A physician has just weighed all of a patient's symptoms and tests, arrived at a diagnosis, concluded what drug to administer and determined the type of specialist to recommend.
Now comes the tricky part.
In this era of managed care, doctors are faced with divining not just what type of drug to prescribe but the particular brand covered by the formulary of each patient's health plan. Next they have to figure out what specialists are on the plan's provider panel and are eligible for referrals.
Lab and diagnostic tests are other concerns. Physicians have to be aware of limits on the choice of facilities to which they can refer patients, not to mention curbs on the number and types of tests the plan will cover.
Formularies and referral constraints may be cornerstones of cost management, but the information available to play by the rules is usually insufficient at the point of most decisionmaking-a cramped examining room.
But what if all that information were available on a computer pad as handy as a stethoscope? Some physicians say the device could become their practice companion.
The stakes are certainly high. A wrong guess or an outdated manual can cause delays in getting patients a needed drug or appointment. Worse, it can postpone or prevent patient treatment, said Glenn Parker, M.D., a Florida internist. "If you don't stay within the rules, people get sicker, not better," he said.
However, any attempt to infuse patient-specific information into the physician practice had better take into account how doctors work, Parker added. If the solution takes doctors out of a practice routine, it won't be a solution for long.
Problem-solvers. Concerned about the impact of prescription and referral foul-ups, Parker sought to create a computerized link with managed-care plans that would provide continuously updated ordering guidelines for physicians.
Two years ago he founded a company with partner Lewis Stone, a software systems architect and engineer, to develop an approach to feeding managed-care details to doctors on pocket-sized computers.
The Fort Lauderdale, Fla.-based company, ParkStone Medical Information Systems, has tested the system in Florida and is preparing to roll it out nationally. A key marketing tactic is free distribution to doctors, the cost sponsored by pharmaceutical companies and pharmacy benefit managers.
Parker isn't the first physician to recognize the prescription and referral headache and set out to find a cure. In early 1998, a gastroenterologist in the San Francisco area got the idea to start a company, ePhysician, to forge a two-way link to the Internet at the point of care through palmtop computers.
The founder of ePhysician, Stuart Weisman, M.D., said his system is in the test stage and should be ready for launch nationally by the beginning of 2000. As part of the launch, ePhysician will give away 10,000 palmtops to selected physicians. A monthly subscription fee will be determined once testing is completed.
With practicing physicians at the helm of both start-up companies, the initiatives capitalize on a practical sense of what will work and what will fail in a doctor's office.
"The success of a particular vendor will depend on how the functions that they offer fit into the workflow of the physician," said Peter Kilbridge, M.D., director of emerging practices with the Boston office of First Consulting Group, a healthcare information technology consulting firm.
That's the strategy behind serving up point-of-care information on palmtops. "We're trying to address the fact that physicians have not up to now been inclined to use desktop applications," Weisman said. "And we think that will be the inclination forever."
Prescription for frustration. Even if a product or service is free, physicians "are unwilling to invest any time in something you don't get an immediate payback for," said Emmet Kenny, M.D., an internist and associate director of the internal medicine program at Cleveland Clinic Florida in Fort Lauderdale. "The principal thing a physician doesn't have is time," he said.
A user of ParkStone's system since June, Kenny said it "attacks a problem that needs to be fixed, and it attacks the problem extremely well."
The Cleveland Clinic administration had given department directors an edict to prescribe less-expensive drugs when possible. But that was easier said than done.
With eight managed-care plans under contract, each with its own choice of drug in a given therapeutic class, physicians had to know not only market price but also the particulars of each plan's wheeling and dealing.
"The plans all cut their own deal with distributors," Kenny said. A doctor may know the cheapest ACE inhibitor for heart patients, for example, but it may not be the cheapest in a given plan-and it may not be included in the limited formulary.
Moreover, a new deal can change the choice at a moment's notice. A prime example occurred in July when a major health plan replaced its favored ACE inhibitor, Zeneca Pharmaceuticals' Zestril, with Merck & Co.'s Prinivil. "The phones in this place went crazy with people calling and saying, 'Please change my prescription to something they cover,' " Kenny said.
It's an all-too-common plaint. At 6 p.m., after a steady stream of calls from patients or pharmacists about prescriptions that could not be filled, a pile of change requests typically awaited action, he said.
