor using it can complain that they didn’t get what they paid for.

I have a feeling that this conversation will continue in the comments. See you there.

Full Disclosure: Practice Fusion is an advertiser on EMR and EHR. Although, I’d provide the same opportunity to any EHR vendor that would like to respond to comments I get about them.

I’ve been writing about the various open source EHR software options for about 5.5 years right now. I’ve been intrigued with open source for much longer, so it just made natural sense for one of the first things for me to look at would be the various open source EHR options.

5.5 years ago the open source EHR market (although EHR really wasn’t in vogue yet back then) had a solid foundation, but still had quite a ways to go for it to be a great option for doctors interested in an open source EHR option.

I haven’t done an in depth look at the various open source EHR options for a while (I should), but I think the fact that many open source EHR software are now certified EHR and can help physicians show meaningful use and receive EHR incentive money is a good sign. Most of you know that I’m not a big fan of EHR certification, but I do believe that EHR certification takes a certain level of commitment to be able to achieve. Therefore, I think it’s a great sign that the open source EHR options have enough steam and commitment behind them to become certified EHR.

A recent Open Health News post listed the following certified open source EHR:
Ambulatory Open Source EHR
ClearHealth
OpenEMR
Tolven eCHR
Vista (inpatient) Open Source EHR
WorldVistA EHR
OpenVistA
vxVistA
Other (inpatient) Open Source EHR
Indian Health Services’ RPMS

I’d love to hear reviews and experiences that people have working with open source EHR software.

Here’s another tip I learned over the first year in my solo practice that has really added efficiency and productivity to my office.

Tip #2. Use an electronic health / medical record system (for free, if you can).

I’ll admit I’m biased here. I hate buying something that I can get legally for free.  And as far as EMR systems go, there’s more than one option on the market at the present time.  In my office, we use the guilty pleasure of Practice Fusion and have been pretty freaking happy for a year now. Mitochon Systems is another company that offers such an EMR system, although I confess I haven’t tried it.  Practice Fusion now claims about 60,000 users, although these are not all physicians. For a recent review of their stats, an interview with the CEO can be found at HisTalkPractice.com.  These companies often use alternative sources of income in order to avoid passing on their business costs to the providers and staff using their systems. In the case of Practice Fusion, we see small ads for medications at the bottom of the screen or off to the side.   For me, this is tolerable, and I don’t feel any pressure to prescribe these drugs. They are not popup boxes that would require you to close before being able to work on patient charts, and so this allows them to be minimally invasive into your daily activities.

In bipartisan fairness, there are a variety of systems that you can pay for if desired, and indeed there is a pay-for option to use Practice Fusion without the ads for around $100 per month.  If you have ethical qualms about using a reportedly “free” system due to supposed “hidden costs”, financial and “otherwise”, that someone else will need to pay for, then you may wish to pay yourself. Just please please please don’t make the mistake of thinking that free systems are somehow less capable or functional, simply because they are free to users, and “after all, how good could it be if it’s not expensive?”.  As the old saying goes, “Don’t knock it until you’ve tried it.”  Now, as for my soapbox on drug companies and their tactics to ruin physicians’ ability to choose drugs they would really like to prescribe, we’ll have to save that one for another post…

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

Full Disclosure: Practice Fusion and Mitochon Systems are both advertisers on EMR and EHR, but I’m not sure Dr. West even knew this when he wrote the post. Plus, Dr. West didn’t get paid to write this post either. He just loves EMR and is glad to share his good and bad experiences with it.

In the vast amount of information that comes through my email, Twitter account, RSS feeds, etc one of them recently caught my eye. It was a webinar called, “Insane Ideas in Healthcare IT” by Christine D. Chang; Ovum, Analyst of Healthcare Technology (you can find the archived webinar here if you click around a bit). Here’s the description for the presentation:

All great ideas sound “insane” at first. This presentation will describe three insane ideas that Ovum believes will transform healthcare in the future including:
• Telehealth is for everyone, not just the elderly.
• Patient self-diagnosis is good and should be promoted.
• Personal health records are not just a passing trend, they are the solution.

I really love the concept of considering “insane ideas.” So, my question is what EMR ideas do you have that most people would consider insane?

On EMR and HIPAA, I wrote about an EMR platform which I think some might classify as an insane idea. Sometimes I wonder if becoming a full time entrepeneur doing mostly EMR blogging is an insane idea;-) I think that many might consider the Free EMR software an insane idea.

I had one EMR vendor recently ask me to write about them. He hoped that people’s response to my post would be that they all think it’s crazy to try and build an EMR company that way. I guess he prescribes to the best ideas sounding “insane” at first.

Let’s hear what ideas you think might be insane.

