Realizing IT's potential.

In early 2004, Manhattan Research described the results of a survey of more than 1,200 physicians (1) that revealed the top two emerging trends in health care:

1. Demand for online patient-physician communication

2. Use of secure connectivity and messaging among physicians, labs, hospitals and pharmacies

One of the challenges faced by small and mediumsized practices in meeting these demands is choosing among the various models of connectivity and component function. For the busy physician, simpler is better.

More importantly, an integration strategy such as interfacing an off-the-shelf Web-based EMR with practice management systems and secure physician-to-physician and physician-to-patient messaging services will prove to be better and more economical than non-integrated solutions, expensive retooling or new development efforts that are time intensive and cumbersome.

Before evaluating an integrated IT strategy, there are key questions you should ask:

* Does such a solution actually reduce my workload, increase my efficiency and improve my workflow?

* Are the systems and platforms on which the solution is built reliable? Is the underlying architecture accessible or standards-based?

* What is the cost (in time and dollars) of integration or interfacing between my existing systems and any new strategy adopted? Is integration feasible and practical? What about data conversion strategies and costs?

* Does the solution have capacity for growth and inexpensive expansion?

* Does the system or platform have the capability to communicate with other systems via HL.-7, XML or other open standards?

* Can the solution evolve or will it be outdated in three to five years and need to be replaced?

* Are mandatory maintenance and support costs justified, explicitly stated and affordable?

* Can the system or platform actually decrease my operational overhead?

* Does the system support an option for increased income via payer reimbursement or direct charges to the patient?

* How does the technology impact patients who do not have or do not use computers?

Forging a new design

Our experience in exploring IT and IS adoption with physicians reveals that most respondents request only a few things from information systems before making a final choice among multiple design options. Typically, physicians want:

* IT that's easy to adopt, intuitive to use, and helpful in making daily life and practice better.

* IT must be affordable given the economic realities of today's practice.

* IT must not require expensive upkeep, costly software updates or become outmoded in a few years.

* The system must be able to support office workflow, manage tasks such as prescription refills, make and track appointments, order and track lab, X-ray and other tests.

* A system that communicates with other physicians and specialists, service providers and third-party payers.

* A system that communicates, in a secure environment, with patients, and provide-patient access to medical records, and health care information.

Some forward-thinking physicians also require:

* Technology for office use should actually reduce costs in patient care.

* Technology platforms need the option of being a new source of revenue.

* Privacy and security (HIPAA compliance) should not be burdensome.

* Electronic communication with patients should save time and enhance the physician-patient relationship.

To achieve these goals, an integrated EHR that includes a Web-based platform linking online communities including physicians, hospitals, medical services providers, payers, and patients becomes the foundation for connectivity and communication.

Each component of this simple model must be interfaced or integrated with the other components. Each component stands alone yet is interdependent for the model to function successfully.

For the foreseeable future, data necessary for comprehensive medical health care delivery resides in different systems. Shared or common data depends on the use of open standards, Web services, and widely available tools, platforms and software.

The open EHR

The EHR described in this model must integrate with the demographic and billing data contained in the physician's practice management system. Scheduling must interface with a patient-accessible online appointment request system.

Medical records that are electronically entered as the patient completes an encounter must automatically drive the coding and charge capture process. This in turn produces electronic claims that are submitted without the need for labor-intensive data entry.

The tablet computer or similar device becomes the physician's vade mecum. Data entry for the practitioner is accomplished using the touch pad tablet and wireless handheld devices via a combination of voice-activated dictation, voice and keystroke macros, and practice specific templates.

Physicians have access to patient data not just in the office but at home or anywhere they travel. There is no need to rely upon access to paper records. Complete electronic files can be shared among the online community with the click of a mouse. Automated fax servers can support those not connected.

Clinical services orders and results tracking are no longer dependent on paper requisitions, dedicated printers, and copy machines. Lab and medical test results pass seamlessly from lab or hospital to the EHR for physician review and comment.

