Rufus, who lost a leg in an auto accident, works security and reception at DoctorQuality.com, a fledgling online venture outside Philadelphia.
A scrappy 2-year-old mutt, Rufus doubles as mascot for the ragtag band of healthcare executives who abandoned their high-powered hospital jobs last year for the uncharted wilds of the Internet.
Like Rufus, they have endured their share of hard knocks and long workhours for no pay while actually seeming to like it. For them, though, the stakes are much higher than their next bone.
Led by David Shulkin, M.D., former chief medical officer and chief quality officer at University of Pennsylvania Health System in Philadelphia, they traded their posts at the pinnacle of traditional healthcare for a risky dot-com start-up that aims to use the Internet to gauge, and ultimately improve, healthcare quality.
"We thought (quality improvement) would happen from within," Shulkin says. "We wanted to believe that in the most desperate way."
Looking back on his fast-track career in healthcare administration, he says, "I made a 10-year bet that it would be providers who made the difference. But I was wrong."
The efforts of Shulkin and his colleagues to increase quality of care from within the healthcare system were trumped by an intransigent bureaucracy and a fragmented payment system intent mainly on cutting costs.
Undeterred, Shulkin and his sidekicks have regrouped to prepare an all-out offensive on quality from outside hospital walls.
The key to change, they say, is to put the right tools in the right hands at the right time. And that, naturally enough, is where the Internet comes in. DoctorQuality.com plans to use the medium of the moment to offer quality-management tools for professionals, expert medical opinions, state-of-the-art clinical protocols for various diseases and credentialing services.
Armed with plenty of brains and world-renowned experience in quality management, Shulkin and his team are scrambling to find investors who will pump enough money into DoctorQuality.com to turn their ambitious vision into reality.
Their giddy enthusiasm for the wide-open spaces of the Internet is infectious. Yet their decisions to leave the administrative mainstream say as much about the diminishing appeal of a profession mired in cost cutting and layoffs as they do about the lure of the online world.
To get started, Shulkin and three other principals plowed enough of their own net worths into the venture that if it failed it would be "quite painful," according to Shulkin.
A private investor, whom Shulkin won't disclose, has already injected a seven-figure sum into the company. Soon Shulkin expects to raise another $1 million-plus through a private placement of company shares with wealthy individuals. And nearly every day, Shulkin and his team tango with venture capitalists, the next and most important cash source. They are seeking the "tens of millions" in funding that he says they will need to nourish the company until the happy day when they can blast off with an initial public offering.
Since last November, when the company was incorporated, Shulkin and his colleagues have been hard at work building a prototype of their service, rolling out some features last month at www.doctorquality.com.
And earlier this month, they landed their first big customer when a large insurer, which they declined to name, tapped their expert opinion service for help with more than 50 corporate liability reviews.
"Our belief is you create something and then you sell it," Shulkin says, emphasizing the difference between his firm and the legion of Internet concept companies.
Of course, plenty of other entrepreneurs, salivating over the marriage of healthcare and the Internet, have a head start. Though there may not be another firm exactly like DoctorQuality.com, several, including CareData.com, Healthgrades.com and AmericasDoctor.com, have a jump in the race to dominate similar slices of the healthcare market.
"There are a tremendous number of competitors going after the same space," says Claudine Singer, a health analyst at New York-based Jupiter Communications, an Internet market research firm. "Whoever gets there the fastest and the best is going to win."
Drawing maps. Shulkin and DoctorQuality.com's 11 other employees are pursuing a three-pronged approach with Internet tools and information for consumers, providers and payers.
David Bernard, M.D., the company's chief medical officer, and Maulik Joshi, senior vice president, both experts in disease management and both former University of Pennsylvania Health System officials, are developing a series of clinical protocols for chronic illnesses, such as asthma, that build on their accomplishments. Doctors could use these road maps, soon to be available online and in print, to keep patients on course. Motivated patients could purchase them to prompt their doctors for the best care. Insurers would be prime customers, Shulkin says, and employers looking to save on healthcare costs might also be interested.
In time, DoctorQuality.com plans to add personalized databases accessible over the Internet to store key patient information, such as the daily use of an asthma inhaler. Patients and their doctors could track clinical progress. Nurses could monitor the data as well, calling patients or physicians if they detect trouble.
In another service, DoctorQuality.com has already assembled a nationwide network of clinical professionals to provide a full range of expert opinions, from simple case reviews and second opinions to expert judgments in cases of care denied by HMOs. Doctors, patients, insurers and even lawyers can tap the confidential panel for opinions based on a sliding payment scale that starts at about $100 for simple second opinions for consumers.
Bernard has already lined up more than 80 qualified experts, with scores more to be added once they pass muster. Though touted on the World Wide Web site, the service won't be available online until DoctorQuality.com gets funding to develop a secure system for transmitting patient data over the Internet.
In a related initiative, Eric Silfen, an emergency physician who shuttles between Reston (Va.) Hospital Center and DoctorQuality.com, is creating an online credentialing service for physicians that would greatly exceed the nearly useless name, rank and serial number approach that prevails today.
"All we know now is that they have licenses and they weren't arrested," Silfen says of the current system.
