Connecting the Dots: New ways to link patients, providers, and students through cyberspace


by Jon Saxton

Dr. G.P. Womed's patient is a 46-year-old male diabetic complaining of persistent headaches. Given the patient's borderline high blood pressure and diabetes, the primary care physician wonders whether she should investigate his current complaint further.

Not being an endocrinologist, she turns to her exam room console and quickly queries her online disease-management guidelines. A diabetes decision tree pops onto the screen, and within 30 seconds, the physician has the guidance she needs to best counsel and treat her patient. She then refers him to a specialist and to the consumer version of the online guidelines, where the patient can learn more about diabetes, track the treatment options recommended by the best available scientific and clinical evidence, and give feedback to his health providers on his compliance, outcomes, and satisfaction with his treatment.

WebEBM



Connecting patient and provider through Internet-based care-management guidelines is the vision behind webEBM ("EBM" stands for evidence-based medicine), a Nashville company that has partnered with the Woodruff Health Sciences Center (WHSC) and four other leading academic medical centers to create online disease-management guidelines.

This partnership is one of several "dot-com" connections made by the WHSC over the past 18 months. All are designed to develop new technologies emerging in "e-health" -- the young but rapidly expanding constellations of health-related technologies and capabilities forming in the aftermath of the recent Internet "big bang."

Like e-commerce in general, e-health signifies a process of change. It's a patchwork of emerging and transitional new technologies, novel businesses and business processes, changing public and private sector behaviors and expectations, newly evolving laws and customs, and new patterns of interaction and commerce.

Amidst a huge amount of hope, hype, and hypertext markup language (HTML, the basic coding language used to create the World Wide Web), e-health has kindled an explosion of dot-coms, dot-orgs, and other dot progeny. The WHSC, like almost all other health care organizations, is eager to connect the dots and to see what can be made of this new digital universe. But e-health's explosive, unpredictable, and uneven growth has created huge challenges for the health professional and health provider organization.

The most widespread development and use of the Internet in health has been in health information. An increasingly health-interested public has unprecedented access to hundreds of health portals and hundreds of thousands of pages of health-related information on the Web. Health portals are adding new types of interactive features, like personal health assessments and family health records management. And they are serving not just the public, but health professionals, medical supply companies, pharmacies, and insurers through websites like DrKoop.com, InteliHealth.com, Medscape.com, and WebMD. Hundreds more websites specialize in everything from disease-specific information and management, to home health care, to medical education, to support of basic and clinical research. Almost all this material is being developed and made available online where anyone with a web browser can access it.

With multiple sources of health content, one of the challenges in e-health is to assess the accuracy, timeliness, or efficacy of online information and services. And since health care itself has historically been a very local affair, standard practices for managing diseases can vary significantly from physician to physician and locale to locale. And even though there is a great deal of research available in the professional literature on best treatments and outcomes, this information can be hard to pull together and interpret. As a result, there are many diseases and conditions for which guidelines or benchmarks are not broadly or easily accessible to either practitioners or the general public.

What works best

Through webEBM, providers and patients can find out what works best and why in modern medicine. Emory and five other leading academic centers are creating comprehensive, evidence-based disease-management guidelines.

This is where webEBM comes in. As webEBM founder and CEO Paul Keckley describes it, "Patients, physicians, health plans, hospitals, disease-management companies, and countless other stakeholders of the health care system need an independent, easy-to-access resource to know what works best and why in modern medicine. Things change fast in medicine. Keeping up is difficult, even for web-savvy physicians and consumers. WebEBM is the solution. We provide up-to-date, evidence-based guidelines in both professional and consumer formats and tools that connect providers with their patients in the care-management process."

Keckley, a health care industry veteran, was previously president of PhyCor Management Corporation, the independent practice association subsidiary of PhyCor, a company specializing in physician practice-management. Several years ago, he projected the need for a care-management product developed in conjunction with leading academic health centers -- one that could take advantage of the extraordinary potential of the Internet as a knowledge and "connectivity" platform between patients, physicians, and others in the health management sector.

