Dr. Eric Fishman, CEO EHRtv interviews Robert Rowley, MD, Chief Medical Officer of Practice Fusion.
Dr. Eric Fishman: This is Dr. Eric Fishman with EHRtv and today we have the pleasure of speaking with Dr. Robert Rowley, Chief Medical Officer and one of the originators of Practice Fusion. We are at HIMSS 2012 in Las Vegas. And Dr. Rowley, thank you for spending a few minutes with me.
Robert Rowley: This is delightful, thank you for the honor.
Dr. Eric Fishman: You must be incredibly proud to have started a product that is now been used by over a hundred thousand physicians?
Robert Rowley: It is amazing to watch this thing grow beyond what I – beyond my wildest dreams.
Dr. Eric Fishman: And so tell me about when you first started it, what the incentive in doing it was?
Robert Rowley: So, when we first started, the product that I had created prior to Practice Fusion was something that originated in my own family practice.
Dr. Eric Fishman: Right.
Robert Rowley: I’m in an insatiable geek as it were and created an EMR produced in my own practice. I tried to get that launched as a product in the market place but it was not very successful.
Dr. Eric Fishman: While practicing medicine?
Robert Rowley: While practicing medicine and realized that, a couple of things. I realized that EHR systems that you expect small practices to install in their local offices was just a no go. I tried giving it away – giving my product away to colleagues and found that they just weren’t able to keep up to servers.
Dr. Eric Fishman: The issue being the client servers, the technology needed in the office.
Robert Rowley: Right. So, it became clear to me then that a hosted service was the way to go for small doctors.
Dr. Eric Fishman: And when was that?
Robert Rowley: That was maybe back 2005, 2006.
Dr. Eric Fishman: Okay.
Robert Rowley: I also had tried standard business model of selling the service, selling the product to physicians who expect to maybe paid either rental or purchase price and that didn’t work very well either. It just wasn’t clicking. I met Ryan who’s the founder of Practice Fusion. We had a great business idea of free advertise-based product for healthcare and the free model in business has been quite well established in other verticals outside of healthcare.
Dr. Eric Fishman: What were the circumstances under which you met him?
Robert Rowley: We met through connections in Silicon Valley. We’re kind of all being part of it – it is such an incubator environment. You meet people who are doing similar things and you get introduced. Somebody is saying, “Well, talk to this guy because he’s doing something similar to what you’re doing.” And through those channels, we met and decided that it would make sense to work together. He purchased my IP and we launched the very first version of Practice Fusion which is based on what I had created and it’s a free model as the basis.
Dr. Eric Fishman: That’s a nice story. And free wasn’t always working but in the internet it works because it can be?
Robert Rowley: The internet works. I mean, look at fairly large companies like Facebook or Yahoo or Google, they have proven that free model can work. There hasn’t been a lot prior to us, there hasn’t been a lot of proving if that can work in healthcare.
Dr. Eric Fishman: Healthcare.
Robert Rowley: So, we are disrupted in that. We did the front, the interface to be web-based rather than a downloaded app and built it on a – sort of we built it on Flash which is something that at that time was ubiquitous. Everybody used Flash. This is before iPods came out. It doesn’t use Flash because we didn’t want to have to build different versions for different browsers. So, that’s kind of how it started. With the web-based servers, one of the things that are just native to that is when you make changes to the product; you are going to roll them out to everybody everywhere all at once.
Dr. Eric Fishman: Instantaneously.
Robert Rowley: So you don’t have to do the, “Oh, my God. Can I survive the upgraded version 3.2 or something like that that I hear people with locally instances.
Dr. Eric Fishman: Daily.
Robert Rowley: Having that issue. So, that’s when it really helped and we’ve just grown because it’s ad-based. Now that model in healthcare means that we have to have active users for us to make our money. We’ll get you the interface for free. Now if you use it, we’ll do well. And so we’re poised to make sure that we actively reach out to people who sign up and try to get them to become active users. That’s what it all is based on and we’ve done a good job with that.
Dr. Eric Fishman: You’ve done a phenomenal job with it.
Robert Rowley: We have and again, it’s staggering how big it’s gone. And there’s a lot of ways of measuring it but we’ve got at this point about 150,000 users. It represents about almost 70,000 unique practices. I’d say a third-to-a-half is active users using it all the time.