DoctorQuality.com will also feature an electronic clearinghouse for healthcare quality information and services including quality ratings of individual hospitals and doctors. Hard to pull off? Sure. But Shulkin's confident there's an appetite for meaningful ratings. And DoctorQuality.com can succeed where others have failed, he says, by applying the team's know-how to data culled from public and private sources.
Also in the works are tools that purchasers of care-employers, insurers and perhaps someday individuals-could use to calculate payment to hospitals and doctors based on the quality of care they deliver. Better care would equal better pay, Shulkin explains, and that would be finding healthcare's Holy Grail.
"We will be controversial but with credibility," Shulkin promises. "We'll bring information about clinical quality that was secret and cloaked out into the open. The paternalism of healthcare is what we'll be fighting."
These may sound like bold plans for a bunch of refugees from the ivory tower. And they freely concede the challenges are many, but they won't brook even the possibility of failure.
"We're planning on this being successful, and we'll do what it takes," Shulkin says.
Time pressure. The unlikely setting for their bold assault is a barnlike two-story house on the edge of an industrial park in Lawnside, N.J.
DoctorQuality.com pays $1 per month for the first floor and dorm-chic basement of the dowdy house thanks to a kindly landlord, who is an old friend of company President Kevin Halpern.
But, of course, there's always a catch.
The building is scheduled for demolition June 1 to make way for a home improvement superstore, as if DoctorQuality.com needed more urgency.
"Standing still is not an option," Shulkin jokes.
On a recent Friday, Shulkin and his team settled into plastic lawn chairs in the basement for their customary weekly review meeting.
While Rufus hopped along under the table looking for a doughnut or a pat on the head, his master, Michael Usowski, DoctorQuality.com's Internet guru, projected the latest updates to the Web site on the unadorned basement wall.
The group critiqued the past week's modifications, suggested more changes to their Internet home page and discussed the potential of the international market.
A UPS deliveryman, obviously familiar with the basement routine, strolled in to get a signature. The group shifted gears and discussed a prototype of the disease-management handbook without missing a beat. Soon it was lunchtime, and the once pampered executives sifted through a grab bag of submarine sandwiches plopped in the middle of the white vinyl tablecloth.
Notes from the underground. The underground is a way of life for DoctorQuality.com.
Starting last summer, Shulkin sketched plans for the company in the basement office at his home in Gladwyne, Pa., when he concluded he would have to leave the Penn system.
At the time, Shulkin and Halpern put their heads together on the business concept. Halpern had been president and chief executive officer of Cooper Health System in nearby Camden, N.J., another system that had fallen on hard times.
Now Halpern handles many of the business details for DoctorQuality.com. He lines up insurance, executes contracts and landed the sweetheart deal on the temporary headquarters that replaced Shulkin's home office as incubator. A jack-of-all-trades, Halpern is also expert at changing the toner cartridge in the fax machine.
Last year, as the Penn system lost nearly $200 million on operations, slashed 2,800 jobs and pulled the plug on the nationally recognized quality initiatives that Shulkin had overseen, several of his trusted lieutenants pledged to follow him. Bernard joined in September 1999. And Joshi signed on in December, rounding out the firm's four principals and becoming the chief architect of the company's quality rating systems and payment tools.
Raising money. The four executives have agreed to work without drawing a salary until July.
But that distant payday depends on Shulkin and his team persuading venture capital investors to jump on board.
They've toured the circuit to meet with private investors and some of the biggest firms around, including Goldman Sachs & Co. and the venture arm of General Electric Co.
With healthcare quality problems making headlines, Shulkin found that it was easier getting access to potential backers than he expected. But for many, the mere description of the Byzantine U.S. healthcare system extinguished any spark of interest before it could be fanned into a funding flame.
Halpern, who has ridden shotgun on many of the pitches, knows the warning signs.
"When they start telling you anecdotes about their own doctors, you know you've lost them," he says.
Dreams for fees. While they press the flesh with potential investors, they've still got a business to run.
And Halpern has gone hat in hand, looking for special deals with accountants, lawyers and technical consultants.
Halpern has a blunt pitch: "We need your help, and we can't pay you."
The approach has worked, believe it or not, with several firms that got the DoctorQuality.com religion.
Pepper Hamilton, a Philadelphia law firm, and Deloitte & Touche, the accounting giant, have agreed to defer their fees until DoctorQuality.com is adequately funded.
A Philadelphia computer firm called Diginexus has started developing the software backbone for DoctorQuality.com and is being paid with a mix of cash and an equity stake.
Venture adventure. The big money is apparently just around the corner.
"We're sold on the CEO, the team and the idea," says Bill Ferretti, a general partner at Mid-Atlantic Venture Funds, Bethlehem, Pa. Ferretti, also chairman and CEO of Medstar Television, Allentown, Pa., serves as healthcare adviser to the investment group, which is a strong contender to back DoctorQuality.com from its latest venture fund, a pot holding nearly $160 million. Ferretti and his partners won't do a deal alone, however, and they've been searching for a technology-savvy co-investor.
In the meantime, Shulkin continues discussions with about a half-dozen other venture capitalists who have shown serious interest.
"They like to go in packs," spreading their investment risk, he says. Ultimately, he figures that several firms will agree to help.
He's confident he can make the right match with funds that have both deep pockets and the business acumen that DoctorQuality.com needs.
From there, Wall Street, if not the sky, is the limit.
"We're shooting for an IPO," Shulkin says. "Don't underestimate us."