American health care, Internet style.

Remember when nobody had a fax machine, then George had a fax machine on his desk, and suddenly everyone had fax machines? Remember when no one had an e-mail address? Then Mary had one on her business card? Then, suddenly everyone did? In a range of ways, health care is at the spot just before the "suddenly everyone" moment.

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Over the next 12 to 24 months, a number of things are going to shift rapidly, particularly in the ways new communications technologies change everyday health care.

The elements of this are widespread and show up in every corner of the health care world. Sift through the blizzard of statistics, studies, and surveys and the deep pattern begins to emerge.

Consumers, for instance, are looking for health information online more often with every passing month. According to the Pew Charitable Trust, 80 percent of U.S. adults who use the Internet look for health care information there--that's up from 62 percent just four years ago. A full 58 percent use it preferentially, before going to any other source, while only 35 percent would turn to a medical professional first.

And people are buying their drugs online. The online drug market is leaping by 50 percent a year. According to Forrester Research, in 2003 nearly half of all U.S. households that are online and need prescription drugs bought some of them on the Internet--and they expect that to jump to two thirds this year, led by Medicare members and diabetics.

If you're trying to influence people--and that's what marketing is--add those facts to this one: According to Saurage Research, "Influentials" (the 10 percent who have the strongest influence on the other 90 percent) are the heaviest users of the Internet. Eighty-two percent go online several times a day; only five percent go online less than once a day.

So the Internet is rapidly becoming the first line of medical information. Would people like to be able to get information from their own doctors online? Over 90 percent of U.S. Internet users said "Yes" in a Harris Interactive poll two years ago, asking a big "Why not?" about getting simple questions answered, prescriptions renewed, appointments made and test results reported via e-mail or a Web site.

Over a third (37 percent) even said they would pay for it--an average of $10 per month extra. A majority said such a resource would influence their choice of a doctor or a health plan. And this is two years ago; the numbers have most likely gotten even stronger since then.

Doctors on the 'Net

Are doctors online? According to a Boston Consulting Group/Harris Interactive survey, as of 2002, 96 percent of U.S. physicians were online, with over 60 percent going online daily.

And they are using it for all kinds of relevant tasks: The same survey, for instance, found that 58 percent of online docs had completed at least one online CME course. But we're in Kipling territory here, where a doc is a doc and patient's a patient, and "never the twain shall meet."

A Stanford Medical Center study published last year showed that only six percent of the U.S. public has ever exchanged e-mail with their doctors. That gap--between the huge numbers of doctors and patients online, and the relative lack of online communication between them--is one of a number of signs that the Internet continues to be a health care marketing opportunity.

Yet, as hesitant as doctors are to move their relation-ship with patients online, they seem quite eager to move their relationships with pharmaceutical companies into the world of bits and bytes. Pharmas have ramped up their marketing departments. According to the AMA, the United States counted some 15 percent more doctors between 1995 and 2002. Yet Verispan says that, in the same period, the pharmas minted 94 percent more marketing reps, for a total of 81,000 in the U.S. alone--despite the fact that 35 percent of all doctors refuse to see them at all, and 43 percent of all visits end at the receptionist's desk.

Tough market. But at the same time, says Jupiter Research, 58 percent of all doctors who go online participate in "e-detailing" programs, reporting their prescribing patterns to the drug companies for compensation. You can expect e-detailing to spread to nurse practitioners and physician assistants, says Forrester Research, led by e-detailing vendors like Physicians Interactive and Aptilon Health.

Doctors are also ordering samples online in increasing numbers, getting around many of the problems of the distribution of sample drugs that they have complained about for years.

EMR emerging

Digitization has spread, step-by-step, throughout health care, from the back office and the administrative suites, into clinical and practice management, through specialized clinical areas such as digitized images and physician order entry, and is rapidly approaching the hospital bedside and the physician's examination room--through the Holy Grail of digitized medicine, the electronic medical record (EMR).

The federal government, employers, the Leapfrog group and private payers are all leaning on providers for fewer errors, higher quality, better accountability and some handle on containing costs. And the EMR is the most efficient tool for those goals.

The U.K. National Health Service and Kaiser Permanente have both just penned huge EMR deals. Hospitals are moving rapidly in that direction, but "the next wave of adopters," says Forrester Research, consists of "the two-thirds of physicians that work in group practices of eight or fewer."

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But what's the form factor that will win that battle of the bedside? Making the doctor, nurse or physical therapist leave the patient to type things in on a desktop or at a kiosk doesn't work. It takes more time, not less, introduces errors and dropped details--and irritates the caregivers.

Wireless Palm-type PDAs are a lot better because you can use them at the bedside and you can write on them, but they are too small to write on in a normal way, as you would in filling out a form--and they are far too small for viewing even low-resolution images.

Various proprietary designs have their advantages, but they have one big disadvantage: they are proprietary, and so not flexible enough to carry out the full range of tasks that a physician or nurse needs--from viewing images and order entry to charting and answering e-mail.

The rise of "tablet PCs" some 18 months ago brings us closer to a universal solution--flexible, powerful, big enough to write on in a normal fashion, light enough to carry around all day, wireless and capable of mounting a wide variety of specialized software.

Once that becomes common-place--a handheld computer, connected wirelessly, right at the bedside or in the exam room--then you have the clinical moment connected directly, digitally, to the rest of the medical/health care world, and all kinds of interesting things start springing up.

For instance, real-time eligibility checks: All that HIPAA work has made the payers much more accessible. Providers will increasingly be able to find out the patients' eligibility and the extent of their coverage whenever they need to. "And," Forrester adds the punchline, "plans will begin to take advantage of this timely communication channel to insert a message of their own: 'Yes, the member is in the plan, and by the way, the patient is a diabetic, hasn't had an eye exam in two years, and should really get one." So a bit of disease management piggybacks on the eligibility.

Outsourced care?

The leg bone connected to the thigh bone, and pretty soon you can shoot that information anywhere you want, across the hall, downtown, to a lab two states over--or to a place half the world away where university-trained, English-speaking people stay up while North America and Europe sleep, doing work we need doing, for one quarter of the cost.

We have long thought of health care as something that you couldn't outsource to the next town, much less across the world. After all, it is all about a physical body, isn't it? That would be like outsourcing your plumbing. Doesn't work.

But suddenly it does. Suddenly it turns out that chunks of health care can be shipped anywhere you like, chunks like medical records processing, transcription, health plan claims operations and radiology readings.

You have a legal department? Indian lawyers are writing contracts for North American and European firms.

You have an IT department? Indian coders work for US$8 per hour, and make a good middle-class living by Indian standards. India has some 50 million broadband connections now, some 100 times the number it had only four years ago. The monthly cost of broadband in most Indian conurbations has dropped to the equivalent of $6.

Suddenly, the big cost-cutting question about any job in health care becomes: Is it transportable? Could it be managed in e-mail, through DHL and FedEx and fax? There will be bumps and starts and missteps. But in time, every health care job for which the answer to those questions is "Yes" will be vacuumed out of the West and into Asia.

I am reminded of something Jane Hirschfield said. She is a poet and a longtime, ordained Buddhist. A friend called up to tell her that he had a contract to write a 40,000 word book to cover all of Buddhism. She said, "That's either way too short or way too long."

"Too long?" he asked.

"You only need seven."

"Which are?"

"Everything changes.

Everything is connected. Pay attention."

Joe Flower is an internationally recognized health care futurist. You may contact the author by e-mail at [e-mail].