Dr. Eric Fishman: That was my question. What percentage of that 150,000, this is the primary way that they maintain the records.
Robert Rowley: Whole lot. That’s what they do. I mean, we…
Dr. Eric Fishman: And you know that data better than any clients who look at it.
Robert Rowley: We look at that data daily.
Dr. Eric Fishman: Right.
Robert Rowley: So we know, we’re the sixth largest channels who share scripts in the country. We created just last month about two million pages of records in the EHR, so that people are using it. People are using it not just because it’s a way to get meaningful use money although it is in a free way really meaningful use of money but because it is – I mean, I want it to be an essential tool for doctors for ambulatory practices. It’s focused on ambulatory practices, not hospitals.
Dr. Eric Fishman: Right.
Robert Rowley: It’s used by practices of all different sizes; many of them are the smaller practices.
Dr. Eric Fishman: But if you look at the bell-shaped curve, how far out does it go?
Robert Rowley: It goes out to – half of our practices are five or less, half to 60% are five or less.
Dr. Eric Fishman: Okay.
Robert Rowley: So the small 1 or 2 physician practices use it well and that has been an impenetrable barrier to most of the vendors for all the reasons that I have discovered when I tried to do my thing and we’ve been successful at approaching them. On the middle-sized practices, now it seems like there’s a shift in the demographics of how physicians are aggregated. So the 1 and 2 physician practices are declining in numbers being replaced by single specialty small practices, medium-sized practices, the 5 to 50 physician single specialty practices, surgeons, there are cardiologists, there are oncologists, etc and they’re taking up this technology as well. We need to make sure that we have a product that provides all of the utility that they need and so we’re always trying to improve the product.
Dr. Eric Fishman: How often does it get updated?
Robert Rowley: It gets updated. Well, last year, we had about a four month hiatus where we didn’t do any update.
Dr. Eric Fishman: Because they’re all “cost?”
Robert Rowley: Because we’re trying to build a product for meaningful use and we could get to that endpoint faster if we just built it and then released it rather than incrementally release or nearly, we incrementally released about once a month with various features. So there is various product roadmaps that drive the product and we release them as best as we can. We need to make sure that when we’re releasing particularly at our current size, that…
Dr. Eric Fishman: That they’ve been adequately tested?
Robert Rowley: That it will be adequately tested and it doesn’t slow people down.
Dr. Eric Fishman: Are you at liberty to tell us what’s on the roadmap for the next 12 to 24 months?
Robert Rowley: The biggest priority and one of the things we aren’t really hearing is chart share. So chart share is a way of getting clinical information between different kinds of practices.
Dr. Eric Fishman: All of whom are using Practice Fusion or who are using discrete systems?
Robert Rowley: So, the way I look at it, there are three general approaches to sharing data. The traditional approach is what I call hub-based or the HIE-based approach.
Dr. Eric Fishman: Right.
Robert Rowley: Hospitals are building their own hubs. Statewide and regional HIEs are starting to come together, but how they aggregate hospital-based hubs, we’ll see and that’s I think one of the biggest challenges. And then that’s an institution play. You know, institutions will probably talk to each other that way. And that’s going on there. There is also what I call “point-to-point connection” which is the direct projects – way of getting similar to faxing. It’s getting data from one place to another place in a push kind of way, in a secure way. And the third is what we call “extend the platform.” So, if you’re a doctor that I want to send a patient to, and you’re not on Practice Fusion, I can send you a message saying, “Sign up”, “log on”.
Dr. Eric Fishman: It’s free and you’ll get the access to the data.
Robert Rowley: It’s free and you are going to log it on right now and you can be up and running in a couple of minutes and you will have my message about the patient that I want to refer to you regardless of what you’re having around.
Dr. Eric Fishman: Interesting model not available to many other companies here?
Robert Rowley: No, it’s a viral spread model and that is one of the priorities that we’re working on right now. And I think that’s going to be very popular in the ambulatory space, so between one clinical doc and another clinical doc, outside of the hospital, sharing records back and forth between practices, that would be very helpful. The goal there is initially, it will just be messages that are sent. Later on, there will be actually selected elements of the chart that we can both write on. So I can see what you are doing; you can see what I am doing; we can both look at the same lab.
Dr. Eric Fishman: How long would that be?
Robert Rowley: My hope is that will come out in an iterative way over the course of this year.
