Practice Fusion’s co-founder Matthew Douglass addresses adoption rates, interoperability and the next challenges for EHR systems.
Matthew DouglassEditor’s Note: Matthew Douglass, co-founder and vice president for platform of Practice Fusion, recently spoke with Medical Economics about the present and future of health information technology. Here is the full interview. Excerpts of this interview were published in the October 25, 2013 issue as part of the publication’s ranking of the top 100 EHR companies.
Medical Economics: In what ways is technology transforming medicine?
Douglass: I like to say that technology is transforming medicine in very practical ways, but there is a broader strategy happening. Technology is not really a panacea to solve all of our problems. If anything, it is a necessary support structure to unlock the potential that doctors are not able to right now.
If you look at a physician's daily life, they show up to the office, they start seeing their first patient at 8 a.m. and basically every hour they see patients back-to-back, and they repeat that for about eight hours and then go home.
And somewhere in there, they have to find time to order prescriptions, talk to their front office, make sure bills are being paid. They tend to be small- and medium-sized enterprise owners. And then they have to document their encounter with their patients.
That's a whole lot of daily activity to expect the doctor to work through without any technology supporting it. Until a physician incorporates really smart technologies and customize workflows into their day, they're stuck behind the eight ball, not seeing as many patients as they can see and not being able to spend as much time with their current patients as they would like to.
I think of technology as the thing that helps doctors unlock extra time with their patients.
Medical Economics: If you could think about the delivery of medicine in the next 5 years, how will it change? How important will technology be in helping to guide this evolution?
Douglass: If we look back 15 years ago, we had almost zero doctors using EHRs. We had definitely zero patients being able to access their medical records in any way other than maybe requesting a chart from their doctor.
Prior to 2008 and the American Recovery and Reinvestment Act, we were working with about 7% of doctors in the United States using EHRs. We had less than 1% of patients accessing their medical records online. About $20 billion was earmarked for doctors to adopt systems. That has gotten us, basically, to today where we have about 40% adoption in the United States.
Meanwhile, patients were able to access their records online a little bit more often, but I still think we haven’t gotten over that hump of true impact of technology with doctors and with patients and with the data that’s connecting them.
We’re on the precipice. There are a lot of companies working on a lot of big ideas, and we obviously have ours, as well. I think the real power of technology within a practice and within the physician/patient experience is ahead of us; it’s in the future. And hopefully, it’s not too far off.
That’s a future that likely consists of patients being able to message with their doctors. Patients able to share data they’re collecting about themselves, or home monitoring devices are collecting it about their daily lives and syndicating that information to the doctor. It’s not that far off to have basic apps that patients can use powered by their medical charts.
I’m more excited now than I have ever been about the future of technology in healthcare, because it’s all coming together.
Medical Economics: We are 3 years into Meaningful Use. Our government continues to incentivize and will ultimately penalize physicians for not adopting EHR systems. Why has it taken such a massive push to get physicians to adopt?
Douglass: Getting physicians to adopt EHRs is a very complex issue. I would say if you ask 100 doctors, you would get 150 answers. In my opinion, prior to the stimulus bill where doctors were bribed to adopt, there were actually disincentives set up for doctors to adopt systems. The systems that were available in 2007-2008 were largely client/server model. It was a very 20th century way of thinking about technology in a small, medium enterprise.
(While cost remains an issue for physicians trying to maintain profitable businesses even with incentives), there are also psychological components to digitizing health records. Physicians walk into their office every day and they see a wall of paper charts. It serves as a mental block for them turning it electronic.
They need to think about it as, ‘Let’s start with a fresh chart with every patient that I’m going to turn into a digital patient.’ From a 100-page paper chart, you need two or three of those pages digitized. The important areas to convert are allergies, current medications, past medications, and current problems. And then there are the additional nice-to-haves, like previous lab results, previous vital signs, previous chart notes.
If you go back to 2007, we were at about 7% EHR adoption, but we had about 95% of doctor’s offices with a billing system. So, they have electronic systems. It’s not that they’re against having electronic systems in their office. It’s just they’re against having an electronic system in their office that’s not providing value to them. They need to feel that immediate value, and most EHRs don’t provide that. Or they certainly didn’t in 2007.
More recently our government doubled-down on the bet that doctors need to move toward EHRs by including in the Affordable Care Act these provisions that start to move the United States away from a fee-for-service model and more to a pay-for-performance model. So you’re starting to see over the next few years, 1, 2, 3% of all Medicare and Medicaid payments are going to be tied to quality measures.
We’re going to increase those percentages as time progresses. To manage the quality of your patient’s health, you need a clinical documentation system like an EHR to do that.
Medical Economics: Will interoperability drive consolidation of the market?
Douglass: I don't see interoperability driving consolidation as much as I see doctors not choosing products that don't work for them driving consolidation.
Medical Economics: Do you think we're ready for interoperability?