I’ll admit to being a huge fan of contests. What can I say? I love to win free stuff. I think everyone does. Plus, I love pretty much any competition. However, today when I read about the Cerner and CDW Healthcare EMR Technology transformation contest, something didn’t feel quite right. I’m sure it’s just an extension of the Cerner and CDW Healthcare EHR partnership, but let’s take a look at some of the details.

Sure, it’s great that they’re giving away $50,000 in EMR software and technology. They’re also partnered with Lenovo, Intel, EMC, Brother, Canon and Nuance. I like all of those companies for the most part and so the technology will be great. I’m just not sure winning a contest is the right way to decide to use that EMR software.

You can read more about the details at the contest website, but basically it will be in 2 rounds of judging. Here’s a description of the first round of judging:

Round 1 Judging: A panel of qualified judges comprised of representatives of each of the Sponsoring Vendors (Brother, Canon, Cerner, EMC, Intel, Lenovo and Nuance) will review and evaluate each eligible entry on the basis of the following criteria: (a) demonstrated need of Company for an electronic medical record application and an overall technology makeover(40 percent); (b) creativity of submission (20 percent); and (c) perceived ability of CDW Healthcare in conjunction with the sponsoring vendors, to improve productivity of entrant’s Company through installation of a medical record-keeping system and upgraded technology(40 percent).

The second round the vendor sponsors will do site visits to further evaluate your clinic. Not sure how this is going to work. Are they planning to select the clinic with the least amount of tech that will likely have a hard time implementing an EMR and going through all the changes? Or will they select the company who uses technology, but hasn’t yet implemented an EMR? The second clinic might be better prepared for an EMR implementation. Seems like all a marketing ploy without much thought for who they really want to award the prize to that will have the best impact.

I also think it’s interesting that they plan on parading the 3 finalists around at the HIMSS conference. Ok, maybe it’s not quite parading, but that’s kind of what it feels like. I looked through a lot of the official rules and didn’t see anything that forces you to implement the actual EMR. Seems like the form is simple enough to fill out that it might be worth getting all the technology for free. Plus, the free trip to the HIMSS 2010 annual conference might just be worth the entry. Then, you can have a chance to compare a whole bunch of EMR software. Not sure what Cerner will think about that, but maybe that’s the reward for not winning.

I previously did a post about some of the problems with Vista-FM. I considered that it was different than Vista, but wasn’t sure completely. The beauty of blogging is that when you make mistakes smart people come and correct you in the comments. This is one of those times. Plus, along with helping me understand the difference between Vista and Vista-FM Chris Richardson, provides an update on some of the other things happening with the open source community around Vista. I don’t agree with everything he says, but it’s definitely interesting. The following is Chris’ comment:

You jumped at the wrong conclusion when you jumped on VistA as being the faulty item here. What has failed is the “-FM” portion of the GAO report, the Foundation Modernization. You see, VistA is NOT VistA-FM. VistA-FM is the effort to dismantel VistA. Just like all of the other Attempts in the past nearly 20 years, these efforts are under-functioned, over-priced, and way over their delivery schedule. A mere fraction of the cost of what has been expended to replace VistA would have made VistA able to totally out-class every other approach to EHRs. There is work currently going on in the Open Source community to extend VistA and it is working very well. Here are some of the projects that are currently on the way or already in production;

Lab, while the VA is outsourceing to Cerner (with interesting results), the rest of the community outside the VA is continuing on with enhancements and options that will make it easier to install and higher functioning as well as affordable to nearly everyone.

Continuity of Care Records and Data (CCR/CCD) while this standard is a bit anemic, it does promise that we might be able to project all of the VistA databases to other systems or accession data from others.

Holographic EHR – This is one of our concepts, basically you could think of it as “VistA for One” (or a small group of patients), a self consistent subset of the parent VistA environment which could be booted separately. The self-consistent “VistA for One” becomes a mechanism for complete transfer of patient data from one site to another with merge capability. It also becomes an in-hand user copy of his records which can be protected via a network keying system which registers the data set, and records the efforts to open the data set and by whom, and who is attempting to accession the data to what target VistA system.

CPRS
This is fun. I cannot tell you the number of times that I have heard, we need to keep CPRS, but get rid of VistA. The engine behind CPRS IS VistA. Without VistA, CPRS is a screen-saver. The Open Source Community is making enhancements for the CPRS/VistA environments. There is another group that is working on the webification of VistA with open source tools.

By the way, I worked on the proposal team for CHCS-I and we used MUMPS to build interfaces for various other vendors to communicate with each other. In fact, the MUMPS interfaces worked better than the Clover-leaf connection engines.

