Marcia brier was suffering from vertigo when she arrived for a doctor's appointment one morning this past winter. But as she soon found out, that wasn't her only problem. Brier had been referred to an ear, nose, and throat doctor at Boston's Beth Israel Deaconess Medical Center, and his office staffers couldn't locate the referral number that Brier's internist had given her. They wanted payment up front.
But unlike most patients who are powerless in the face of medical bureaucracy, Brier was armed with an unusual tool -- online access to her own medical records. "I said, 'Look, do you have PatientSite access?" recalls Brier, referring to a Web-based repository of the records of 5,000 of the 1 million patients enrolled in CareGroup HealthCare System, based in Boston. The office had access to the site, so Brier dashed behind the counter, took control of the keyboard, logged on to the secure site, and pulled up her referral number. It was in an E-mail from Dr. Steven Flier, Brier's internist and codeveloper of PatientSite.
Up and running since April 2000, PatientSite puts into patients' hands information that traditionally has been hidden within the confines of medical-records departments. Using the technology, Brier can E-mail her doctor to make an appointment, get a referral, or refill a prescription. She can also review the results of laboratory tests and radiology reports, all on her home computer.
"The system lets us take away the trivia of medicine -- appointments, prescriptions, referrals -- and focus on patient care," says Dr. John D. Halamka, chief information officer of CareGroup, who also helped develop PatientSite. The service, which CareGroup may begin licensing to other health-care systems, operates within secure firewalls -- much like an online financial-transaction service -- in order to protect patients' privacy.
A technology that gives customers immediate access to all their own data is old hat in any number of other industries, from banking to office supplies. But it's downright revolutionary in the medical field, in which papers, pencils, and manila folders are still state-of-the-art. "You can go to an ATM and get $20 from your bank account, but it's very hard to get an appointment with your doctor," says Halamka.
After years of resistance, the medical field is finally in the process of getting wired -- and going wireless. Web technology is empowering patients, and handheld wireless devices are beginning to wean doctors from their dependence on paper. Physicians are beaming prescriptions to pharmacies and scanning bar codes on patients' wristbands as if they were moving groceries through a checkout line. And doctors and patients alike are finding that technology is beginning to ease the perennial battle with insurance companies.
"The medical field is five to seven years behind other industries," says W. "R.P." Raghupathi, associate professor at Fordham University School of Business, in New York City. On average, hospitals and doctors groups spend just 3% of revenues on information technology, compared with the 5% spent by financial services and 7% by the communications sector, according to one Gartner Group study. In addition, a network that could seamlessly connect doctors to hospitals to patients to insurance companies seems as elusive as a cure for the common cold. The roadblocks to creating such a system are huge. Many doctors fear that technology will replace their decision-making authority, and patients worry about privacy.
Federal legislation and regulations are proliferating to safeguard the exchange of confidential medical data among providers and insurers. But as consumers experience the unfamiliar taste of access to their own medical information, it's hard to imagine that there will be any turning back. What may truly drive further technological developments are consumers themselves, who may begin voting with their feet for doctors who have access to seamless communications systems and smooth connections to insurance carriers.
Creating Patient Communities
Phillip L. Webb began surfing the Internet for medical information in the spring of 2000, soon after he was diagnosed as being infected with the potentially fatal hepatitis-C virus. The automotive technician from Bakersfield, Calif., believes that his membership in the online community Hepatitis Neighborhood ( www.hepatitisneighborhood.com) may well have saved his life.
"When I first found out I had the virus, I thought it was a death sentence," says Webb, who was referred to the online community by the pharmaceutical company that manufactured his medicine. "If I hadn't had access to Hepatitis Neighborhood, I would have been in the dark."
Even though the Web can't replace doctors, it can collect and disseminate medical information with unprecedented efficiency. Having access to online communities is a breakthrough for chronic-disease sufferers like Webb, who have flocked to the Internet for information not just from doctors but also from people who are similarly afflicted.
Hepatitis Neighborhood, which is a combination support group and medical-information warehouse, is a typical example of the new communities. The secure site provides personalized information to hepatitis sufferers, depending on the strain of the virus they have -- A, B, or the dreaded C -- and offers support and detailed data about treatment. It also monitors patients' drug therapy and tries to head off problems with medication noncompliance.
The Web site depicts a homey neighborhood consisting of a series of buildings that dispense different types of information. The Food Market gives dietary advice; the Clinic and the Library house volumes of data about the disease; the Town Hall offers forums; and the CafÉ hosts chat rooms.
"When you have one of these diseases, it dominates your life. You want to communicate with others in the same situation," says Steve Cosler, president and chief operating officer of Priority Healthcare, which owns the site. The company, based in Lake Mary, Fla., is a specialty pharmacy and distributor that dispenses primarily biotechnology drugs for chronic diseases. Not surprisingly, one of the buildings in the Hepatitis Neighborhood is the Pharmacy.
Patients who get a lot of medical support tend to be more compliant about taking their medication, says Cosler. As one indication of that trend, Priority Healthcare's call center receives slightly fewer phone calls from patients who are members of the Neighborhood, he says. Such encouraging indications have inspired many physicians (primarily gastroenterologists) to recommend that their patients enroll in Hepatitis Neighborhood, and some doctors even provide links to the site from their own Web pages.
Cosler estimates that Priority Healthcare entices two to three patients a week to sign up for its distribution services. Drug manufacturers pay about one-third of the cost of developing and maintaining the site, says Cosler, although he declines to disclose what the sum is. "As a stand-alone business, the Web site would be brutal," he says. "But we've got a real business behind the Web site."
Heartened by the success of Hepatitis Neighborhood, Priority Healthcare launched Pulmonary Hypertension Neighborhood in November 2000. And this year it plans to unveil Fertility Neighborhood, Hemophilia Neighborhood, and Anemia Neighborhood. Drug manufacturers will help Priority defray the costs of the new sites as well.
As technology allows for virtual visits to the doctor, it's also changing the dynamics of actual medical practices.
Dr. Lloyd A. Hey, an orthopedic surgeon and assistant professor at Duke University Medical Center, in Durham, N.C., wields a Palm handheld with a bar-code reader across the top. He uses the device, which was developed by a company called MDeverywhere, to scan patients' wristbands. That allows him to instantly confirm a patient's identity and also access the person's medical records. Hey carries note cards in his pocket that list common orthopedic diagnoses and procedures. Next to each diagnosis or procedure is another bar code. After Hey comes up with a diagnosis, he scans the bar code on the appropriate card, and the diagnostic information eventually becomes part of the patient's permanent record.
Hey isn't just a client of MDeverywhere, the company that developed the scanner. He's also its founder. Many years ago, Hey, who studied electrical engineering at MIT as an undergraduate, had ample opportunity to observe the inefficiencies in the health-care system thanks to a leg injury he suffered as a teenager. He landed in the hospital for three months and required subsequent doctors' visits over the next two years. Now he's using his experience to help streamline the system for other patients. "I'm trying to lead a compassionate process-control revolution," he says. That means he's developing a system that quickly records technical details and allows him -- and other doctors who use the scanner -- to spend more time focusing on patients.
Hey hopes the bar-coding system will eventually eliminate such hospital errors as prescribing the wrong medication or assigning the wrong procedure -- or, in extreme cases, operating on the wrong patient. For instance, if Hey enters information into his Palm handheld that says he's going to perform hip surgery on a patient who is scheduled for a knee arthroscopy, the device beeps and reminds him why the patient is there in the first place.
Of course, such warnings go off only if a physician is using the device. But the incentive to use it is built right in. Each time a doctor uses the Palm (or another compatible handheld device, such as the iPAQ Pocket PC), the computer records a "patient encounter" -- each of which constitutes billable time. By recording encounters as they happen, the software decreases the amount of time that it takes for a doctor to receive payment. For instance, Dr. David Diduch, an orthopedic surgeon at the University of Virginia, says that his billings have gone up since he started using the device, last September. It used to take two to three weeks from the time he saw a patient until a bill for the visit would leave his office. Diduch would dictate a note; a clerk would transcribe it; Diduch would sign the transcription; then a clerk would assign an "evaluation and management code" to the item and send it to a billing clerk. Now the information goes straight from the handheld to the billing clerk.
While Hey and Diduch are using their handhelds in the data-collection process, in Darien, Conn., family physician Stanley R. Skolnick is sending prescriptions through cyberspace. He's one of some 500 physicians who are using the wireless application PrescriptionCenter, which was developed by LogonHealth, a company based in Morris Plains, N.J. Instead of carrying around a prescription pad, Skolnick uses a tiny Palm keyboard to write up to 40 prescriptions a day.
"It saves me not only time but, more important, frustration," says the 63-year-old physician, who is living proof that the older generation of doctors can learn new high-tech tricks. Skolnick had long ago grown weary of calling in prescriptions to pharmacies, only to encounter busy signals and endless automated menus. It's no longer necessary for him to speak to pharmacists. After he enters a prescription into his handheld and sends it, the prescription is transmitted to LogonHealth, where computers download the prescription and fax it to whichever pharmacy the doctor has selected.
Skolnick has contact information for about two dozen pharmacies already loaded into his Palm. In addition, he has all his patients' names, dates of birth, and insurance providers recorded there as well. LogonHealth updates the computer system at Skolnick's two-doctor practice, Darien Medical Group, every week or two, entering or changing patient information, adding new pharmacies or drug choices, and updating information about insurance coverage. The latter feature has been one of the biggest time-savers for Skolnick. If he tries to send a prescription for a drug that a patient's insurance company doesn't cover, the Palm will alert him, and he can choose another medicine.
As the practice of scrawling prescriptions fades, so too will the horror stories about the illegibility of doctors' handwriting. But that problem may be coming to an end anyway. Several states are considering "legibility laws" mandating that doctors' handwriting must be readable. If passed, such legislation would certainly drive more doctors, with their notoriously poor penmanship, to technology for assistance.
Staking a Claim
If patients and doctors are two legs of the health-care stool, insurance vendors are the third -- and the one that often makes the whole operation wobble. Insurance companies and managed-care groups frustrate doctors and patients with rejected claims, denied coverage, and general micromanagement. But insurance vendors also have their beefs -- with patients and doctors.
Both doctors and patients have been known to submit inaccurate or even fraudulent insurance information, and insurers have been slow to develop systems that can efficiently recognize bad claims. But technology is beginning to catch up with the overwhelming number of medical procedures, laws, and regulations that affect how even the simplest claims are paid.
"You need a little army to run a claims department," says Grace Mary Trocchio, cost-containment manager of Vytra Health Plans, a managed-care organization in Melville, N.Y. The 200,000-member health plan receives an average of 9,000 claims each day. Trocchio's aim is to make sure that Vytra isn't paying any more than it must to satisfy those claims. Despite using software that's designed to catch such billing errors as duplicate claims, Vytra was still seeing money slip through the cracks from overpayments. "We were missing claims-savings opportunities," says Trocchio, resorting to industry jargon.
In October 1999, Vytra started sending its claims for review to a Norwalk, Conn., company called IntelliClaim. Although a redundant system hardly sounds like a model of efficiency, running claims through IntelliClaim's "extra loop" not only catches errors but also alerts insurance companies to entire categories of mistakes in their claims, according to Kevin F. Hickey, IntelliClaim's CEO. The company places an extra layer of protection over a system that may not have the personnel or the money to routinely update information from doctors, hospitals, and government regulators.
Each business day, Vytra sends its thousands of claims to IntelliClaim in encrypted files over the Internet. IntelliClaim's computers analyze all the data, matching standards that Vytra has set against the submitted claims. IntelliClaim continually updates its software with changes in regulatory information, such as revisions from the Health Care Financing Administration -- a task that would be prohibitively expensive for Vytra to handle. IntelliClaim returns the verified batch of claims over the Internet by the next day.
Vytra found it was overpaying doctors for such things as sending out duplicate bills or charging double for supplies -- for example, charging for sutures when the cost of the material had already been included in the surgical bill, says Trocchio. So far the extra effort is paying off big time, she says. In 2000 alone, the system saved Vytra more than $1 million.
While insurance-company and health- plan executives are working to avoid paying out too much, hospital officials are striving to prevent insurance companies from paying them too little. Reimbursement headaches used to be a chronic problem for the Cape Fear Valley Health System, a North Carolina network of four hospitals and about 500 physicians. The hospital group has now linked up with HDX, a subsidiary of Siemens Medical Solutions Health Services, based in Malvern, Pa., to ease its insurance-reimbursement problems.
The system that Cape Fear has adopted is familiar to anyone who has ever used a credit card in a department store, but it's unusual in many health-care settings. The system checks all patients' insurance information at the time they enter the hospital. Within two to three seconds, a Cape Fear admitting clerk can find out whether a patient has private insurance coverage, Medicare, or Medicaid; whether the insurer requires a copayment and, if so, how much; and whether the patient will have any out-of-pocket expenses. Once the HDX system verifies the information, the insurance company's data automatically appear in the hospital's computer, eliminating the need to rekey any information. "It even tells us if the name is incorrect," says Keith E. Hullender, director of system support and development for Cape Fear. Prior to implementing the system, Hullender says, "we were getting a lot of denials in cases where the name didn't match -- say, if someone checked in as William rather than Bill. And the insurance company wouldn't pay."
Before it started using the HDX system in 1996, Cape Fear verified insurance coverage only for certain patients: those who were being admitted to the hospital, having day surgery, or receiving expensive outpatient services, like chemotherapy. Admitting clerks had to contact insurance companies directly for those verifications, which totaled about 2,500 a month. Today Cape Fear verifies as many as 20,000 accounts a month, without having added any additional staff.
Hullender estimates that Cape Fear is saving more than $100,000 a year by exposing such simple data-entry mistakes as transposed numbers and misspelled names. The hospital has realized additional savings by identifying patients who were covered by Medicaid but didn't know -- or couldn't tell hospital staff -- they were. "In the past we might have never found out they had any coverage," says Hullender. And consequently, the hospital wouldn't have collected a dime.
Hullender says that the hospital is passing on its efficiencies from the verification system to both doctors and patients. The hospital gives the insurance information to independent physicians, such as radiologists and pathologists who work at the hospital, thereby serving to boost their collections as well. And patients are seeing fewer denied claims and exorbitant hospital bills that their insurance companies should have paid. That helps keep the three legs of Cape Fear's health-care stool on even ground.
Michelle Bates Deakin is a freelance writer based in Arlington, Mass.
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