Douglass: Interoperability readiness is a very interesting topic. Ultimately what that boils down to is when patient goes to see a new doctor, or is at the hospital or is somehow disconnected from their primary care physician, can that new caregiver access anything about that patient? I think for us to call interoperability in the United States health care system a success, we need to be able to answer that question in the affirmative, every time.
That's a very high bar for us to strive for, but I do think it can be accomplished. I think we're probably 10 years away from being able to answer that question yes every single time. But I think we are already seeing that question being answered yes today, and I think we can probably get to 50% of all patient referrals or encounters outside of the primary care setting within the next 5 years. We're on the right track.
It's a technology challenge. Especially when not all EHR platforms are in the Cloud, they're not actually able to communicate with each other. In a lot of cases, the servers sitting in doctors' broom closets can't even access the Internet. They can't access the outside world because they're firewalled off, ostensibly for protection of health information.
As a country, we need to get a little more comfortable with sharing patient information appropriately and securely with the right people. I would argue there is a cognitive or psychological hump we need to get over. This data is needed by any caregiver who is seeing that patient. It's information about the patient, and it's owned by anyone in that care network. The technology underpinnings to make sure interoperability works are currently being built by all EHR vendors. We have to do it to become certified through the stages of Meaningful Use that were set up as part of the stimulus bill to offer physicians incentives to adopt technology.
Ultimately, that's driving the need for greater interoperability among systems. It did take a massive federal investment and really specifying what these EHRs have to be able to do to get all of this off the ground. And we're seeing it happen.
Medical Economics: How do you think the market will shift when the incentives run out?
Douglass: These investments that happen at the federal level that are tied to Medicare and Medicaid payouts tend to permeate the entire industry and they're not limited just to doctors that are seeing Medicare and Medicaid patients. This is a sea change occurring across the entire industry.
It's anybody's guess what happens when the incentives run out. There are some prevailing opinions. I've heard some people say that it will stop adoption immediately. It will mean that those doctors already using an EHR will stop using it, because they're no longer incentivized to do it through the stimulus package. I think that's shortsighted. I think they're not looking at the behavioral changes that are happening, all the great benefits that come along with adopting EHRs.
Medical Economics: How important will mobile technology be to the future of medical delivery?
Douglass: We are in a highly connected world, where you're rarely more than 5 feet away from your mobile device and you rarely spend less than 30 minutes away from it during any particular day. We are not quite at a place where healthcare has really jumped on that bandwagon, yet. I think the entire EHR industry is taking a wait-and-see approach. I think smart phones have permeated about 70% of the U.S. population, at least in adults, and you're looking at a fewer number of physicians having adopted mobile smart phones or tablets.
But, you don't want to be doing your clinical documentation on a tablet, unless the dictation is really, really good. And we're not quite there yet, from a natural language processing standpoint. Try teaching dictation software how to spell staphylococcus. Again, I think very much like interoperability, very much like just technology in general, we're on the precipice of a lot of great things happening in mobile.
Medical Economics: What do you think are the exciting technological advances for physicians?
Douglass: I'm mostly excited about physicians being able to see the entire medical history of a patient, no matter what physician that patient saw. Having a cradle-to-grave vision of a patient's health history is super-critical.
More important, though, is displaying that information to the physician in a way that is consumable. Having a 100-page paper chart as the analogy makes it pretty obvious that someone can't flip through all that information in just the 90 seconds they have to prep for that patient visit. But if they're using a technology that can alert them when a patient checks in on their Wi-Fi scale at home with a weight 5% over what it was when they last checked in, that's a value that's probably very important to that doctor that's treating pre-diabetics.
Knowing a patient's blood pressure because they just checked in on their Wi-Fi-enabled blood-pressure monitor at home, and that's set up to flow directly into their personal health record and then onto their doctor and the electronic health record, that's a supremely valuable data point.
Really it's about interconnectedness. It's getting all that data that's currently siloed away on your mobile device or on your medical devices at home. Getting that flowing into the physician setting is absolutely critical to make sure we're treating patients in the right way that their health should be managed.
Medical Economics: What do you think HIT companies are going to be talking about in five years, as it relates to technology?
Douglass: Five years ago we assumed that there was a future where all electronic health records would be in the Cloud. People told us that we were crazy when we launched the product. They said doctors wouldn't adopt it. They expect something to be in-house, this was not something they were going to adopt en masse, and sure enough, we proved them wrong.
I think if you look into the future even just five more years, you're going to see even more doctors utilizing Cloud-based EHRs. I don't think there's a future where that doesn't happen.
I think we're also looking at a lot of that interconnectivity, where medical devices and mobile applications are funneling data that they're collecting on a daily basis through to the health record.
The fact that we're in 2013 and we don't have that yet kind of ticks me off and gets me riled up to make sure that happens and that Practice Fusion is a leader in that regard.
Douglass is co-founder and vice president of platform for Practice Fusion. He is credited with creating the SaaS technology framework that enables rapid development of the EHR’s national platform, now used by more than 100,000 medical professionals. He has spoken on healthcare technology at SDForum, Health 2.0, the Massachusetts Institute of Technology, Stanford, and Microsoft events.