He recruited Vanderbilt University Vice Chancellor for Health Sciences Harry Jacobson, who helped open the doors to colleagues at Vanderbilt, Emory, Duke, Washington University in St. Louis, and the Oregon Health Sciences University. After months of negotiations, those centers last spring agreed to help webEBM develop comprehensive and up-to-date care-management guidelines for use by clinical professionals, patients, health plans, and others. A sixth academic medical center -- Mt. Sinai NYU Health -- joined the consortium in November.

Emory and the other centers each agreed to designate one or two clinical advisers to coordinate the development of more than 400 planned guidelines over several years. Physicians Kimberly Rask, assistant professor of medicine and public health, and Bill Bornstein, chief quality officer for Emory Hospitals, represent Emory Healthcare. Rask and Bornstein, along with their colleagues at the other academic centers, have recruited guideline authors within (and where necessary outside of) the university and coordinated and edited content with webEBM's chief medical officer.

This group of clinical advisers has worked feverishly over the past eight months to prepare an initial set of 40-45 completed guidelines that can be licensed for use by health plans and hospitals. In addition, webEBM has retained a web development firm to make the site easy to navigate and provide tools for patients to report their progress, satisfaction, and compliance with recommended care guidelines.

Other features of each guideline include easy links to scientific references, a key points summary, a decision-tree map, definitions, significance, causes, signs and symptoms, screening and diagnosis, prevention and treatment, clinical indicators, prognosis, alternative/complementary medicine, research frontiers, frequently asked questions, evidence grades, and references. Each guideline is written in both a professional and a companion consumer language.

Rask, who along with Bornstein has been working on Emory's share of guidelines development, has found the venture surprisingly compelling. "I certainly went into this not entirely sure what we could or would accomplish working across so many centers and attempting to pool resources and develop consensus on the best approaches to the various disease processes. But after these many months of effort, I've developed a new appreciation for what is possible to accomplish through such a consortium effort. We are producing top-level material that could be very important to the future of medicine both online and offline."

Bornstein concurs. He has volunteered several times to speak at conferences and meetings about the webEBM effort and has found surprising interest. "I have been impressed with the increasing receptivity to the need for guidelines development and broader use of guidelines in practice. Some of this is driven by recent reports of the extent of the medical errors problem nationwide.

"But more than that," Bornstein says, "I see professionals who are now beginning to appreciate the benefits of having guidelines accessible to patients that enable them to better understand the care process and thereby become more participatory in their own evidence-based care."

Altogether, about 35 Emory faculty will have participated in the preparation of the first round of guidelines this year. An equal number will participate in each of the next two years.

All guidelines authors and reviewers are compensated by webEBM. The agreement with webEBM also provides for compensation to each of the academic centers in the form of an equity stake in the company that vests over a period of years, based on each center's continuing to meet its obligations to produce and review its share of the guidelines.

Test the market

The WHSC's participation in this venture has been good for Emory, believes Michael Johns, director of the WHSC. "This effort was entered into only after a great deal of planning during which we weighed the risks and benefits of venturing into Internet-based health content development," Johns says. "In exchange for lending our name and other resources to the project, we wanted to be sure we understood what we wanted to get out of it, that we had the right partners, and that the company was committed to creating a good and worthwhile product."

"We were able to answer each of those questions in the affirmative. Now, on the basis of much good work by our people and the others, the company appears ready to test the marketplace. But whether or not this ends up being wildly successful commercially, it has already been very successful from the point of view of our having gained invaluable experience in the Internet arena."

The next few months will be critical to the success of webEBM. As the partners' clinical advisers and contributors continue to develop state-of-the-art content, it is up to webEBM's marketing and sales efforts to sell the product in a demanding and diverse marketplace. While the guidelines have been piloted successfully in several health centers, the true test of any product is whether there is a market for it.

