When did digital healthcare start to take off and become more prevalent? What has been your role in this? How and when did you get started in this business? We figured the Internet was particularly useful for finding information and was a good way to look for people. Patients move around, change doctors, and when they get a health condition that needs treatment, they want to know what doctors are available in their city. When finding a provider directory, if the patient were to go through their health insurance company, those directories were usually out of date; they were printed because this information can change so quickly. Thus, our initial concept was to publish an online directory that allowed people to search for doctors over the Internet. It was a pretty novel idea at the time. Initially, we went to doctors and asked if they d like to pay for a physician web page, charging them $200 to build their page and $50 a year to host it. That did not fly at all in 1996; there were a lot of hesitancies about doctors wanting to be exposed on the web. They thought the worldwide web would give them a lot of exposure to unwanted attention and they were really nervous about it, because in the early days of the web, there still existed the early problems that included insecure transactions and communications. In 1996 we spent a year marketing to physicians, and at the end of the year, we had found only 11 physician web pages so that business model just wasn t working. Other companies have since tried it and it still really isn t in place. What we did find was that hospitals were using the Internet as a marketing tool they were basically publishing their brochure wear and a physician directory on their hospital website. Thus, we ended up finding customers in that market and simply growing in that market vertical. We now knew what hospitals used the Internet for, and as they adopted more of the Internet browser technology for communicating, they brought it in-house as well, using Intranet. In fact, a lot of systems are digital and with the proper interface can use the website browser to view the data. Let me give you some background on this first. In hospitals, and in all of healthcare, there are a lot of data management that goes on, called Health Information Technology (HIT) systems. They can do everything from processing lab test results, digital imaging, billing, or population analysis for best care practices. It is all digital information, since it is all data they do a lot of data mining. Their systems have been in place for a long time; there are systems still being used that are 20 years old that manage all of this data. The problem is that they all are different databases and different technology. Cerner has its technology, JOX has its technology, and you can t easily go from one piece of data to another without looking at each computer its like having to run around from computer to computer in order to see what s going on inside. The web browser, which was the big revolution in the Internet, allowed you to look at data from other computers only using a browser such as Internet Explorer. One could actually look at the data that resided in other computers. This is where the big leap has come, because what the Internet has done is provide an umbrella in order to look at other existing information systems. As long as everyone agrees they are going to have a web browser to look at the information, they can all share and exchange information, regardless of what kind of computer they are on. Yes, the Internet has changed dramatically the way I do my job. I do so much research on hospitals every day, but there are still a lot of hospitals that aren t on the web or have updated web pages. Yes, that s exactly right. There are different phases of web technology. Phase 1 is publishing your brochure online, while Phase 2 is being able to search on a site and doing a little more interactive stuff. Level 3 is being able to do such things as request information, sign up for a class, schedule appointments, or talk to a physician you know, actually start to interact and transact with that website. Level 4 is actually looking into the future at self-care medicine, such as being able to log in and pay your bills online; however, you wouldn t be paying your bills over the website, you would be connecting to someone s bill paying system. It is the advanced E-Health that ultimately everyone is trying to get to. What are the first steps a hospital will have to take in order to become fully digital? What are the costs involved? What are the most common barriers in preventing a hospital from switching over? The first step is always planning. The whole organization needs to be involved as well, because if the hospital goes digital, every piece of the organization ends up having to participate. We ve helped hospitals build their digital strategies, which include asking these questions: 1) how this is going to serve the physicians, patients and employees, and 2) how their existing technology is going to interface with this. Planning can be very high-level and expensive and easily take 10 years to implement. We focus most on the marketing website and the corporate Intranet; our part of the digital strategy revolves around that kind of information flow. However, the very first step would be to decide what current systems you have that aren t digital that you have information you are trying to get to, who wants to see that information, and what is the best way of getting that information moved through the system. Most hospitals will have a website that shows the basic marketing materials, but behind the scenes, we re starting to think about things like physicians having a browser-based order entry system, or the patients having a computerized patient record system. If you had a patient record system, you could do such things as look up results from your lab test this information would be brought in from lab results software. It might have information in it about the last notes that your doctor wrote on your chart, and that would have to be transcribed into some digital method, not just his voice on a recorder. Then, that information would be published on your health record. So in order to consolidate these records and make the information easy to get to, it has to be digitized. Ultimately, the healthcare organization needs to decide: What information are you trying to get to, who is trying to see it, and how in a digital world are you going to view it? Is it true that only 13% of today's healthcare organizations are wired, or has the number increased since then? That is an interesting number the word digital would probably better be termed as using Internet technology. They ve all been digital for a long time, to a degree, but are they wired for the Internet technology. The percentage of 13% is probably changed by now, because more and more are using Internet technology to pass information around and at different levels. It is a hard number to define, because we have to clarify what we mean by a digital hospital or wired hospital. I would say that most hospitals have some kind of website, whether it is just a picture or some words about them. Do you agree? Yes, most hospitals have a basic website, but not all have searching mechanisms or thorough data. Exactly. Would you qualify these as being wired? I guess not, especially considering what technology is like now. There are magazines that report and evaluate the most wired hospitals. The Hospitals and Health Networks (HHN) evaluate hospitals for how wired they are based on all different levels whether their administration or bill paying is wired. and then score them. Hospitals are really excited about being published as a most wired hospital. In your opinion, what percentage of healthcare systems will be digital (from 13%) in 5 years? Do you know if there is a timeframe when you expect to have all hospitals included on it? I think we will see 50% of healthcare systems wired