Before prescriptions were written on the computerized system, "probably one in five had to be altered for formulary adherence" in a routine that included message-taking by a secretary, chart-pulling by a nurse and flipping through an insurance formulary book that was usually out of date, Kenny said.
With up-to-date information supplied when prescriptions are written, the callbacks have virtually ceased. "I saw the effect about three days after I started using it," he said. "It cuts down on one of the real anger-generating steps of the day."
For Sheldon Staller, M.D., an internist in Pembrook Pines, Fla., the ParkStone system has saved him about 45 minutes a day. "I used to have anywhere from 30 to 40 or 50 messages a week from pharmacies to change medication," he said. Now he gets one or two a week.
The computer link hones accuracy and saves physicians from rummaging through files, said Jerry Manoukian, a Mountain View, Calif.-based internist in practice with his wife Mariam, an endocrinologist.
Manoukian said he usually took the time to check formulary files himself but still got a call a day for formulary conflicts. Now he checks with an Internet database through the ePhysician handheld electronic pad.
"My overhead is $2 a minute," he said. "If it saves me time, it saves me money."
The benefit isn't just for doctors, Parker said. Say a patient needs an antibiotic to fight a respiratory infection. "If I give a prescription not on formulary and the patient doesn't get (the right drug) in time, now the patient has pneumonia," he said.
Referral roulette. The same danger of delays is present in a fractured referral process that can allow patients needing timely treatment to slip through the managed-care cracks.
Limited time and clunky reference options often force physicians to go from memory, leave the patient to look up a name or abdicate the choice of referral to someone else.
Staller said he used to rifle through books of approved physicians "if I wasn't too busy," but it could take 10 precious minutes and still didn't preclude the prospect that a physician left the panel after the directory was published. Staller's practice contracts with at least 15 plans.
A missed handoff to a specialist means a longer wait or even, unbeknown to the referring doctor, the patient's failure to reschedule with an approved alternative, Parker said.
As with formulary information, the ParkStone system posts additions and subtractions from managed-care provider panels each day and transfers the information to handheld devices for doctors to consult during their time with patients, Parker said.
The devices also allow doctors to concurrently add the referral to a "tickler file" that issues reminders at a future date to follow up on whether appointments were kept, he said.
The ePhysician system for now is concentrating on direct electronic referrals to laboratories along with electronic transmission of prescriptions to pharmacies and pharmacy benefit managers, Weisman said.
Through ePhysician, every lab and pharmacy in the country should be able to receive orders, Weisman said. The only requirement is a fax machine.
Inner workings. Because of the time-honored resistance of doctors to computerized intrusions into their practice flow, the ambitions of both companies are predicated on a big "if," said First Consulting's Kilbridge.
"The premise overall is that physicians are going to have lower resistance to using a handheld device," Kilbridge said. "I know of no formal evidence to support this."
The crucial objective is ensuring that doctors don't have to break stride, he said. Normally after finishing with one patient, physicians go to the next room, look at the chart, write in it while talking to the patient about his or her problems, put down the chart to do an exam and then go back to talking and writing.
"That's a lot of moving around, and there are usually a lot of things going on at the same time," Kilbridge said. If a doctor has to juggle the chart for documentation and a device for ordering, "they have to work well together."
Cleveland Clinic's Kenny said the handheld device is "not an interference in the workflow." Writing a prescription on the pad, for example, is similar to writing one on a paper pad. And with his admittedly horrible handwriting, there's the added benefit of having the prescription come out legibly after being sent by infrared communication to a printer.
Manoukian said he dashes off a request on his computer pad at least 10 times a day to an Internet-based computer server maintained by ePhysician. "It's very small and cute and fits right in my shirt pocket," he said.
ParkStone loads the day's updated managed-care information into a computer at a practice through the Internet or a telephone modem.
Typically once a day the palmtops used by each doctor are cradled into a computer connection to receive the latest formulary and referral changes, Stone said.
ParkStone doesn't yet offer electronic transmission of prescriptions to pharmacies or referrals directly to labs or specialists. It's still up to the patient to take the printed slip to the destination.
Both companies plan incremental expansion of their system features but are starting with a few functions to gain acceptance from physicians and avoid overwhelming them with a raft of options all at once.