Beam Me Up, Scotty.

Managed healthcare isn't rocket science. It's just not connected yet.

Do you remember the Jetson's? George Jetson zooming to work in his one person flying car, Jane Jetson getting her house cleaned by the family Robo-maid? Meals prepared by pushing a button, and mass transit via automated walkways? And remember Elroy playing virtual reality games on portable electronic devices, while Judy selects her evening datewear via electronic catalogues?

It's interesting to make comparisons of what was envisioned for George and his family and what has actually happened through our technology improvements in the last two decades. How far in the future can flying cars be when the space shuttle is routinely traveling to the stars? Robots now build our cars and create microelectronics in factories around the world. How long will it be before they mow our lawns and vacuum our homes? The microwave has made meal preparation as easy as pushing a button, and getting through some airports on automated walkways has almost become a requirement (think Dallas-Fort Worth and O'Hare). And we only need to say the words Sony, Nintendo and Gameboy, and we all know how technology has improved (?!) the lives of our children.

The question often comes up about how technology may improve the way healthcare is delivered and administered. Everyday, we read about breakthroughs in medicine and surgery techniques that help to improve our quality (and quantity) of life. But today, physicians still see patients in an office, make a copy of the patient's ID card for billing purposes, write up a paper chart, send a piece of paper to the insurance company, and await payment by check through the U.S. Postal Service. Oftentimes, a physician may never know whether the therapy, prescription, treatment or surgery he or she prescribed was the correct course of action for that patient. There must be a better way.

Picture a different scene. My son Keegan, a future standup comedian and otherwise (somewhat) normal six year old, wakes up with a bad cough before school one morning. Mom and I escort him to the computer where we hit the Internet. We hook him up to a home monitoring system that measures pulse, temperature and blood pressure and then send this information through the Net to the electronic medical record system where a real time severity of illness algorithm determines whether Keegan should be seen by a physician. In this case he does require a personal visit, so we hit the "appointment" button to check the schedule at his Primary Care Physician's office. We select a convenient time and log off, knowing that we have already cur me first half-hour off of the office visit.

The time comes for our visit. We all hop in the family teleporter (I know, I'm getting carried away), and arrive at the physician's office. A nurse has already received the information from tthis morning's Interne transaction, and built a virtual patient record for Keegan by accessing real time information through the Internet from the Pharmacy Benefit Manager, the lab for any test results, the social service agencies (for Medicaid and Medicare recipients) and any number of other entities and systems. This data will provide the physician, prior to his or her actual meeting with Keegan, useful information about what other treatments, medications or therapies other physicians may have prescribed for him as early as this morning.

Real Time Records

In the examining room we meet with the physician, where he or she discusses Keegan's symptoms, his current vital statistics, and his preliminary diagnosis. A microphone in the room picks up key words and phrases and, using voice recognition software, builds a complete electronic patient record from this visit incorporating SNOMed (standard nomenclature of medicine), ICD-9 and CPT-4 codes. The physician makes recommendations for treatment, including any prescription drugs, labs or x-rays necessary, and completes the visit. All the information from this encounter is relayed real time to the local server via radio or microwaves, where it is compiled into an e-mail message sent to the patient's home. Part of this message may include websites where additional patient education can take place from home.

The rest of the information gleaned from the visit is sent through the Internet to other service providers, such as the patient's drugstore for prescriptions. Lab tests are ordered from a lab associated with the patient's network, and x-rays are scheduled with an appropriate facility through Web based enterprise wide scheduling systems. If a referral is necessary to a pediatric pulmonologist, a screen launched through a Web browser opens access to a referral entry system, which gets completed by a nurse or physician. The referral is then transmitted either directly to the specialist using the same technology tools, or deposited via e-mail into his or her in-box for daily processing. A copy of the referral data is also e-mailed to the patient at home, including appointment time and instructions for procedure prior to the visit.