Paul Keckley is unrelentingly optimistic about the prospects for success, even with the recent downturn in the e-commerce marketplace. "I firmly believe we will play a prominent role in the market," says Keckley. "Our timing is good, and our combination of industry-wise investors, reputable academic medical centers, and web-based content and tools is unique."

MiniMed on the web

EmoryÕs MiniMedical School on Medscape is designed to function as an online series of courses that anyone can take or audit at their own pace and leisure.

Emory entered into a second dot-com partnership in Spring 2000, this time with Medscape, a major health portal that pioneered provision of news, information, journal and conference reports, and other resources to medical professionals.

However, the initial idea of putting Emory's MiniMedical School online came up during discussions with the American Medical Association (AMA) about whether the WHSC would renew its sponsorship of public health-related information on the AMA's fledgling website. Discussions began in earnest with Medscape after George Lundberg was unceremoniously dismissed from his leadership of the AMA's professional journals and became editor-in-chief at Medscape.

Again, after months of negotiations, the WHSC agreed to translate its popular Emory MiniMedical School into Medscape's consumer-oriented health website. As of this writing, five MiniMedical School units are available online inside the Medscape/CBS HealthWatch site. Another unit is expected to go live shortly.

Emory's MiniMedical School is the brainchild of Emory cardiologist Randy Martin, and WHSC Assistant Vice President for Public Affairs Sylvia Wrobel. Together they assembled an evening program of lectures by leading Emory faculty, covering a range of materials that medical students learn in medical school.

Emory's approach to MiniMedical School is unique, in that it doesn't simply provide "hot topic" lectures on popular issues in health care. Instead, the program takes an organ-and-system approach, presenting units that cover such topics as the eye, the nervous system, and the cardiovascular system. Faculty convey some of the underlying biology and functionality of body systems while also describing leading causes and treatments of disease and damage to those systems.

Demanding but successful

Emory's Clinical Sites
on the Web


Anesthesiology

Breast Health Center

Cancer Clinical Trials

Cardiothoracic Surgery

Center for Heart Failure Therapy

Center for Rehabilitation Medicine

Center for Reproductive Medicine
  & Fertility

Crawford Long Hospital

Emergency Medicine

Emory University Hospital

Emory Transplant Center

Eye Center

Gynecology & Obstetrics

Neurology

Oral & Maxillofacial Surgery

Orthopaedics

Otolaryngology

Pathology

Plastic Surgery

Psychiatry and Behavioral Sciences

Radiation Oncology

Radiology

Sickle Cell Information Center

Spine Center

Sports Medicine

Surgery

Urology

Wesley Woods

Winship Cancer Institute


The approach has worked well. "We wanted to convey to consumers interested in health just how fascinating learning about health and disease can be, as well as show them the tremendous scope and complexity of medical education today," says Martin. "By doing that, we knew that they would have a better understanding of the challenges facing their physicians, including those in training. Most important, we wanted them to learn how today's scientist-physician is their advocate in the health care process."

He knows of no other program that has taken such an organ-system approach to teaching the public about medicine.

Emory's science-based, curricular approach has been successful for a public, nonspecialist audience in great part because of the talents and dedication of its volunteer faculty. Wrobel and Martin ensure the continuity of the program and supporting materials. Wrobel, who coordinates organizing and promoting the evening programs, now also leads Emory's efforts to translate and produce the MiniMedical School courses for the Medscape site.

Adapting the course segments from live presentations with audiovisual support to online text with graphic support is no simple task. Wrobel has assembled a strong editorial board and carefully oversees and edits all course materials. She describes a process that is both challenging and rewarding.

"Under our agreement, Emory is responsible for writing the material, providing the graphics, and reviewing everything for medical accuracy. Medscape formats the material and hosts and promotes MiniMedical School on its website."

So far, it's been a demanding but successful partnership.

"Now that we have a half dozen topics under our belts, it takes us anywhere from three to four months to develop a full course -- what we call a unit," explains Wrobel.

