Neurosurgeons at the University of Missouri treat patients from 23 states who found them through the Internet. Web sites such as CyberDocs.com employ physicians to answer queries about illnesses. Internet-only drug stores are setting up shop in all 50 states.
The Internet is transforming medicine, empowering consumers and offering new opportunities for physicians. Those physicians and health centers that understand how the Web is changing medicine stand the best chance of prospering in the new era. Here are 10 trends in technology that are transforming healthcare and neurosurgery.
1. Healthcare Consumer Empowerment
The most fundamental impact of the Internet on the practice of medicine is the rise of healthcare consumer empowerment. Health-related Web sites have experienced a boom in traffic in the past several years. An estimated 72 million adult Americans have used the Web to seek healthcare information.
Most users are looking for information on conditions affecting themselves or someone in their family. As they become empowered with specific medical knowledge, they seek to become partners in their care.
Although physicians frequently complain about the quality of online health information, consumers have shown a much higher satisfaction with the health information on the Internet than with traditional media; 40 percent are very satisfied with information on the Web, versus 25 percent with magazine/newspapers and 13 percent with television.
The rapid growth of disorder-specific Web sites and chat rooms underscores the empowerment of the healthcare consumer movement. Chat rooms are available for hundreds of disorders and the activity in these chatrooms is buzzing. Healthcare consumers will influence, by their recommendation or disapproval, the flow of healthcare consumers to practitioners. While this has always been true, the Internet will magnify the trend.
Why are healthcare consumers turning to the Internet for healthcare information and interaction? Tom Ferguson, MD, of Austin, Texas, a consultant for online health information companies, believes that healthcare consumers feel there is “something inherent in traditional office-based practice that leaves them ‘wanting more.’ ” C. Everett Koop, MD, the former U.S. Surgeon General who began his own healthcare Web site (drkoop.com), says that the Internet will “change the whole paradigm we’ve been used to in medicine.” Healthcare consumers want partnership. They are “getting more control of the knowledge they have … which enables them to make decisions with their doctor about diagnosis, procedures and treatment,” says Dr. Koop.
2. Supersites and Supercenters
In September 1999, 13.4 million unique visitors visited the top ten health sites. As traffic to these sites continues to grow, new services will be offered, further building the number of users. This may result in consolidation of a majority of healthcare traffic to a few supersites and supercenters.
The world’s largest distributor of healthcare information has been drkoop.com. In September 1999, 5.5 million users visited drkoop.com. The site refers users to certain hospitals, lets them check if their medications will interact with one another and, through a partnership with Quintiles Transnational, allows them to sign up for clinical trials for the pharmaceutical industry. The AANS has partnered with Koop’s site on several public education initiatives.
Despite its popularity, drkoop.com suffered financial losses and, as of press time, was likely to be sold. But the utility of the medium is undeniable. Healthcare consumers are drawn to sites with multiple services. The popular AmericasDoctor.com (AD) employs physicians to provide virtual consultations. AD is negotiating exclusive agreements with health care providers throughout the country. For a fee, AD refers healthcare consumers to a partner hospital within their area.
In a partnership with CenterWatch, AD also allows healthcare consumers to sign up for clinical trials. In return for a referral fee, AD notifies healthcare consumers when a new trial that fits their profile is available. Healthcare consumers complete an online questionnaire to determine if they qualify.
Some supersites target both consumers and physicians. Medscape, whose editor in chief is George D. Lundberg, MD, (former editor of JAMA), publishes several online journals. The flagship online journal, Med GenMed, recently set new benchmarks for medical -publi-cations. Its first original, peer-reviewed study involved re-viewers on three continents and was published within 39 days of submission. Following this success, a complex major article with 18 authors was reviewed three times and published in just 19 days. Clearly, online journals are seriously challenging print journals.
Among the physician services offered by Medscape is Journal Scan. An editorial board reviews articles and publishes synopsis within a few days after publication. Links to abstracts and full-text articles are available. The Medscape medical image database available on Medscape now contains over 6,000 royalty-free images that are searchable by category or keyword. In neurosurgery, our own Neurosurgical Focus has grown rapidly since its 1996 launch. It is one of the most visited parts of the AANS site.
Medical centers are also developing supersites. Among the two most highly trafficked are John Hopkins Intellihealth and Mayo Clinic Oasis. Intellihealth offers the consumers an “Ask the Doc” feature on topics such as allergy, arthritis, asthma, babies, cancer and caregivers. The Mayo Clinic, responding to less traffic on its Web site, has recently partnered with the Shansby Group to more directly compete with the large for-profit sites such as drkoop.com.
