Healthcare and advertising

November 1, 2011 -- Practice Fusion conference -- With 1300 other healthcare workers, I sat in a convention hall in San Francisco and observed panelists debate the merits and issues of Practice Fusion and the electronic health record industry in which it appears to be thriving. PF is an advertising-funded, free-to-its-users, web-based electronic health record.

The company was founded in 2005 by Ryan Howard, a youthful and energetic entrepreneur with big and timely ideas. Five years ago I had coffee with him, having just discovered word of his startup not far from the more conventional electronic medical record company where I was working at the time. I was interested to learn about the direction he was taking and the technology he was fielding. The marriage of healthcare and the web was, I believed and still believe, inspired. Instead, what I experienced was a blizzard of tech-talk buzzwords -- disruptive technology, web-enabling, silo-liberating, blah blah -- nothing about medical data standards, medical office workflow redesign, new paradigms for medical data ownership, and so on -- the meat of the issues that such a system would surely challenge.

The tenor of the conference was much the same -- lots of fluff, a half hour of music by a gospel choir, feel-good cheerleading, not much content. Mr. Howard himself delivered one of the pep talks. In it, he claimed that PF's patient population was bigger than Kaiser and Sutter Health's (our two largest Northern California hospital chains) combined. While it may be true that portions of 22 million patients' medical charts do reside in PF, these patients are not PF customers, they are PF users' patients. Unlike Kaiser and Sutter, PF provides no medical care, nor does it employ thousands of doctors or possess thousands of hospital beds. The comparison is vacuous.

Regardless of flaws in PF's product, is the underlying business model -- and its potential effects on healthcare data management -- sound? Is a database attached to a web server the right place for my medical history? Is the Internet the best way for my caregivers to share and access it? What effect does this model have on costs and especially on outcomes?

The central feature of PF's business model is that it is funded by advertising, not by users. The doctors and clinics that entrust their patients' data to PF pay nothing for it. This surely has some effects on the nature and content of the service PF provides.

This raises several questions. First, is it a strategy for long-term survival? Every Internet user knows that before long, banners and advertisements "disappear". Our eyes learn to ignore them, and we rarely click them. There are even software solutions as popup preventers and flash suppressors to expunge ads from the screen. If the ads don't work, can PF survive?

If the business model is not viable over the long run, how will PF survive? As it is privately held, we cannot know for sure how it is faring financially, but my understanding is that today, after six years, it still runs not on revenue but on venture capital.

The deeper issue, in a medical decision-making setting, is whether advertising is ethical and appropriate. Does it skew treatment decisions? A heatedly-discussed precedent is the advertising of pharmaceuticals. The businesses that advertise make calculations about advertising in any medium, be it television, radio, newspapers, billboards, or the Internet. In any medium, the concern is return on investment. If advertising fails to increase sales, it will not be done for long. Thus, the mechanism must be that well-placed advertisements do indeed skew clinical decision-making toward the advertised products. Is this how we want our treatments chosen?

Any discussion of advertising must recognize the real product; what is being sold to whom. In this regard, the Internet is much like television. As is television to its audience, PF is "free" to its healthcare provider users. The payers are the companies that advertise. These are the real customers, and what is being sold to them is the attention of the users. So, in a sense, PF's product is not an electronic health record but the attention of its users, all those people in that convention hall.

Consequently, PF's product design and support decisions are driven less by the needs of patients, providers, and the exigencies of medical care, and more by what yields the biggest bang for the advertiser's buck. Does PF mine the data? For example, when a diagnosis of diabetes is entered, might an ad for a related product such as Metformin be displayed? I don't know and I bet PF isn't telling.

For strategies such as PF's, improvements in clinical outcomes and reductions in health care costs are at best a side effect. Is this how we want our health care data stored and managed? Despite my doubts about Mr. Howard and his company, I believe that the answer is yes. With HIPAA-compliant confidentiality safeguards, storage on Internet-connected servers enables wide access to patient data. It can spare us redundant tests, and eliminate the siloing of data in the file cabinets and computers of doctors' offices and hospitals.

Dearest to my heart (as is well known to readers of this blog) is technology's potential to put the patients themselves in control of their medical data. The trend is toward patient empowerment in medical decision-making. If PF moves this industry toward those goals, I applaud its efforts.

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