As recently as mid-2000, the Web site for Danville, Pa.-based Geisinger Health System was simple and bare-bones, not much different from the rudimentary, no-frills portals offered by most other hospitals with Internet capability at the time. In fact, the site was little more than "brochureware," a simple posting of addresses, telephone numbers and some useful links to clinical information available in other areas of the vast World Wide Web.
Eager to explore the potential of this new marketing tool at a time when Internet use was exploding, administrators at Geisinger, like colleagues at many hospitals across the nation, decided that it was time to update and upgrade the site. In a little more than two years, Geisinger's Web team spent nearly a half-million dollars in development costs on a soup-to-nuts conversion that has been duplicated by scores of other hospitals and healthcare systems. The makeover transformed an inexpensive site that once seemed perfectly adequate into a state-of-the-art gateway to a virtual world, geisinger.org, featuring everything from appointment scheduling and disease management to physician recruitment and job placement.
"Web sites for hospitals started as something you created just because everyone else had one," says Kathy Dean, Geisinger's associate vice president of marketing, who helped oversee the changes in the system's Internet offerings. "You had a sense that people really didn't know what it was there for. You'd just take printed material and put it up on the Web. That's where we started. That's all changed. We've added interactivity and we're giving people lots of options they didn't have before."
At Geisinger, those added options include the ability to make appointments via e-mail, a broad range of health information, a list of clinical trials and a high-tech system called "MyChart," which allows thousands of patients to renew prescriptions, monitor lab results and view portions of their medical records in a secure, password-protected site. Not quite so technical but certainly as popular is the iNursery, which features digital photos of newborn babies--an essential part of even a mid-level hospital Web site these days.
"We want to make it easy for consumers to find us," Dean says. "We're adding more and more services. The one thing we learned is that the Web is a great place to do things incrementally."
A marketing battlefield
For many hospitals, what used to be viewed as an afterthought has become the next big battleground on the marketing front. Though most hospital Web sites remain relatively unsophisticated, almost every facility has recognized the apparent inevitability of this increasingly vital connection to consumers.
The 2002-2003 Hospital Internet Marketing Report indicates that about 82% of hospitals are using the Internet in their marketing efforts, a sharp increase from 59% in 2000. Of the 352 hospital marketing professionals surveyed, 99% have created a Web site and more than 40% of those individuals say they planned to spend more money on Internet marketing activities in 2003 than they did in 2002.
"Most hospitals have already built basic Web sites that address basic marketing needs," says Danny Fell, a principal with Daniel+Douglas+Norcross, a Chattanooga, Tenn.-based consulting firm that has conducted the national Internet survey since 1995. "Now they're stepping back and saying, 'Where do we want to go from here? How do we get more value out of this site?' They're beginning to take these sites to the next level."
Despite these aggressive steps, Web-site development by hospitals continues to face substantial hurdles. For one, a top-flight site can cost anywhere from $1 million to $2 million, and that doesn't include the hundreds of thousands of dollars spent each year on maintenance costs and salaries, says Michael Schneider, executive vice president of Greystone.Net, an Atlanta consulting firm that specializes in Web-site development for hospitals and the co-author of the national marketing report. At the same time, he says, it's sometimes difficult to accurately gauge the return on investment at a time when many hospitals are losing money or eking out meager profits. Even a relatively basic Web site can cost about $100,000 or so to develop.
"It's goes back to the whole argument of (return on investment)," Schneider says. "How much money, for instance, does a billboard make for your organization? It's hard to say precisely, but many would argue that you need this kind of marketing, even if you can't really determine how much that billboard makes for you."
Although studies such as the Internet Marketing Report suggest skyrocketing Internet use, other surveys are far more cautionary, indicating that many consumers do not trust the confusing array of healthcare information now available online.
Among them: A study in the May 14 issue of the Journal of the American Medical Association that discovered use of the Internet for healthcare information is far less widespread than once believed. Although previous estimates have found that about 80% of adults with Internet access use it for healthcare purposes, the JAMA study indicates that only about 20% of the adult population used the Internet for healthcare purposes in 2001. And only about one-third of those using the Internet say it affected a decision about their health or their healthcare.
In March, Philadelphia-based Cigna Corp. released a national survey showing that about 75% of Americans say they want to use the Internet to access health-related information, but that only 28% use the Web before a visit to the doctor. In fact, the survey of 1,000 adults--titled "The Net Effect: Online Health-Care Tools Still Missing the Mark for Consumers"--found that consumers are twice as likely to use the Web to research a new car purchase or to plan a vacation than to prepare for a visit to the doctor's office.
Just days before Cigna's report was released, the Washington-based Center for Studying Health System Change attracted attention with a survey showing that a sizable majority of American adults--about 62% in all--did not seek any information about healthcare on the Internet in 2001. The "National study disputes notion that most Americans rely on Internet for health information." What's more, the study, a nationally representative survey of about 60,000 adults, found that only about 20% of the 78 million adults who sought health information in the previous year bothered to mention it to their physicians.
