Free EHR software is a Catch-22! “Catch-22” is a phrase coined by Joseph Heller in his novel by the same name, first published in 1961. It was required reading my senior year in high school (confession; I may have used the Cliffs Notes). It is considered one of the great literary works of the twentieth century, and the phrase “Catch-22” has become part of the American lexicon, commonly used to describe a no-win dilemma like, “heads I win, tails you lose”.

Using advertising-supported enterprises is now part of our everyday ritual. We all use Google® and read our local papers online — those companies now make much of their money from ad-supported revenue. With ad-supported enterprises, users agree to be subjected to advertising, or have their data mined, or both, for the right to use or their service. In many industries, such as “web search”, this model makes sense and in fact, in some cases, is helpful to the consumer.

This advertising model has now migrated to the EHR space. There are several companies that will provide EHR services “for free”, in return for being allowed to advertise to you — the physician — and sell your data to third party data mining companies. They hype the fact that they make the majority of their money from advertising to physicians and selling your data after the PHI has been redacted.

Let’s study the model a little closer and see if there is really value in the “free” ad-based EHR.

First of all, the most popular advertising-based free EHRs do not come complete with a practice management system and clearinghouse. They have recommended partners who charge around $300 for those required services, compared to the integrated MediTouch® product that may save a doctor around $200 per month. The real question is whether this “savings” is worth the hassle, the lack of features and integration challenges; we think not.

The more important issue with ad-based, free EHRs relates back to the Catch-22, no-win dilemma that physicians need to come to grips with when choosing a “free” EMR. There are only two scenarios that can develop with regard to a “free” EHR.

Scenario #1: The “free” EHR Company works with an advertiser, as an example — a pharmaceutical company. A banner ad for a drug is presented on a medication or ePrescribing screen, when in the exam room the doctor reads the ad, then clicks on the ad, and is “influenced” by the ad. The doctor prescribes the drug that was advertised by the pharmaceutical company. This is exactly how advertising should work: an advertisement is presented, the ad occupies the attention of the user, it influences behavior, the advertiser sells product, and in this case that sale partially pays for the use of the service — the “free” EHR. Something is very wrong with this scenario!

  1. In the exam room the doctor’s attention should be focused exclusively on the patient. Frankly, I don’t want to seek medical advice from a physician that is distracted from my care by anything or anyone, especially when I am one-on-one with my doctor in the exam room.
  2. Physicians should be making medical decisions based solely on what is in the best interests of the patient. At the point of care doctors should not feel bombarded with ads for treatments that may be more costly or less effective than what is best for the patient. What is the chance that the banner ad is coincidentally for a treatment that is the best one available? Unlikely.

I have spoken to doctors that believe that these types of distractions and financial influences, for the sole purpose of financing a couple of hundred dollars per month, are unethical and pose a liability risk.

Scenario #2: The “free” EHR Company presents banner ads to physicians, and even though the ads may be distracting, the doctor is never influenced by the ad. The advertiser does not get a “result” for the ad space they buy.

After reading Scenarios #1 and #2 I think the Catch-22 should be obvious.

This is an actual slide shown to prospective investors of a prominent free EHR company.
advertisement based EHR screenshot
Note their advertisement and message prompt at the bottom, denoted by the red arrow.

First, if doctors are distracted by ads, and even worse influenced by them, they are teetering on a fine line from an ethical and liability perspective. Could that kind of moral compromise really be worth a couple of hundred dollars per month?

Second, if doctors do not “click”, advertisers will find out quickly that their ads don’t sell their products. Advertisers are capitalists and they will abandon sponsorship of the “free” EHR. The “free” EHR companies readily admit that ad revenue is the key to their success. If doctors act ethically, the resulting lower ad revenues will result in lower company revenues (many ad-based EHRs presently lose money and are financed by venture capital).

Those “free” EHR companies will then have one of three choices:

  1. Go broke
  2. Start charging doctors to compensate for the lack of advertising sales — their user agreement allows for this provision
  3. Sell to another company that charges for EHR services

In addition, some of the “free” EHR companies are not equipped with simple methods to download patient records from their data centers to a machine owned by the provider (MediTouch® does). If they go broke how do you retrieve your data?

Many of these “free” EHR companies really cost more because they can slow down the provider, and they don’t have a set of features that make it easy for the provider to manage patient care efficiently. Many don’t support:

  1. iPad® optimization
  2. Drawing on images
  3. Fully integrated experience across the EHR/Billing/Scheduling/Clearinghouse/Patient Portal
  4. Flow sheets
  5. Longitudinal patient record
  6. Blueprints or templates
  7. Meaningful Use report cards

There is no free lunch. “Free” EHRs are not free; in fact, they are expensive. They require a costly ethical compromise — a bet that the great ad-based EHR experiment will work, and a gamble that settling for fewer time-saving features will not lower your practice’s productivity. Is that risk really worth a couple of hundred bucks a month?