Dr. Eric Fishman: How many programmers do you have developing this?
Robert Rowley: We have – well all of our staff is onshore and offsite. So we’ve got – the company is growing by leaps and bounds. So I’d say a third of the company is engineering product managers and a good two-thirds – I am leaving out of course everybody else but the rest are user engagements and support. Those are also all onsite. And of course, there is clinical and legal and business and all of the other pieces that are part of it.
Dr. Eric Fishman: You need that.
Robert Rowley: But we have a large engineering staff and, our approach is very much influenced by the modern way of thinking or doing user design. So we look at user experience, we do a lot of interviews with people who are going to be using it, like the way that we were taught using the iPad. We’re building an iPad app.
Dr. Eric Fishman: So tell me about that. Your Mobility is clearly a critical issue in this decade.
Robert Rowley: So the iPad app is intended to address – again because we’re built in Flash and iPad doesn’t support Flash. We needed to build a native iPad app and we look at who’s going to be using an iPad, it’s the practitioners, it’s the doctors that will be using it, it’s not front desk. Front desk will be sitting at a desktop so they use the regular app. MAs and nurses won’t be carrying around an iPad. They’ll probably record information probably on a little piece of paper and that’s what they do in my practice and go to a workstation and enter the vital signs information and all of that information but doctors want something portable and so the subset of workflows that the iPad is addressing are what doctors do. So the process was interviewing doctors, getting scenarios and stories. So the storylines are unused cases and then from that doing user interface, from that doing product development, and from that, doing engineering. So it’s very much a user experience driven model that we’ve actually started to incorporate into everything that we designed onto the native website as well as the iPad app. So, it’s exciting. We’re looking also at some mobility apps and some Smartphone apps that again are functional subsets of who’s going to be using the Smartphone. Well, certainly not nurses and doctors in the office but doctors who are out of the office.
Dr. Eric Fishman: But the doctors…
Robert Rowley: At home, they might want to look at the schedule or they might want to generate messages or they might want to look at record requests, so those kinds of for the functional subsets will be things that makes sense to have as mobile apps. And when you do your message on your iPhone while commuting in on the subway, it’s at your office’s desk like, “Something’s come up. Reschedule my morning patients” or something like that. It will happen because the data is all hosted in the cloud.
Dr. Eric Fishman: You mentioned paper in your office. So are you still practicing?
Robert Rowley: I’m still practicing.
Dr. Eric Fishman: How much? How do you split your time?
Robert Rowley: I’m in my practice half time.
Dr. Eric Fishman: Okay.
Robert Rowley: And then I’m in Practice Fusion half time and they both take up full time space in my head.
Dr. Eric Fishman: Welcome to my world.
Robert Rowley: Welcome to mine. That’s the way it is but this is an exciting year. I mean, we’ve gone to the point where people know who we are. We have, I believe, demonstrated that free model works in healthcare.
Dr. Eric Fishman: Clear.
Robert Rowley: And we want to anticipate where healthcare is going, understand how healthcare works and where, how can we create products that will capture clinical quality measures that will help organizations, physicians, ACOs, medical groups that are being – more and more are going to be reimbursed based on a performance-based measures rather than just piece work. And we wanted to have products that support that, anticipate that, and relate that. Involving patients in it that will have a patient portal. So patients can look at their problem list or medications, their allergies, their immunizations and their next appointments. Those are all there now and I’d like to see that become much more robust.
Dr. Eric Fishman: Tell me something else that will come in the next year.
Robert Rowley: So, the PHR should have two-way interface.
Dr. Eric Fishman: Good.
Robert Rowley: Meaning, messaging back and forth between the doctor and the patient. I want to see that happen. I want to see the clinical quality measures be much more robust and more complete. Again, Chart Share and really developing that is probably the number one priority for us this year and then the mobile app. We’re also going to do an API for connecting other outside sources of data. So LOINC.
Dr. Eric Fishman: I would say everybody wants to connect to Practice Fusion and it’s probably a time consuming event to your team.
Robert Rowley: Well it is. So we want to do an API build out for instance, that will allow local doctors to go to their hospital and say, “I want to get your lab data. Here’s the way of doing it. Here’s the plug.” And then if that hospital is able to generate HL7, LOINC encoded lab data that can be imported as structured data. So, that will be pretty exciting. The API, I’m fairly excited about. We’re looking at a lab API; we’re looking at billing, more generic billing system API and exporting and importing the CCR and CCD kinds of data with the summaries, the problem list, the medications, the allergies which RECs and HIEs and Reos are interested in obtaining and sharing and so I want to be able to do that probably through an API.