Paul Ginsburg, president of the not-for-profit research organization, says the numbers will grow only when consumers develop more faith in the often-unreliable stream of information offered via the Web. As hospitals tap this burgeoning population, focusing marketing efforts on their Web sites, they also run the risk of driving up costs and increasing healthcare utilization, much like the highly controversial direct-to-consumer advertising by drug companies has heightened consumer demand for the most expensive drugs available, he says.
"The money that's put into (Web sites) has to be recovered through (higher) prices," Ginsburg says. "Another dimension of this is whether it could, in fact, have some effect in increasing hospital use. This is a signal of how much more active hospitals are getting in promoting themselves directly to consumers. Hospitals are no longer competing just by lining up doctors; they're going straight to the consumer."
A trustworthy source?
To some observers, the results of the Cigna and HSC surveys provide a compelling argument for investing in hospital Web sites because they appear to show a huge, untapped market of potential customers searching for information they can trust.
"Different surveys show different things about consumers' use of the Internet for medical information," says Bridget Meaney, editor of Medicine on the Net, a monthly newsletter and electronic journal that covers a broad range of Web-related topics. "But the crux of the matter is this: We're going to eventually see a time when health information is available only via computer. When that will come down the line--five years, 10 years, we don't know--but it's going to happen."
And that, Meaney says, is why hospitals across the country are positioning themselves for this new, all-digital era in healthcare, recognizing that the steep costs of Web-site development are just part of the price of doing business under the new rules of the Internet universe.
"Web sites," she says, "are becoming just one more extension of the hospital facility."
Like many other industries, healthcare began developing its first Web sites in the mid-1990s. The majority of hospital sites remain fairly basic, typically including lots of static information, simple interactive tools, a list of hospital services and a physician directory, Fell and other experts say. The next step for many of these hospitals is adding the capability to schedule appointments, track patient records and provide online medical education for clinicians.
One important evolution involves the development of a content-management system to provide easy access to a constantly changing database of information on everything from class schedules to patient-privacy issues. Another vital feature is a medical library--an online compendium of health conditions, technical terminology and fitness advice among other information. The more sophisticated Web sites, like those operated by large academic medical centers, have created easy access to a huge range of databases and clinical content.
One other big leap: The ability to e-mail physicians in private communications, a function still in its relative infancy for several reasons, including reimbursement concerns. Fell says only about 5% of hospital Web sites boast some version of a personal medical record for patients, and that perhaps only half of those provide patient-to-doctor e-mail communications. (Some hospitals, however, offer an "ask a doctor" feature, providing access to a panel of physicians for general health questions).
"There's a lot of reluctance from physicians," says John Estafanous, president of Estco Medical, a Bethesda, Md.-based consulting company that specializes in online marketing initiatives. "Mostly, it's tied to time and money issues. I think it's going to be quite a while before (provider e-mail) becomes accepted."
Despite this barrier to physician-patient communication, Web sites are becoming more consumer-oriented, providing a long list of interactive tools that draw patients to the site. The Web also is being used to integrate other marketing initiatives, often in connection with call centers.
"Hospitals are starting to realize they're not just in the business of providing information on the Web," Fell says. "They're in the business of acquiring patients on the Web."
Following the lead of many other hospitals scrambling to get into the game, Deaconess Health System, Evansville, Ind., decided in early 2000 that it needed "something bigger and better" than the electronic billboard it posted for a relative handful of users, says Ann Stegall, director of what the system calls its "Web center," deaconess.com. The two-hospital system, anchored by 339-bed Deaconess Hospital, spent about $500,000 for initial development--and plans to spend about the same each year in maintenance and upgrades--for a system that went live Feb. 1.
A "very basic" system that was updated about once every three or four months, Stegall says, was replaced by a marketing-driven site that features a wide range of linked, interactive medical information, a drug database, appointment scheduling and recruitment. Stegall says the system will begin actively promoting online scheduling for the first time next month. Online job applications have doubled, to about 400, since February, and total page views--a standard measure of Web activity--have increased from about 90,000 per month before the switch to almost 148,000 last month, she says. Total visits in the first three months are up by about 168% over last year's first quarter, she says.
"Web sites are extremely important for marketing and promotion," Stegall says. "But more than anything, they've come to be expected by the consumers. You've got to be able to provide this information."
Methodist Health Care System, a five-hospital Houston-based system anchored by 780-bed Methodist Hospital, recently spent about $1 million on a comprehensive content-management system that will allow patients to register as a "My Methodist" user, build their own Web page, bookmark their doctors and highlight their personal preferences. A soon-to-be-installed patient portal will allow users to retrieve laboratory results, schedule procedures and manage their bills, says Erin Skelley, Methodist's director of marketing/Web, who says the site, methodisthealth.com, has an annual budget of about $300,000.