3. New Opportunities for Physicians
The Internet is providing new opportunities for physicians. Consumers identify doctors as their most trusted source of information, according to public opinion surveys. Doctors are responding by becoming active participants of the electronic healthcare revolution, currently referred to as e-healthcare.
Certain specialties are ideally suited to providing online consultations. Radiology, an image-based specialty, is increasingly moving to digital imaging, and reading films through telemedicine is becoming increasingly common. As the capability of the Internet increases, radiologists will increasingly use it to read films online, allowing them to provide services worldwide.
Online consultations also can impact the direct treatment of healthcare consumers with neurological diseases. At the Atoka Memorial Hospital in Atoka, Okla., the brain CT scans of healthcare consumers with acute stroke are sent through the Internet to neuroradiologists at another Oklahoma facility. The scans are reviewed within 30 minutes and provide information needed by the physicians to determine if t-PA should be administered.
At a recent meeting of the AANS, John Tew, MD, demonstrated an online intraoperative consultation. It is likely that surgical consultation services will be available through the Internet later this decade. Surgeons will register for the service and will be able to obtain intraoperative consultations provided through the Internet by senior surgeons covering an on-call schedule.
Web sites such as CyberDocs.com and AmericasDoctor.com are employing physicians to respond to questions from healthcare consumers. Those consumers needing “immediate medical consultation” are asked to make their payment, through the CyberCash credit card system, prior to the consultation. The company claims 100,000 visits to its health site each month.
4. Online Health Record
For the consumer, one of the most significant contributions of the Internet to healthcare will be the development of the online health record. Various models are being developed. AboutMyHealth.com, a service of MedicaLogic, Inc., and Yourhealthchart.com, by Elixis, Inc., will allow patients to maintain their own record.
The most developed patient-based online health record belongs to PersonalMD.com, which has 100,000 registered users. Consumers can post current medications, family medical history, lab reports, living will, immunization record and health insurance data. The patient decides who gets access to the record. The patient also keeps the record current. Health systems are also planning to offer control of a portion of the health record to patients. At Providence Health System on the West Coast, patients will be able change their own demographics, review post-operative recommendations from their doctor and make appointments, all online.
5. Online Disease Management
Several companies are developing tools and Web sites to provide online disease management. The Health Buddy is an example of an Internet-based system that will enhance home care. A wireless unit in the healthcare -consumer’s home is connected to the Internet through a phone line. The healthcare consumer responds daily to health questions and the answers are relayed electronically to a nurse or physician. The system is currently being evaluated with cardiac patients at the Mercy Heart Institute in Sacramento, Calif., and with multiple sclerosis patients at the University of Southern California.
LifeChart.com has developed the Airwatch Asthma Monitor, an electronic monitor that measures airflow and sends the results to asthma specialists at LifeChart.com. Reports are sent to the patient’s doctor. The service is available for $9.95 per month. LifeChart.com is also developing disease management programs in diabetes and cardiovascular disease.
HealthScreenAmerica.com, another disease management Web site, is developing services to monitor or manage cholesterol, body fat, osteoporosis, diabetes, cancer, heart disease and other ailments.
6. Online Pharmacies and Prescription Services
Internet-based drug stores such as DrugStore.com and PlanetRx.com are obtaining licenses to operate in each state. Other traditional drug stores such as Walgreen’s are successfully using the Internet; Walgreen’s currently refills 1,400 prescriptions on the Internet each day. The $44 million in online pharmaceutical sales posted in 1999 are expected to jump to $2 billion by 2004.
The National Association of Boards of Pharmacy recently began granting a seal of approval to Internet pharmacies that meet the criteria of Verified Internet Pharmacy Practice Sites.
7. Further Development of Evidence-Based Medicine
As the number of consumers searching for health information and physicians on the Internet increases, they will increasingly compare the quality of the services provided. At our center, a father recently presented doctors with a notebook full of material obtained on the Internet. Tabs separated the information posted by various neurosurgeons, which included pertinent medical articles published by each practitioner. The father obviously was attempting to compare the quality of care. This interest and demand on the part of the public will enhance the move to evidence-based medicine and outcome measurements.
Many health sites are focusing on evidenced-based medicine. For example, the National Guideline Clearinghouse Web site (www.guideline.gov) contains 286 guidelines developed by specialty societies. This number is expected to increase to more than 3,000 within three years.