Content development is guided by faculty who are expert in their particular fields. They are normally assisted by professional medical writers, while medical illustrations are done in house by Patsy Bryan in biomedical media. Medscape editors and medical professionals then review our content, and we go back and forth with edits for both clarity and functionality in the web environment. The final product reflects Emory's medical expertise and our growing ability to produce content for the web, and Medscape's web expertise and commitment to highest-quality health information.

The online program currently contains five finished units: the cardiovascular system, the eye, the nervous system, the kidney and urinary system, and cancer. The endocrine system will be added next, followed over the next four months by ear, nose, and throat; the skin; and the musculoskeletal and immune systems.

The Emory MiniMedical School on Medscape is designed to function as an online series of courses that anyone can take or audit at their own pace and leisure. "Students" can take an interactive test during or at the end of each unit.

As Medscape makes agreed-upon improvements to the site's functionality, students will be able to store their test results, track their progress, and earn a "degree" that consists of a certificate of completion from Emory MiniMedical School. Audio feeds will supplement some text and medical images, along with links to related resources at Emory and elsewhere.

The goals of the WHSC in this venture are similar to those in the webEBM partnership, beginning with trying to further connect the dots and create something of value in the e-health space. The hope is that the online course can help people become better educated about their health and better able to work with their health providers in managing their care.

The agreement has little to do with remuneration to Emory. It calls for the WHSC to receive a relatively nominal yearly fee or royalties should Emory agree to some form of advertising on the MiniMed site.

More than any other consideration, perhaps the biggest benefit expected from connecting to this dot-com is the tremendous audience reach of the CBSHealthWatch site, which with Medscape has more than 3 million registered users. This partnership gives Emory the opportunity to showcase some of its extraordinary educational resources to an international audience, while serving an important public service function in promotion of health literacy.

MD Technologies

Through MD Technologies, Emory is moving toward a web-enhanced practice environment that promises to reduce management costs, improve work flow, and increase patient satisfaction.

The third major WHSC connection to the dot-com universe is in the final stages of negotiation. Its goal is to meet two of the biggest challenges for any health care organization seeking to connect the dots in this new digital universe: web-enabling physician practice-management functions and providing patients with web-based interactive connectivity to clinical and health-related resources.

Practice-management functions include patient scheduling, insurance certification and eligibility confirmation, billing and collecting, medical records keeping, prescription ordering, and various types of related office administration. These functions can be cumbersome and costly to manage.

Web-enabling these functions promises to reduce costs and complexity, and improve work flow and patient satisfaction. Emory 's partnership with Louisiana-based MD Technologies is designed to enable Emory Healthcare to move incrementally toward a connected, web-enhanced medical practice environment.

Other service industries -- travel and banking, for example -- have web-enabled their key consumer service, product functions, and transactions. In the travel industry, users now routinely go online, not simply to find information, but to make a full range of travel plans. Travelers can research, book, and choose seats online for a one-way, round-trip, or multicity flight. Upgrades can be transacted, and hotel and car rental reservations secured. Travel sites have links to local travel and entertainment guides and many other forms of information, services, and products.

In the banking and financial industries, consumers now can now go online to access accounts, pay bills, transfer money, and arrange loans and lines of credit. Individuals can buy and sell stocks and bonds online at will. In the retail sector, almost all major stores now provide online product catalogues, purchasing, and customer assistance. In these and many more industries, business-to-consumer and business-to-business electronic service and transactions can be conducted securely in real time.

There are many reasons why the health care sector has been slow to adopt such capabilities, including lack of capital to invest in new information technology, practitioner resistance to untested technologies, the stubborn legacy of dozens of proprietary and incompatible practice-management systems developed to serve local practice needs, and the sheer complexity of the health care data-management environment. But the most important obstacle has been the lack of truly effective new technologies that can reliably enhance the clinical encounter or improve practice management. While many dot-coms have promised a revolution in e-health care and management capabilities, few have delivered anything of real value to the clinical setting.