Methodist, which Skelley says logged more than 444,000 visitors in March, charts how many patients request an appointment or referral online, matching that information with the database for patient billing. The Web site gets credit for any matches of Web-site activity and actual appointments or referrals, even though officials acknowledge that many of those users are likely to wind up at the hospital anyway.
In 2002, Skelley says, Methodist attributed $1.7 million in expected revenue from the Web, a figured based on "all patients who contacted our physician referral-appointment center through the Web," or who cited the Web as a source for contacting the hospital by telephone.
Although it's hard to show a clear financial return based on Methodist's formula, Skelley says, "I can prove that the Web is one of the cheapest ways to communicate, from a marketing standpoint. When you look at the number of visitors, and you look at how much money we're spending, it's peanuts."
The numbers, at least those that don't appear on a profit-loss statement, appear to support her case.
Manhattan Research, a New York-based healthcare marketing information firm, released a study late last year showing that consumers' use of Web sites has tripled in the past year. About 10.3 million people accessed a hospital Web site during the third quarter of 2002, a nearly 250% increase from the 3 million who did so during the same period in the previous year, according to the survey of about 3,000 consumers.
"This is becoming a key way for consumers to get health information," says Mark Bard, president of Manhattan Research. "Hospitals have come to the realization that they may be losing out (on new business) if they're not out there."
The Chicago-based Healthcare Information and Management Systems Society's annual survey of information technology trends conducted this year shows that about 98% of hospitals now use their Web sites for marketing and promotion, up slightly from 2002. About 91% used the sites for employee recruitment, and 79% posted a provider directory for consumers.
The numbers dropped precipitously, though, for other functions. Only about 27% provided patient health-assessment tools, 11% offered online scheduling and just 2% allowed patients to access medical records. But those functions, many experts believe, eventually will be available on a routine basis at the more sophisticated Web sites operated by larger hospitals and healthcare systems.
With its dramatic upgrade, Geisinger, a two-hospital system that provides care to about 2 million people in 38 counties in central Pennsylvania, is following the high-tech trend of major academic medical centers that already have invested heavily in Web development. And, like those big teaching facilities, Geisinger has had to pay the price.
It's difficult to break out total costs of Web development because the site often taps into portions of the existing IT infrastructure, says Dean, the hospital's spokeswoman.
But she estimates that Geisinger has invested at least $500,000 during the past three years for the software and servers that directly support its Internet and intranet sites, and spends approximately $500,000 a year in maintenance and support costs. In 2002, Geisinger logged about 1.8 million unique visits, a 50% jump over the previous year, Dean says.
James Walker, a physician who is the system's chief medical information officer, says about 4,400 people now use the MyChart feature, nearly double the number of last November. The e-mail system is linked to the patient's medical record, allowing physicians to immediately view the electronic medical record, complete with notes from the previous visit. Walker says these sophisticated functions are simply a precursor of what's to come--electronic medical records as standard operating procedure.
"Everybody's going to have to face the reality that they're going to have to have an (electronic medical record)," he says.
For most hospitals, the big question, now and well into the future, is whether Web sites can or will deliver an acceptable return on investment. Greystone.Net, the e-health consulting firm, now provides a benchmarking tool that helps hospitals judge how they fare against competitors in areas such as the frequency of visits to the Web site and the number of appointments confirmed online.
So far, about 100 hospital organizations are involved in the proprietary survey, says John Eudes, the firm's chairman. Based on data supplied by survey participants, Eudes says, hospitals average about 60,000 user sessions per month on Web sites. He says they are still trying to develop a more efficient way to quantify a return on investment.
"Administrators are asking, 'How do we evaluate the effective use of the money we're spending on the Web?' " Eudes says. "As long as the interest was strong and the Web sites were new and exciting, most people just accepted them as the cost of doing business. Now, with the problems involving Medicare (reimbursement), people are saying, 'Hey, you've got to justify these costs.' "
Fell says he believes that only about 2% of all the hospitals with Web sites make any money on their Internet investments. Most sites can track the number of visitors, but few have the wherewithal to precisely measure whether the information on those sites has led directly to increased revenue through new patients.
He says that may be why his survey, which shows such an overwhelming growth in Web-site development among hospitals, also indicates an increasing level of discontent among hospital administrators. Two years ago, the study showed that 31% of hospitals were "very satisfied" with their Internet marketing efforts; last year, that number dropped to 22%.
"When you're doing more things online, running a bigger budget," Fell says, "there's much more pressure to say, 'OK, what is the benefit of this? What are we getting out of it?' Lately, the more sophisticated organizations are drilling down and asking whether they're getting any return on this investment. And most of them aren't."
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