In the daily battle against managed-care red tape, things are really beginning to click for doctors and staff at Spokane (Wash.) Internal Medicine.
A few clicks of an icon on a computer screen determines a patient's insurance eligibility and coverage. That information automatically loads into a referral form, which goes simultaneously to the specialist and to the health plan for authorization.
Minutes later, the approval is done and arrangements are made. No one hovers over a fax machine or picks up a phone and endures Muzak while waiting for a real voice.
The average cost saving per referral, according to one study, is $60. The average time saved: two hours.
Two years ago that tidy little process would have been impossible-or at the least, costly and cumbersome.
But a potent combination of Internet technology and entrepreneurship is collapsing the expense and time required to get essential data to and from providers for quick, easy reaction.
"The Internet can provide an effective channel for healthcare organizations and physicians to meet their needs for clinical performance data and the demands of managed care," says Rick Ratliff, who heads the sales and marketing operations of Healthvision, a new joint venture between two healthcare technology organizations. Healthvision is jousting with a batch of start-up for-profit companies for a share of the emerging Internet market.
The joint venture includes the Internet-based products and services of VHA, an Irving, Texas-based healthcare alliance, and Eclipsys Corp., a Delray Beach, Fla.-based healthcare information systems vendor.
Advocates for physicians say the mounting costs of managed-care bureaucracy are making doctors willing partners in Internet services that hit close to home-like the one that neutralizes Spokane Internal Medicine's clock-eating insurance chores.
Nearly everything the practice seeks to accomplish outside the office requires a referral, from ultrasound and X-rays to hospital admissions and various therapies, says Tom Carli, the practice's administrator. "A referral used to be calling the specialist's office and saying, 'We're sending someone over.' Our tasks increased dramatically as we got deeper into managed care."
Automated eligibility verification and referral authorizations have piqued more interest than other electronic services such as claims processing, says Scott Decker, acting chief executive officer of Healthvision. Doctors "want to get their staff off the phone," he says.
Those complaints have paid off for Internet companies like Bellevue, Wash.-based Pointshare Online Healthcare Solutions, organizer of an Internet-based transaction network in Washington state that was first tested at Spokane Internal Medicine.
The network has signed up 10% of the state's physicians in just the past year by, among other things, delivering insurance information on 80% of the state's population. Pointshare recently began engineering a similar network in Oregon.
At Dallas-based Baylor Health Care System, a poll of physicians revealed that the No. 1 problem they wanted relief from was the increasing managed-care overhead in their practices, says Peter Dysert, M.D., chief medical information officer. Internal research at Baylor pegged that overhead at $30,000 to $40,000 annually per practicing physician, he says.
Consequently, physicians "wanted administrative aspects of managed care automated and on line" before anything else as Baylor sought to create a systemwide communications network, Dysert says.
The top priority. By helping to buffer physicians from the economic highs and lows in the industry, Baylor aims to build a strategic market advantage based on cooperation with physicians in containing costs and improving performance, Dysert says. The system identified relationships with physicians as its No. 1 strategic priority more than three years ago.
As healthcare organizations diversified in the 1990s and started to organize for the care of health plan enrollees, outpatient and physician sites began to figure more prominently in plans to treat patients more cost-effectively and with prevention in mind.
But executives soon realized their hospital-centered information technology efforts were not reaching those outposts.
A survey of 300 senior healthcare executives conducted by VHA in 1996 discovered so much demand for links between physicians and data sources that the alliance refocused its efforts away from the hospital and toward technology to connect doctors to clinical and administration information.
But the inclusion of physicians in the information loop continued to be more talk than action. For example, respondents to MODERN HEALTHCARE's 1999 survey of information systems trends identified information networks with links to physicians as their top priority for developing an integrated delivery network. However, only 38% said they had an operational connection with physicians.
Until the recent maturation of Internet technology Baylor couldn't find an economically viable way of connecting with 5,000 doctors across the Dallas-Fort Worth area, Dysert says.
Though Baylor saw potential in the Internet, healthcare industry vendors weren't interested, says Robert Pickton, senior vice president and chief information officer. "Their view was to own the desktop," he says, referring to the conventional approach of piling software into brawny computers for each physician and connecting them by phone lines to bigger computers in an electronic network.
"The Internet model of business scares them to death," Dysert says. "They see it as a threat."