For more than 15 years, MD Technologies has provided management services to small physician practices, mostly in the Baton Rouge area of Louisiana. Over the past few years, the company has developed for its clients a state-of-the-art, online practice-management product, Medtopia. Most of the practice-management industry is migrating toward fully online technologies of this type. The company has recently developed MyMedtopia, a complementary suite of patient-focused, interactive capabilities. MyMedtopia provides patients with their own secure web page on which to store personal health data and from which to communicate with physician offices and clinics for appointments, insurance status and payment review, bill paying, prescription refill reminders, lab results, and other functions.

The problem for most vendors and for health care organizations like Emory is that they must continue to support and improve existing installed systems as they struggle to migrate to easier-to-use, cross-platform compatible, and secure online practice-management systems. And adding patient connectivity to the office or other provider facilities entails rethinking and reorganizing patient-related administrative and service processes.

Unlikely match



At first blush, a small practice-management group and a large, multifaceted academic health center might seem an unlikely match. On closer examination, the relationship may fit the needs and capabilities of both organizations.

MD Technologies created its state-of-the-art system in-house and, like the most successful dot-coms, is focused on refining and expanding its industry-leading technology. To date, its products have been used only in small group practices. MD Technologies has sought a large physician organization with which to partner in expanding its products' capabilities and become a major market player.

Emory Healthcare, like most other health care organizations, while currently relying on cumbersome and expensive practice-management systems, must migrate eventually to the emerging new generation of online capabilities. Emory will not move precipitously onto a new technology platform, but is keenly interested in carefully evaluating and incrementally testing such promising technology.

The partnership with MD Technologies, therefore, involves the licensing of the existing technologies and agreement to co-develop features that can function well in a complex practice environment like Emory. In exchange for a combination of equity in the company and royalties from product sales, Emory will lend to the co-development process its expertise in a complex environment and the willingness to carefully and incrementally evaluate and test MD Technologies' systems. Should these provide capabilities that Emory Healthcare, Emory physicians, or Emory clinical units desire to implement, they can be installed for Emory's use.

Also, as the Emory Healthcare website starts rolling out in February 2001, MyMedtopia features will become available for testing and use with patients -- again dependent on review and acceptance by Emory physicians and clinical units.

Beyond brochure ware

Over the past two years many potential vendor and partner relationships in e-health have been evaluated, and new ones arise all the time. In the meantime, many individuals, departments, and clinical units in the WHSC have taken the initiative to connect to the web environment.
In this Issue


From the Director  /  Letters

Connecting the Dots

The Doctor is Always In

Governmental Regulation
of Research: The Good,
the Bad, and the Ugly


Moving Forward  /  Noteworthy

Second Chance for
Boarder Babies

There are now more than two dozen websites sponsored by Emory Healthcare clinical units, and dozens more sites sponsored by departments among the schools of medicine, nursing, and public health. (See listing of some currently available clinical sites on page 9.) These websites provide online information about particular Emory faculty, clinical programs, and facilities.

Creating such online "brochure ware," as it is known, is a vital first step in connecting to patients, colleagues, referring physicians, and others who use the Internet to communicate and gather information. But few health care organizations, including Emory, have moved beyond such elementary efforts. Few use technology that provides patients and practices with interactive or transactional capabilities that can enhance the clinical encounter and the care process.

The launch of a comprehensive Emory Healthcare website in early 2001 will provide the platform for Emory Healthcare to move beyond brochure ware. (See article in the Fall 1999 issue of Momentum.) The strategic partnerships with webEBM, Medscape, and MD Technologies will enable the Woodruff Health Sciences Center to carefully and incrementally explore and develop appropriate, interactive, online health-related resources and capabilities. Through these efforts, Emory is connecting the dots in e-health and giving shape to a whole new universe of health care capabilities in Atlanta and beyond.


Jon Saxton is a special consultant to the Woodruff Health Sciences Center. In addition to serving as executive editor of Momentum, he is responsible for the evaluation, negotiation, and management of WHSC e-commerce ventures and partnerships.

 


Copyright © Emory University, 2000. All Rights Reserved.
Send comments to the Editors.
Web version by Jaime Henriquez.