Everything that has occurred so far has been, in effect, copied to a virtual data repository. In fact, the software driving this communication link is regularly querying those systems to which it has been interfaced, like lab, pharmacy and hospital, so that at any given time a physician has the most current, complete information about a particular patient. Because this data has been stored in a "data warehouse," it can be accessed later for more sophisticated reporting.

Before Keegan leaves the PCP's office, the office manager accesses another Web address that hosts the practice management and billing system. An interface with the electronic medical record extracts the information from the visit, as well as the total time expended, and codes the patient bill. For instance, during the visit the PCP discussed Keegan's diagnosis and treatments, so that information is translated into coding that the insurance company's managed healthcare information system (MHIS) can understand.

Preloaded Profiles Save Time

The MHIS has been programmed to accept EDI transactions through the Internet or various other direct connections, like clearing-houses. Keegan's benefits nave been preloaded, as have the contracted fee schedules, withholds, and risk sharing codes for the providers in the network. Approximately 80% of all claims received Dy this system are paid or denied in a real-time fashion, and the resulting fee for service reimbursements are deposited through electronic funds transfer to the provider bank accounts. Since the transaction occurs real-time, while the patient is there, any cost shares are communicated and collected at that time, eliminating the need for balance billing.

The information from the EOP (explanation of payment) for patient account posting is transmitted daily through the Internet via an e-mail attachment file, which opens upon receipt and posts the billing system with the appropriate payment data. For the 20% of claims that have been pended for whatever reason, a sophisticated artificial intelligence algorithm uses predictive logic to prepay the provider. When the claim is finally resolved, an adjustment is transmitted. If a balance bill to the patient is necessary, this is automatically done through the MHIS/billing system interface.

Well, that takes care of the visit and the treatment, but we still have problems with compliance, patient satisfaction, outcomes measurement and provider profiling, not to mention chronic disease management, intensive case management and early warning of high risk patients for proactive medical management. Can technology address those issues, too?

When Keegan arrives home, an e-mail message is waiting for him (or us), requesting information about the visit. Using standard surveying techniques, the on-line form allows us to respond at our leisure about the visit, and our e-mail back is then compiled by the MHIS at the health plan for future patient satisfaction reporting. We continue to receive e-mails daily that are the result of Keegan's prescription drug and other treatments and therapies prescribed by the PCP. By e-mailing back, we provide data to the health plan about compliance with the treatment program, so that results can be measured in outcomes reports.

But how does someone create these reports? And what value are they if they are giving us information about the past? How can we use this data to change our behavior, and our providers' behavior, in the future?

We've all heard the terms data warehousing, artificial intelligence, fuzzy logic, etc. Maybe some of us have heard words like adaptive neural systems, clustering and data mining. How do these things help in healthcare?

Predictive Technology

Technology exists today that can help us predict trends, but not just global events, like an overall increase in healthcare costs. Trends like a health plan's VBAC rate will increase 1.8% from last year to this year. Or diabetic induced vision problems will decrease by 16 cases this year. Or the capitated cardiac carveout will lose money this year on over utilization, and will likely want to re-contract. Or the competing health plan's market share will increase next year based upon the changes in the case mix index of the hospitals it has contracted.

Even better, how about High Risk Patient Indexing Systems that identify patients before they are sick? Using demographics, patient assessment data and predictive logic, it is possible to target potentially high dollar patients and aggressively manage those cases early.

If all of this seems kind of like Star Wars, it's not. Everything we've described exists today, and all that is lacking is the connectivity between the parts. Taken in pieces, examples can be shown for each technology event in this article. Dragon Software does voice recognition, Medi-Web and Healtheon do Web enabling, TXEN does integrated billing and managed care for adjudication of claims, Nichols Research does sophisticated data mining and predicative algorithms. Take a stroll through NMHCC and HIMSS, and just picture a future using all the technology that is represented there, all working together. Or better yet, hop on the automated walkway and save your legs. There's a lot more coming!

Scott McFarland is vice president of Sales and Marketing of TXEN, Birmingham, Ala.