The same problem plagued Memorial Hermann Healthcare System when it planned a physician network, says Hugh Gilmore, M.D., vice president for clinical affairs.
Houston-based Memorial Hermann investigated computer networking possibilities more than two years ago with no delusions about the probable cost and complexity. Still the options were "much less practical and much more costly than we even imagined," Gilmore says.
For one thing, Memorial Hermann couldn't afford to supply powerful personal computers to 5,000 physicians in private practice, he says. In addition, connections through local phone lines had to be established one by one. "It would have taken years to hard-wire doctors' offices."
What's more, the expense of supplying hardware and telecommunications to a predominantly independent practitioner network could well have raised the question of inurement, the use of charitable funds for personal profit. "That's an insurmountable hurdle," Gilmore says.
The missing link? Both healthcare systems picked new entrants in the Internet networking business instead.
Baylor last year entered an agreement with Healtheon Corp., a Santa Clara, Calif.-based company developing secure Internet technology in healthcare. A handful of physicians are testing electronic sharing in a pilot project that began in April.
Memorial Hermann signed with VHA to develop a customized "portal" for clinical and administrative information on the healthcare alliance's Internet network, called PhysicianLink Online. About 20 physicians are piloting that project, Gilmore says.
Anyone with a personal computer and World Wide Web browser can be contacted on the Internet. That's conquering the problem of how hospitals, ancillary facilities and health plans can plausibly exchange data with thousands of independent and far-flung physicians.
"The (Internet) network model is so compelling, once you really understand what the issues are, you realize you've got no choice (but to use it)," Dysert says.
Baylor's goal is to have most of its doctors using an Internet-based network as a day-to-day tool within two years, Pickton says.
The construction, configuration and capital involved in extending a conventional computer network to that many outlying physicians would have been daunting if not prohibitive. But once Baylor's Internet pilot takes off, the rollout will be no big deal. "With one flip of a switch, we can deploy this across our network all at once," Dysert says.
And once deployed, the network can add new features "weekly, daily, hourly if you need to," Pickton says.
Memorial Hermann is making a top priority out of timely access to clinical results, which can make a difference for patients by enabling physicians to reach appropriate decisions more quickly and get to the next step in a treatment plan faster, Gilmore says.
One project involves using Internet technology to selectively extract data from a nursing order entry and documentation data system installed in eight community hospitals, says David Bradshaw, Memorial Hermann's CIO.
The complicated application is oriented around the information and functions nurses need to take care of patients on an eight-hour shift. A new Web application called Physician Fast Path eliminates all the routine notes and data pegged to the nursing operation and aligns information according to the way a physician practices medicine, Bradshaw says.
"We can make a big difference without multimillion-dollar investments in technology," Gilmore says.
Crashing data barriers. Internet solutions like Memorial Hermann's Physician Fast Path help reap information from fragmented and inaccessible sources of key data scattered throughout a healthcare organization.
Internal data access isn't the only barrier, however. For many providers, equally big problems are the cost and frustration of getting insurance or clinical data from outside "trading partners" in the larger healthcare industry.
The slickest Web application for displaying insurance eligibility or brokering referrals is hollow unless it's connected to the latest data and used by enough local insurers and providers to make participation worthwhile.
With that in mind, Pointshare Online conceived a strategy to overcome the tendency of healthcare players to wait until others commit to a collaborative arrangement before committing to it themselves, says Timothy Kilgallon, president and CEO.
Starting in early 1998, company representatives blitzed the state of Washington with their medical data management products, promising to automate transactions that were phone-based and paper-intensive. But the initial effort was not so much to wow people with technology as to broker the simultaneous commitment of payers and providers.
"Critical mass is where it's at," Kilgallon says. "Eligibility (information) is a key draw to bring physicians into the network. You have to be able to look up the eligibility of just about every person in the state to make it work."
The company says it now has contracts with insurers representing 80% of the insured population in Washington, excluding fee-for-service Medicare. That in turn has attracted 21 of the state's 93 hospitals, 10% of its doctors, the two largest reference labs in the Northwest and two large diagnostic centers.
The trick was to find a few key players that are so important to the local market that others have to join, Kilgallon says. The company has a foothold in 15 of 20 identified communities in the state. Four communities are at the "critical mass" stage of participation by healthcare players, he says.
