The Internet has revolutionized nearly every industry, and there's no reason to think healthcare will be exempt. In fact, it's my belief that the World Wide Web is our best hope for speeding up or eliminating the costly and time-consuming transactions that add layers of waste and inefficiency.
So why aren't we further along and enthusiastic about embracing the latest in information technology? Roadblocks include healthcare's complexity, its current financial straits, and the requirement to operate in a morass of government regulation.
But part of the problem stems from failed attempts at selling doctors on the intrinsic attraction of communicating with computers. Until physicians are persuaded, all the good intentions of healthcare leaders and software makers will get nowhere.
Most hospitals are still paying for the non-Web-enabled information systems they bought just a few years ago -- systems they had hoped would help improve efficiency greatly but didn't do enough. Not only that, but past investments in information systems to improve efficiency have had limited success or outright failure.
Consider this bit of personal experience. Several years ago, when computer systems to track patient information were in their infancy, I tried to convert an eminent Baylor internist into a computer user. I watched him struggle with the light pen, screening page after page of admitting and billing information that were largely irrelevant to him. He gave up in disgust, forgoing computers for good and telling me, "Dysert! I only want the (expletive deleted) computer to show me what I want to see!"
Though I didn't know it at the time, this doctor had precisely described the ideal patient information system for physicians: It would show the doctor only what he or she wanted to see.
That's not the philosophy behind the electronic health record, the traditional focus of information system initiatives. Most have failed to deliver because they were merely the electronic form of a paper-based record, developed with inadequate technology and planning and without physician participation.
The typical EHR has too many fields to maintain and, with its strictly hospital focus, is incomplete for a physician to use for after-hospitalization care. Plus, it requires a lot of typing by physicians, who resist because they view this as akin to being made into a clerk.
Of course, the EHR isn't the only venture into Internet technology that physicians, hospitals and entrepreneurs are making. Some healthcare organizations do successfully use the Internet to achieve savings in supply costs, for claims transmission or other business-to-business purposes.
These are good places to make a case for computers. Healthcare generally remains paper-based and dependent on inefficient means of technology. Analysts peg the cost of waste and inefficiency in our industry at $250 billion to $400 billion per year. According to one investment banking firm, "the arrival of the Internet in healthcare is long overdue and perhaps just what the doctor ordered."
High levels of regulation, managed care, and convoluted billing and payment systems add to the waste. It typically takes 12 transactions, for example, to complete a physician office visit:
1) Scheduling an appointment.
2) Registering a patient and obtaining payer-specific information.
3) Verifying insurance coverage and eligibility for benefits.
4) Ordering treatment or diagnostic testing.
5) Requesting follow-up care, such as return visits or referrals.
6) Requesting authorization from a payer for treatments or referrals.
7) Filling a prescription.
8) Reviewing formulary limits of a payer or pharmacy benefits manager.
9) Receiving test results and conveying them to patients.
10) Submitting clinical documentation.
11) Generating bills for patients and/or payers.
12) Submitting claims to third-party payers.
It gets a lot more complex with a hospital admission.
Today we routinely conduct such business via mail, telephone or fax -- yesterday's technology. We know the frustrations associated with this: Telephone lines get busy; faxes jam; our office staffs wait interminably on hold trying to ascertain eligibility information from the 1-800-4DENIAL nurse.
A recent study by the American Medical Association estimates that one physician could save $10,560 worth of office overhead annually if we could convert the current manual system of determining eligibility (just one type of routine transaction for the average practice) to an electronic data interchange. The Web can be the catalyst for change.
First, it can provide a nearly instantaneous pathway for transactions.
Second, it can manage healthcare's typically fragmented and dispersed sources of healthcare information -- stored in multiple locations, in multiple computer languages, on multiple computer platforms with different operating systems.
Third, and most important, consumers love the Internet. Their demonstrated power to bring about change will ultimately be the cause of dramatic transformation in healthcare.
Some healthcare organizations have placed their dollars in business-to-consumer ventures, such as paying for medical content to enhance their Web sites. But more is possible, and I predict sweeping changes that will truly reveal how the Internet can overcome fragmentation of information and improve the ability to communicate and enhance efficiency.
I am particularly excited by the application of XML, or extensible markup language, to healthcare. This could be the way to integrate the many information systems now in place, create a patient record that physicians will use, and improve the quality of care.
What's so different about XML?
Most Internet users are familiar with HTML, or hypertext markup language, which is what most Web-based search engines use. HTML is unidirectional. It can instruct a program to find a specific piece of data, and most times the computer will "fetch" it -- from every conceivable Web place, usually without much regard for healthcare-specific context.
Now imagine a computer application that shows a healthcare worker or physician only what he or she needs to see. XML is bidirectional. Data elements can be "tagged" with extra clues about the nature of the information contained within, and similarly tagged data can be aggregated within physician-designated parameters to yield information.
Take for example a test for prostate-specific antigen, or PSA. The program might "interpret" that a certain PSA value indicates a positive finding of prostate cancer. This lab value, plus the analysis, is sent to the physician's office, the medical record, and even one day to the patient with instructions on what to do next.
XML also has the ability to be a universal translator of the various and incompatible information systems we have today, for accounting, administration, admissions, scheduling and patient information. It can search and bring back relevant information about a patient and present it in one place, allowing the physician to quickly access exactly the type of information needed.
In other words, the patient record becomes a Web page, a portal through which reports from various systems are organized as an assemblage of accessible information. Couple this with voice-activated technology, already on the market, which removes the need for any typing whatsoever, and you have a lot more potential to get physicians interested in using computers.
This development work is already under way, but to a great extent it's happening without the participation of physicians and hospitals. Some doctors are caught up in longing for the good old days; some healthcare executives are understandably so focused on today's problems that they lack the time and energy to look ahead.
The key challenge for healthcare executives and physicians is not to fight the future but to embrace it, to see the potential for good in what's coming and want to play a part in it.
The potential begins to be tapped in basic areas such as administration, but the groundwork laid for solutions to those problems can be used again and again. Ultimately the means for using Internet technology will expand into a new infrastructure upon which all of our other dreams for information will be built.
But unlike previous information systems that had to be constructed expensively, compatibly and in advance of any payback, this new infrastructure embraces diversity yet is integrated visually. It can support incremental improvement instead of forcing big changes all at once. And it can be the launching point for new approaches to enhancement of care.
We in healthcare have the right to influence this work for the good of the patient. But first we must seek a seat at the table.
Peter Dysert, M.D., is chief medical information officer of Dallas-based Baylor Health Care System, which includes about 5,000 physicians on staff at seven hospitals.