Results, once signed-off by the physician with recommendations for follow-up, can be viewed via a patient-accessible secure Web site. Patients can respond with questions, request additional information, and seek more advice through online consultations for non-urgent matters.

If the physician or practice so chooses, the platform can be used to support an additional revenue stream by charging patients for certain online services. (3) Several pilot programs and preliminary studies have shown that patients will pay for connectivity, access and convenience.

In a handful of states, online consultations are reimbursed by insurance companies. A new CPT code already exists for online consultations. It is conceivable that additional revenue generated from charging for these services will pay for the costs of the new technology.

Security is an issue. E-mail use for patient-to-physician communications has become widespread with 85 percent of respondents to a physician survey indicating that they use it. (4) E-mail is not synonymous with HIPAA compliant patient-to-physician messaging. Yet, private, secure online communication is essential to any health care information technology strategy.

Patients must be authenticated and allowed access to protected health information (PHI) only after successful logon to secure sites made available to them by their physician. PHI should not be passed via public e-mail for obvious reasons. When PHI is transmitted, it must be encrypted and conform to HIPAA transaction formats where available.

An optional component for the model is a Web-enabled communication call center. (5) This component can either be outsourced economically for the small practice or added in-house for larger practices or organizations.

The call center can wrap all modalities of telephone, pagers, fax, e-mail and Web contact into a package that connects patients and physicians with a live answer operator or "agent" on a 24/7 basis. The call center agent, with access to the secure Web site, now can perform many more essential services than tracking down the physician and forwarding messages.

With permission granted by the patient at the time of the call, the agent can:

* Track and record all contacts

* Access patient specific health records

* Push relevant health care information via the Web

* Provide online or fax copies of the patient's medical record or lab results

* Forward requests for callbacks

* Make appointment requests

* Forward cancellation notices

* Expedite other patient requests

Pointing the way

The adoption of emerging technology does not have to involve high cost or risk. The technology solutions for the primary care physician are proven, tested, and available now at nominal cost. The right system has the potential to both decrease operating expenses and serve as a new source of revenue.

Claude DeShazo, MD, CPE, FACPE, is CEO of ePractice Solutions in Bellevue. Wash. He can be reached at 425-458-4484 or [e-mail].

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Ron Fessenden, MD, MPH, is senior vice president of ePractice Solutions in Bellevue, Wash. He can be reached at 425-458-4484 or [e-mail].

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Peter Schock, MD, ABFP, is senior partner of Bellevue Family Medicine Associates in Bellevue, Wash. He can be reached at 425-454-5311 or [e-mail].

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References

1. Manhattan Research, "253,000 physicians represent the future of digital medicine." March 17, 2004, www.manhattanresearch.com.

2. Molfenter, T, MHA, and others. "Patient Internet Services: Creating the valueadded paradigm," Journal of Healthcare Information Management. Vol. 16, No. 4, 2002.

3. Manhattan Research, "The Connected Physician: E-mail, Communication, and Connectivity." June 17, 2004. www.manhattanresearch.com.

4. Manhattan Research, "In the age of online convenience, the doctor visit has yet to go digital", June 17, 2004, www.manhattanresearch.com.

5. Divis, KL. "The Web-Enabled Call Center: Adding Voice Capabilities to Your Web Site," Journal of Healthcare Information Management, Vol. 17, No. 1, 2003.

By Claude DeShazo, MD, CPE, FACPE Ronald Fessenden, MD, MPH and Peter Schock, MD, ABFP

Figure 1

Figure 1 illustrates the historical and present state of systems in use
by a majority of primary care practitioners today. Most practitioners
have some electronic practice management system but few are integrated
with an EMR and even fewer with communications systems that interface
scheduling requests from patients via the Web or phone systems.

Figure 2

Figure 2 illustrates a model for connected health information
technologies. It is an integrated model in which online physician
communities and their patients communicate virtually and in near real-
time. Multiple clinical services providers share electronic health
records, physician's orders, and medical test results in a secure
environment (2). It is a solution that does not depend on common systems
or software, but on integration strategies that are inexpensive and
rapidly implemented.