Health Systems International is launching a system in Philadelphia in May that could prove to be a giant leap for managed care.
HSI's new medical management system is based on providers having instant electronic access to information about the patient and about best treatments.
Although HSI declined to give the system's cost, a spokesman said the company expects that through increases in quality and cost reductions it will contribute to the bottom line within three years.
Providers would constantly update medical information, as the patient's electronic record travels with him or her through the delivery system and as doctors participate in refining best practices.
The system is unique because no other HMO has linked the entire delivery system electronically, using the information gathered to affect decisionmaking, said Peter Boland, a healthcare analyst in Berkeley, Calif.
Woodland Hills, Calif.-based HSI's "fourth-generation" medical management aims to improve quality and reduce costs. But even HSI admits the cultural obstacles the system faces-among doctors and patients-are daunting.
Critics have labeled less ambitious efforts "cookbook medicine" that robs physicians of their autonomy.
The system will radically change the way patients interact with physicians and other providers. Right from the start, HSI enrollees needing medical care will no longer call the doctor's office but a 24-hour call center staffed by registered nurses who are case managers.
Thus, the system relieves primary-care doctors of the much-maligned "gatekeeper" function, said Philip Katz, HSI vice president and chief information officer. The press has viewed that function as a conflict of interest for a capitated primary-care physician who is allegedly tempted to deny care to save money for himself, he said.
The nurses, backed by a medical management team that includes doctors, will have immediate computer access to every piece of information available on a patient, in the form of an electronic medical record. The record is kept at a regional data repository.
In questioning the patient, the nurses will use "triage algorithms"-an ordered set of decisions-to reach conclusions about possible care. The nurses might direct the patient in self-care or to a primary-care physician, specialist or emergency room.
The call centers also will be used to remind enrollees to come in for needed tests or to take medications. "Health Net (HSI's HMO) advertises itself as `The Wellness Company,' but we have lacked a mechanism for assisting our members in self-help protocols" until now, Katz said.
On their office computers, doctors will have access to patient medical records, best-practice protocols and tools to compare their performance with their peers'.
Doctors even will be able to schedule specialist visits, obtain treatment authorizations, order laboratory tests and perform individually tailored functions on their personal computers. Home-care professionals eventually will be on the system.
HSI's program uses San Bernardino, Calif.-based Health Data Sciences Corp.'s Ulticare Patient Care Information System.
Malik Hasan, M.D., HSI's president, chairman and chief executive officer, said he is counting on the system to differentiate HSI from its competitors in a marketplace where payers are increasingly demanding cost reductions and proof of quality.
But in the eyes of physicians such as Albert Barnett, M.D., HSI's system is just another sign that "health plans are searching for some method to establish their validity in the marketplace." Barnett is chairman and CEO of Friendly Hills HealthCare Network, an integrated system based in La Habra, Calif.
Analyst Boland agrees. Apart from the electronic wizardry, he said, HSI's system "is a common-sense approach to healthcare management that HMOs should have been doing all along. If you can't do it, what does an HMO do?"
HSI's system "is not a major differentiator until the data show that we're reducing the cost of care and getting results. At that point, there's no question it will be a major differentiator," he said.
If that happens, within a year it could become the benchmark that employers and patients use to gauge the effectiveness of managed-care plans, Boland concedes.
HSI's seamless system is unique. "Except for certain areas like chronic diseases, there is virtually no mechanism in place for insuring integrated case management for members across the continuum. That doesn't exist anywhere," Katz said.
HSI's system is different, Boland agrees, because it brings together all the electronic pieces that exist here and there in certain systems. The result is that "information technology is used to change medical delivery itself, to improve decisionmaking."
Although other HMOs have invested in information technology for recordkeeping and other purposes, no information system has been so patientfocused, Boland said.
If the system works, it will enable HSI-more than any other HMO-to satisfy payers' hunger for accurate information on cost, quality and access, Boland said.
The first physicians to begin using HSI's new system in May will be the 30 physicians of Philadelphia Health Associates, an IPA serving 35,000 enrollees of HSI's new subsidiary, Greater Atlantic Health Services, an HMO with 100,000 enrollees. The call center will be tested beginning in April and will be fully operational in July, Katz said.
In the fourth quarter of this year, HSI's system will be set up at Founders Healthcare, a group of 100 physicians in Philadelphia owned by Graduate Health System. The system will be rolled out to all Greater Atlantic's enrollees by the end of the year, Katz said.
When HSI acquired Greater Atlantic last year, part of the agreement was to manage the seven hospitals of its Graduate Health System. Five of those hospitals have been using Ulticare to link all hospital activities since 1987, and the other two will be added this month, Katz said.
HSI also plans to set up the system at an unspecified West Coast site in the fourth quarter of this year. But HSI already recognizes the giant hurdle of implementing the system outside its Philadelphia subsidiary, especially on HSI's home turf.
Doctors in California "will be furious with it. They'll see it as a total intrusion," Barnett said.
Many large physician groups such as Friendly Hills already integrate a patient's care and will one day use electronic medical records. But so far, the confidentiality problem associated with those records has not been solved. What happens when they are accessible to thousands of doctors and hundreds of hospitals? asked Barnett.
Katz countered, "Our experience with electronic systems is that they tend to be far more secure and confidential than manual systems," and that Ulticare is equipped with powerful security programs.
Barnett adds that HSI's system "may work in some areas of the country, where it may be better than what they've got." But the question is, "Will it remain better as physicians become more sophisticated?"
The bottom line, Barnett says, is "when a patient comes to the office, do they want the doctor searching a computer screen with their little arrow, or listening to them, making eye contact, all of those things" that patients are used to now? Won't patients see the system as impersonal?
But Katz says patients will come to appreciate the fact that providers have quick access to all the information they need to treat.
Still he concedes that, ironically, "because of the maturity of the California managed-care marketplace, we think the development and deployment of our system in California is much more sensitive culturally."
HSI is putting together an advisory committee of doctors in California "to discuss and design a deployment scenario with minimum fallout," he said.
Katz said he has received good feedback about the system from California physicians who see its advantages. HSI will assume the entire cost of developing the software and will provide electronic interfaces with systems doctors already may be using.
"We think the system will provide for our physician partners the ability to improve the quality of patient outcomes and simultaneously decrease overhead in their practices," Katz said.
Although the system will be voluntary, HSI network doctors who do not wish to use it still will have to demonstrate cost and quality, as they do now. Katz said he is convinced that the success of doctors using the HSI system will persuade others to participate.
The system provides "lots of economic advantages to our physician groups," he said.
"There's no question there will be a cultural reaction, defensive in nature, from our physicians," Katz said. "We need to work through the cultural issues with doctors" so they realize the system provides "the highest quality of care and convenience to their patients."
The stronger the partnership HSI can build with its doctors, the better the system will work to produce the best outcomes, he said.