Sometimes the participation breakthrough resulted from getting everyone in the same room. In rural Yakima, Pointshare found an influential computer reseller who got the local physicians to come together for the sales pitch. Afterward "people looked at each other and said, 'I'll sign up if you sign up,' " Kilgallon says. About 50% of doctors joined within four months, and 80% of physicians, both hospitals and a major imaging center have since joined the Pointshare data network.
It helped that Pointshare is politically neutral-not affiliated with participants or their customers, including healthcare software vendors or pharmaceutical companies.
Pointshare wasn't sponsored by a local big gun that tried to force its will on others, Kilgallon says. And the Web services don't replace or attempt to supersede the information systems of vendors.
"It fits in quite nicely and complements the things we are doing," says Spokane Internal Medicine's Carli. The practice has been progressively automating its medical and business records on desktop computers since 1991.
Think like a physician. The ability of Web technology to fit in and be customized could finally make information systems adaptable enough for physicians to embrace in their daily routine, says Memorial Hermann's Gilmore.
Previous attempts have centered on building software and getting physicians to change their ways, he says. But that ignores the behavior patterns that have worked for them in a fast-paced and demanding career, whether it's talking on the phone or refilling a prescription. "We do become creatures of habit," which is why change is difficult "even with the allure of doing things better," he says.
Gilmore says any information technology has to address two main issues for doctors:
* Improvement in the work process, whether it means accomplishing something more efficiently, making a physician's life easier, reducing practice cost or enhancing revenues.
* Improvement of the patient's experience and outcome, including making an encounter more palatable and potentially improving a patient's condition.
That's why eligibility, referral and diagnostic data are rising to the top as the hooks that snare physicians' interest, Gilmore says.
But they're only interested if the demands to change are light, says Baylor's Dysert. "The design needs to be (role-centered) and personalized." For example, two physicians practicing in different specialties should be able to see different sets of data pertinent to their disciplines, and each doctor should be able to progressively narrow and tailor a set of information to suit individual preferences.
That's something Web technology can do with ease in healthcare the same way it personalizes information for subscribers to Internet portal services such as Yahoo, Dysert says.
In fact, role-centered computer screens can be personalized to the point that a lab result or discharge posting will trigger another activity, says Baylor's Pickton. For example, the computer can be programmed to fax the information to an office, send a message to a pager, put the information in a secured electronic mailbox or send copies to a nurse and to the front desk, he says.
Economic payoff. At Spokane Internal Medicine, X-rays of patients come in through Pointshare every 30 minutes, attached as a file to an e-mail. An employee who monitors the electronic traffic forwards the files to the appropriate doctor and loads them into the practice's electronic medical record, Carli says.
In addition, batches of lab results come in four times a day, affecting the management of about 150 patients on a given day with conditions that often need close supervision, such as diabetes or blood-thinning medication therapy.
The employee in charge of routing the results was hired more than two years ago just to facilitate referrals by phone and fax, Carli says. Since those referrals were automated, her workload has been reduced to just half a day, allowing her the time to take on all the routing duties even though a doctor and a nurse practitioner have been added to the medical practice. The office now has six physicians and two nurse practitioners. "We've been able to grow the practice without adding new (support) staff," Carli says.
A study published in the April issue of Advance for Health Information Executives chronicled the cost of a manual referral at about $70, including the expense of sending the request, routing it through a payer, dealing with denials and receiving the final approval.
By automating the process, systems can reduce the referral cost to about $10. And the time from start to finish drops to 10 minutes instead of 21/2 hours.
That's the type of efficiency that has sent Internet companies rushing into healthcare. According to a research report by Nashville-based SunTrust Equitable Securities Corp., it's "the single most attractive growth opportunity on the Internet today, with over $250 billion in administrative and redundant costs waiting to be streamlined."
But winning over skeptical providers could be a much bigger challenge than enticing information-hungry consumers, Dysert says.
During the past decade or so, providers have watched information technology purveyors enhance their market value "based on investments we as providers make" but with no real payoff yet in strategic market advantage for the millions spent on information systems, he says.
"Doctors and others are tired of doing the heavy lifting, making the investment and having everyone else capture the value." This time around, Dysert says, providers are determined to get their due. "What's on the table in most organizations is the strategic value of the investment in information technology."