There is a reason that the Subject Matter Expert developed systems of the VA, DoD, and IHS have been so effective and difficult to replace. VistA is a whole enterprise solution that the vendors hope you never find out about. The vendors focus on dismantling VistA to provide a new niche to build “customer loyalty” (make it too painful and expensive to move to something else so the customer is essentually stuck with the vendor’s solution only. With the VistA model the SMEs are the folks at the point of care, and not a programmer who has never spent an hour in a hospital, yet is charged with the setting of policy for the hospital in his interpretation of the requirements (which may or may not reflect the intent of the SMEs).

By having VistA as Open Source, this means that the cost of doing development has dropped right into the basement. Success can be tried in a thousand places, but with Open Source, as soon as someone comes up with an enhancement or corrects a problem, the change can go out to the rest of the World. The best of breed solutions float to the top to be applied everywhere.

You know, VistA is still running the VA hosptials for over 30 years, don’t you think that if the vendors could have replaced it, they would have? They have tried and gotten paid well for the attempts. But this is part of the problem. There is no incentive to ever complete a task or attempt because then the paydays end. This is why they have confused the community with the use of VistA-FM, use their failures as justification to try to replace VistA yet again.

Let’s take a look at some of these magnificent failures. How about the replacement of IFCAP (the financial part of VistA) with Core-FLS. Now get this. The VA developed IFCAP (by the way, it was not vendors who did this work, it was the VA SMEs who did the daily work of inventory and supply and finance) and owned the code. The VA paid nothing for the code other than the VA programmers and SME’s time. Then they were going to replace it with a package which would only have to do 30% of what IFCAP did. Congress committed $470 million to replace something the VA already owned with something that had less functionality but was more glossy and the VA would have to pay big bucks to the vendor to support. The roll-out of the product was done at Bay Pines VA Medical Center and was so bad that they had to close elective surgery. The vendor spent over half the money just to install the first site and the project was mercifully stopped and IFCAP was re-installed. So much for modernization. This is not an isolated incident.

There was the Spanish Pharmacy labels. Peurto Rico and many of the boarder VA Medical Centers needed to be able to produce Spanish Labels for the Hispanic Patients. This was done by duplicating code rather than completing Internationalization that was started back in the early 1990′s, but stopped by the Clinger-Cohen Act. It would have taken less time and less money to complete internationalization for all of VistA than it took to do a one-up parallel code base for Spanish Pharmacy Labels. Adding another language would mean even more complexity (such as French or German), would be even more duplicate code for a single functionality. By myself, I built a tool to convert all of VistA into being ready for Internationalization and made it so there could be any number of languages that could be selected by the user and not necessarily locked to a single language. It takes about 50 minutes to parse all of VistA into the instrumented code and load the DIALOG file with the words and phrases, ~165,000 phrases in all on a 800 mhz laptop. It does not modify the distributed code but builds the instrumented code in a separate location. This code is available for free download from WorldVistA.

The community is alive an well, and vibrant with new ideas. We are starting to catch up from the “legacy era” and allowing the evolution of the tools to progress again. Want to join in?? It is a lot of fun and a set of real challenges that will bring the power of what needs to be done, back into the hands of the people who are at the point of care. Interesting thing about the word “Legacy”, people think of it as old or non-functional. It really isn’t. It also means that the code is doing the job and doing it just fine. Can it be improved, sure, VistA was made to be improved, to expand beyond what was known and what was learned. But, do remember, VistA-FM is NOT VistA, it is the attempt to break up the integrated hospital system into a series of stove-pipes. VistA-FM is the worst of all FUD (Fear, Uncertainty, and Distrust). VistA is still running the hospitals and it is running more community hospitals every year.

There’s no doubt that Practice Fusion has been making a big splash in the world of EMR. They were the first EMR company that I’d seen that was pioneering the “free” ad based EMR on the web. You can read more about my first impressions of their free EMR offering on EMR and HIPAA. This interview with the CEO of Practice Fusion is pretty interesting as well.

Now Practice Fusion has made the next logical step and added a PHR front end for patients to be able to access their clinical record. From the look of the screenshots (see below), I’m not seeing anything particularly special about the PHR. In fact, I’d likely say that this isn’t much more than an initial PHR offering. Since it is their initial offering, I guess that makes sense. Certainly they’ll be building it out over time.

What I find more interesting about this new PHR is that Practice Fusion built the PHR on top of Sales Force. SaleseForce.com recently made an investment in Practice Fusion and so this seems to be an extension of that partnership. I see this as a really interesting move for Practice Fusion to build a healthcare application on top of the Force.com cloud. It also will be interesting for SalesForce.com to enter the healthcare space.

Check out the following screenshots of the PHR application: