By Thomas W. Reinke
The sizzle has gone out of the dotcom companies, at least temporarily. It is now apparent that Internet-based E-tailers will not replace retail storefronts. It is also apparent that E-health companies will not replace physicians practicing in hospitals and office settings.
It is important to understand that the demise of dotcoms is due to the lack of sustainable business models, not inherent faults in the Internet, on which they depend. In fact, Microsoft’s latest business strategy sends an important message to physicians about the future impact of communications, the Internet and computerization of medical practice activities. Microsoft’s view of its future is that computing and software are shifting from personal computers with installed software to constellations of computers, devices and services that work together through the Internet to deliver broader functionality. In essence, Microsoft believes that it will move from being a developer and retailer of software and operating systems to providing services over the next generation Internet. It is shifting its product development focus from Windows and Microsoft Office to (NET, an advanced new generation of software that melds computing and communications in a revolutionary new way.
The message for physicians that is embedded in Microsoft’s radical change is that they should have a clear understanding of the impact that computer technology, especially communications, will have on their practices. More importantly, this understanding should be coupled with a cautious plan to take advantage of the power, functionality and efficiency that computerization and communications technology can bring to the practice of medicine.
The need for caution is indicated by two recent surveys. In the first survey, the Voluntary Hospital Association (VHA), a large and reputable hospital alliance, reported that while only three percent of patients said they use e-mail to communicate with their physicians, 90 percent of those who do use it find it valuable and convenient. In an era where it is often extremely difficult for patients to reach their doctor by telephone, e-mail is becoming an important and efficient tool for patients to communicate with their doctor about routine aspects of their care. The tendency for e-mail users to constantly monitor their messages also means that patients are likely to get a rapid response to their questions and requests. The VHA survey also found that approximately 75 percent of patients do not know if their physicians offer e-mail communications. As the world goes online, the use of e-mail will grow rapidly.
The second study highlighting the need for caution was conducted by the First Consulting Group, a California-based health care consulting firm. This study shows that computer-based personal health records containing a summary of key medical information (such as active problems, prescriptions and recent treatments) are being adopted very slowly by the general population. Likewise, provider organizations have not aggressively promoted the use of personal health records. The study attributed the industry’s and patients’ hesitation to concerns about privacy and security. The study concluded that, for personal health records to be effective, they must be used and supported by a combination of patients, health plans, employers and health systems.
The risks in an overly aggressive computerization strategy include being a guinea pig for software applications that are not completely and fully developed. An important rule of thumb in all computer applications is never to buy the first generation or first release of software. First releases are usually characterized by the goal of delivering a product to the market. True functionality, innovative features and user friendliness usually occur in later versions. Another risk of aggressive computerization is that the software applications will not become widely used, and will eventually be abandoned. A low software adoption rate is a particular problem with Internet based applications. The public simply is not quick to accept many innovations offered through the Internet.
In spite of the risks, several important trends virtually ensure that automation of medical practice operations, including certain clinical activities, will grow significantly and rapidly. One of these trends is the tendency for more patients to assume greater control over their health care and their interaction with doctors, hospitals, health insurers, pharmacies and other elements of the health care system. Patients are demanding more information about all aspects of their interaction with health care providers and other segments of the industry. Furthermore, changes in health insurance benefits demand that patients take more responsibility and be more involved in their care.
These factors are self-reinforcing: the availability of medical information over the Internet plus forced involvement with the health care system drives patients’ increased demands for information and control. Technology adds additional reinforcements by making information readily available and by providing a powerful communication mechanism between patients and providers or payers.
While there may be concern that this demand for information can lead to misinformation and increased responsibility for physicians, there is a fundamental positive aspect as well. Patients who seek information and want to be involved in their care are driven by an objective to be and remain healthy. In the managed care environment that will be with us for the foreseeable future, that should pay off for providers and patients in the long run. Patients who want to be healthy will demand health care services. Politicians, health care regulators and health insurers ultimately must respond to the demand.
Automating Practice Management
The computerization of practice management functions will occur in many different ways and on many different levels. It is entirely possible that most rapid automation of practice activities will occur in the communications and telecommunications areas. Telephones, “Palm pilots” or PDAs, and other handheld computers are emerging as powerful communication tools that streamline operations.
An example of how telecommunications devices can streamline care is the automated prescription refill software used by pharmacy. You phone the pharmacy, type in your prescription number and specify when you want to pick up the refill. The software verifies the number of remaining refills and confirms certain personal information. Then you pick up the refill at the designated time. Efficient for the patient and the pharmacy.
There are parallels for daily practice management. I work with a large group practice that has programmed its voice mail system to accept requests for prescription renewals. The voice mail system prompts the caller for information about the patient and the prescription. This practice receives 75 requests a day and this enhancement has eliminated telephone backlogs and reduced interruptions for the nurses and office staff. The efficiency of the office has increased because the staff can pull all renewal requests at once, at a time that is convenient for them.
Another exciting aspect of communication technology involves PDAs. Several companies including one local company have developed products that use PDAs as data collection tools for billing information. Software is installed to collect required information and wireless communications allow the doctor to transmit visit and procedure information to the billing system in his or her practice. This application is great for physicians who see hospital inpatients or nursing home patients. The companies offering these applications are also developing software to download an inpatient census from hospital information systems and transmit it to the correct attending physician via a wireless PDA, allowing the physician to check his or her workload before leaving for the hospital.
Another driver of increased communications technology that will benefit physicians is the HIPAA standards, which are now being developed. HIPAA has received attention because of patient confidentiality issues, but the underlying thrust is to develop a uniform protocol for the communication of health insurance, health claim and similar information. The day of real time verification of insurance benefits and authorizations is here and will be expanding.
The underlying thread for all of these advances is that doctors and their practices will become increasingly connected to hospitals, pharmacies, payers, their patients and other providers, such as nursing homes. As the number of connections increases, all of the computers and technologies used by doctors will become more integrated. Billing systems will expand to become comprehensive practice management systems. Cell phones and PDAs will become the remote link between doctors and their practices and other segments of the health care system.
There is no need for these connections to stop at the borders of the health care industry. Doctors and their practices will also become connected to people and organizations outside the health care industry. They will be able to be connected to whomever and whatever they choose.
The rapid expansion in communication technology, plus other advances in hardware and software technology have a significant impact on the near term computerization plans of medical practices. Should practices add new in-house software applications such as computerized medical records? What hardware and type of network should practices choose for the long run? Will any major hardware and software purchase today become obsolete before it is paid for?
These questions are difficult to answer, but several principles can be applied to technology decisions that need to be made today. One of these principles is “return on investment.” Any technology decision should be able to demonstrate a positive return on investment within a reasonable time frame. In other words, the benefit of technology upgrades or expansions should outweigh the cost before the estimated maximum technological life is reached. The key phrase here is “estimated useful technological life.”
Technology is evolving rapidly and the pace of new developments may even increase. Postponing an upgrade decision “until the new generation is available” isn’t logical because the next generation product is always on the horizon. Medical practices cannot stand still forever. So, useful technological life is often determined by the practice’s decision about how long it intends to stay with the technology it has chosen. If that life expectancy is reached and the economic model is valid, the system will have paid for itself.
Other items that provide a decision framework are clear plans that delineate the technologies that are critical to the success of the practice and an understanding of the major technology trends in the health care industry.
Thomas W. Reinke is a senior manager in the healthcare consulting department of BDO Seidman, LLP, Philadelphia, Pennsylvania.