Dr. Eric Fishman: One final subject area we didn’t touch upon is clinical content and template. So now I’d think that you’re in a very enviable position that if you could put together a template sharing methodology between your various specialties, your various physicians that would have an incredibly robust set of clinical content.
Robert Rowley: That’s correct and we do. We have currently in a library of templates that are prebuilt. There are about 180 some templates that are built around, types of exams like physical exam for different ages, or types of diagnoses. And they can be anybody can claim any element from the library and then it’s your copy of that template and you can modify it at will.
Dr. Eric Fishman: And do your users upload?
Robert Rowley: They don’t upload it to the library. The Library is curated but they can upload or say they can give me examples of templates they would like to have viewable by everybody. Templates can be shared within a practice, between practitioners within a practice. You can create your own template that works the way you want it from the scratch or you can modify one from the library, and people do that all the time. Sharing between practices is something that needs to go through the library and needs to be curated. So I can upload; I’m always uploading to the library but then that is manual.
Dr. Eric Fishman: Are you the curator?
Robert Rowley: I’m the curator, yes, yeah.
Dr. Eric Fishman: Very well.
Robert Rowley: As I am the clinical guy, I’m the curator, so.
Dr. Eric Fishman: Oh god. That’s all and anything else you want to talk to us about this afternoon?
Robert Rowley: I think we’ve touched on many of the different topics. I think the patient view, patient centricity. One of the other things is for physicians who want to go to meaningful use. So we have had a lot of people who were able to achieve meaningful use successfully using Practice Fusion. The dashboard – we built-in a meaningful use dashboard into the product so you can see at any time on any day…
Dr. Eric Fishman: How close to it?
Robert Rowley: How you’re dealing with all of the different measures, where you succeeded and where you still need to work and that’s very helpful. You don’t need a consultant to necessarily come in and extract the information from new EHR. It’s right there, you can generate the reports that you need and then use those reports to go into test.
Dr. Eric Fishman: And if you have about a thousand consultants available to help implement Practice Fusion, if…
Robert Rowley: Yeah, and that’s something actually that we didn’t really talk about. We do have a certified consultant network for practices that are still trying to implement their EHR. They’re afraid; they’re not sure of how to get from paper to…
Dr. Eric Fishman: They’re not geeks.
Robert Rowley: They’re not geeks, you know. They’re not going to jump in with both feet. They may want to have stepping stones to get from one shore to the next. And we have on the ground consultants who are consultants in all the different communities around the U.S. who have signed on to be Practice Fusion certified consultants. They can help people with mostly the workflow that we design. What are you going to do with all the paper that comes in? How are you going to do the transition of – often, there’s a transition period where you’re using an EHR and you got your old paper chart and you’ve uploaded all the demographics from your billing system. So that’s been done and we do that for free in about a day. So you’ve got all of your chart notes but they’re empty at first. So every one of your patients is like a new patient at first. So there’s going to be not a…
Dr. Eric Fishman: Not a fun day in the office?
Robert Rowley: Not a fun day in the office. So you use your old chart and as you see patients, we will recommend it but as you see the patients rather than bulk uploading everything in your chart record, you enter the pertinent information as you go and then once you’ve seen the patient with both, you retire that chart. And overtime, most of the patients you’re going to see – you will have seen and you won’t ever be needing to pull out the old chart. So there is that transition phase so kind of one and the other. If you are going from one EHR system to a different EHR system, then actually importing that data is a different conversation but – and we can work with people who want to do that. We have a number of people who are saying, “I was using system x and I don’t like it. It’s old and costing me too much money and I want to go with you guys.” We can help them do that. So they don’t have to go through that phase of “every patient is a new patient” as far as your encounter is concerned.
Dr. Eric Fishman: Dr. Rowley, it’s been fun meeting you and chatting with you.
Robert Rowley: Thank you, thank you. This has been good.
Dr. Eric Fishman: This is Dr. Eric Fishman with EHRtv. We’ve been speaking with Dr. Robert Rowley, Chief Medical Officer at Practice Fusion, thank you.