8. Online-Facilitated Clinical Trials
Many published clinical research trials involve a small number of healthcare consumers because of the expense of large multicenter studies. The Internet has the potential to change this. Through the AANS/CNS Web site Neurosurgery On-Call®, neurosurgeons are able to download research trial databases for local use. The data, with the identifiers striped, can be sent to the central database repository for analysis and comparison.
American Oncology Resources, Inc. has developed an innovative system likely to be replicated by other organizations. Its SecureNet database contains the files of 85,000 healthcare consumers in 18 states. The database automatically reviews healthcare consumer files for potential matches for drug trials and notifies, through e-mail, the healthcare consumer’s physician, nurse and clinical research coordinator. For new healthcare consumers, the clinician can enter the disease type, stage and principal therapy into SecureNet and the database shows which trials are available for that consumer.
9. Medical Associations Will be Transformed or Fade Away
The Internet poses a major challenge to traditional medical associations. The usage figures from 1999 were a wake-up call to associations such as the AMA. In February 1999 the number of visitors to the AMA Web site were similar to those of drkoop.com: 324,000 visitors to the AMA site and 369,000 visitors to drkoop.com. By September 1999, drkoop.com had 5.5 million visitors while the AMA’s site remained relatively flat at 404,000.
The AMA is responding to the Internet challenge by spending $2 million on a new site called named Medem. The site is being created in participation with several specialty societies: the AANS, American Academy of Pediatrics, American Academy of Ophthalmology, American Society of Plastic Surgery, American College of Allergy, Asthma and Immunology, American College of Obstetricians and Gynecologists, and the American Psychiatric Association.
10. Online Health Networks and Business Services
Investment firms, believing that Internet technology can revolutionize healthcare business processes, are focusing on healthcare. The development of online health networks and business services is changing the relationship between consumers and physicians. The following is a survey of some recent ventures.
Health Plan Intranets. Kaiser-Permanente (KP) has developed a secure Web server for its healthcare consumers. Through the KP site, healthcare consumers are able to e-mail their physician and, in a breakthrough step for a healthcare provider, can communicate with other KP healthcare consumers having similar disorders. Healthcare consumers can also contact their service representative and schedule clinic appointments online. Physicians estimate the network is already providing a 10 percent timesaving. Efficiency is likely to increase when new services such as eScripts, an online prescription service, is added.
Online Health Networks.
Healtheon/WebMD is moving aggressively to become the nation’s first comprehensive online health network. Like the other large healthcare Web sites, Healtheon/WedMD provides health information for consumers and physicians (AANS is a regular contributor of online content.) But the site also provides a host of continuing education and practice management services:
- Healtheon/WedMD has taken over the cmeWEB site and now offers 400 CME accredited courses. Physician members can obtain credit toward the AMA Physicians Recognition Award. The CME Logbook is an innovative feature that allows users to log CME credits and print a status report for submission to licensing or accrediting bodies. Individual state CME requirements are listed on the site.
- Physicians are able to check healthcare consumer eligibility online. The site serves as a single point access to multiple payers, which respond to inquiries real-time. The site automatically sends secondary coverage inquiries when appropriate. In addition, the referrals section allows users to submit referrals to payers and verify authorization status online.
- Insurance claims can be processed online. The system reviews claims automatically for valid CPT and ICD codes, duplicate records and invalid combination of procedures with age/sex. The system is designed to be consistent with payer-customized rules. In an agreement with Humana Inc., WebMD will allow physicians to file claims electronically, significantly reducing the cost of each claim. Bad claims will be automatically returned for correction and good claims will be paid within a week or two instead of the current average of 45 days.
- A fee schedule analyzer allows the practitioner to develop fee schedules that fits their community. The practitioner enters their zip code and specialty and the system provides guidelines for reasonable and customary charges.
- An online diagnostic laboratory ordering service connects physicians to pathology laboratories. Results appear on the physician’s desktop as soon as they are available.
Conclusions
The Internet will transform many healthcare processes during the next decade. Those centers with vision, courage and efficient execution will decrease their overhead costs and improve efficiency. More importantly, healthcare consumers will become empowered and seek partnership with their physicians. The drive for evidence-based medicine and outcomes, combined with the capabilities of the Internet, will allow healthcare consumers to be more selective in choosing their providers. Those physicians and centers that provide a new level of service and measurable outcomes will prosper.
John Oro’, MD, is Professor of Neurosurgery at the University of Missouri. He is past chairman of the editorial board at NEUROSURGERY://ON-CALL® and serves as director-at-large to the AANS Board of Directors.