in 1-2 years. Movement is very quick. They did a survey in 2001 looking at the most wired hospitals having, for example, physicians who use email with patients. In 40% of these hospitals, physicians were using email with their patients. The least wired hospitals who fell below average had only about 20% of physicians who did this. Certain health systems can say 100% of their physicians within their health system are using email with patients, so the data is all over the map. However, I think the adoption is increasing rapidly and the reason is that the patients want it. The benefits for both the patients and physicians is tremendous. Exactly. Business works by demand, and if you would choose between a bank with ATMs and a bank with no ATMs, you would choose the one with ATMs there is no question. In the future, you might not think of considering a doctor who wouldn t give you an online prescription, bill and a chance to email him. Describe some of the benefits a healthcare organization will see when getting online. In addition, what are some of the downfalls? Some of the risks involved in going to digital are that you miss the patient/physician interaction that gets built in a relationship during the healing of the patient. Healthcare can only go so far in using statistics to evaluate the patient s condition and the patient s path to healing; that really is a very personal, one-on-one thing; how does that get accomplished without being in front of your doctor? On the other hand, in going digital, something like a prescription refill can be handled efficiently without having to take time away from the doctor s day, because you simply submit a request. Technical aspects for security are really technical problems, and solving those are not really as difficult in solving the personal challenge of making sure the treatment path is properly followed. The other probably most major hurdle right now is not technical at all, but financial. If the patient doesn t show up in the office, there is no model currently in place to pay the physician for his time. So the doctor could spend all day on email answering patients, but never get reimbursed for that time. Thus, the buzz in the medical community today is trying to figure out a way of reimbursing physicians or patient encounters digitally. There are some experiments going on right now where if a doctor emails a patient, he ll be paid $20, and that will be considered an online visit which will qualify for reimbursement. There is another movement, which is called information therapy it is paying doctors to supply information to their patients. It is the right information at the right time, in the point of care. An example of this is a patient comes to your doctor and he suspects they might have cancer. Well, the last thing the doctor wants to do at that point of treatment is give you information about chemotherapy. He might want them to first start learning about skin care (for skin cancer) or how if they had a lump what the procedure might be and what the after-care might include. The patient could get that on their email and ultimately be a better informed patient when they got to his office. In addition, perhaps the doctor removes the lump and sends it to pathology he could email the patient some information about what pathology does, what the tests can mean, and what they re looking for. Let s say the test results show the lump was benign, but they want to do some follow-up treatment; the doctor could send another email and explain what that follow-up treatment is and what some more preventative methods could be. However, who is going to take the time to find that information and appropriately send that information, thus helping educate the patient? Doesn t it make the patient more in charge of their health and a better patient if he/she is informed? Well, a major percentage of patients really like this idea, but others don t want to know the information. The bottom line is, though, that if it is a positive thing, then we have to decide who is going to pay for it. That type of information therapy is being campaigned right now at government levels and industry levels for reimbursing. The area of digital technology has become a hot topic. What other new information have you seen come out of trade shows and conferences? It is actually such a new topic there is a big information therapy conference in September in Park City, Utah. Vendors, physicians, thought-leaders and insurance companies from all over will be meeting and discussing the future of this. The company holding the conference is called Healthwise. If you go on their website, they have information about it and names of people to contact. But the question we all have to ask right now is: How does all this affect the patient and what are some of the ways that are preventing it from moving forward? How long will it take? The driver is really going to be if the patient demands it and if the insurance company is going to support a way to pay for it to happen this way. Can you describe this federal mandate HIPAA that will take effect, requiring doctors and insurance companies to have a standardized, electronic method for the exchange of patient information? Also, what provisions have been made in protecting patient privacy? HIPAA are standards that were placed for the purpose of increasing efficiencies in the healthcare system. They have rules for how electronic healthcare transactions should be conducted, such as what the privacy rules are around the handling of health information, security requirements for passing information around digitally. Healthcare companies have been spending money making sure they are compliant to this rule and don t get fined. They have to comply by April 2003, although there are some delays that might apply which may give you some extensions until 2004. There is expected to be huge savings in healthcare by promoting use of these electronic transactions and eliminating paperwork Gartner estimates that a large hospital system could save $15 million per year just on reducing rejected claims. So as much as it is a huge expense on the part of the hospitals to comply with these rules, there are savings that will be accounted for in the efficiency that they create. How do you help the healthcare organizations who don't have the staff or the funds to develop a fully operational system prepare to comply with this federal rule? There is some investment in making sure that a healthcare system s electronic transactions are compliant. They have to choose vendors who are providing compliant systems sometimes that means changing from an old system and purchasing a new one. That would be for things like claims, although that has pretty much been done and electronic claims are pretty much in place. I think what hospitals are looking at now is the electronic patient record, and how they are going to look at a lot of non-digital information and securely host it. Patient privacy is a big issue; however, a lot of it is simply practice and education among people in an organization. In fact, one of the jokes in the medical community is that the area with the most breach of privacy in most hospitals is the hospital elevator. It is in the elevator that a doctor might discuss with another doctor the condition of another patient, even though there might be a visitor there who shouldn t be hearing the information. That is where patient privacy comes in it is not just a technical solution, but also a practical practice solution. What these hospitals have to understand is that we have to train the front desk person not to give out information, even such as new birth information. Any information over the phone, especially in this case, would be a breach of privacy, because you are giving personal health information about that baby to someone you don t even know is a relative over the phone. The awareness training is so much a part of what HIPAA is about. What advances do you think we'll see in the next 5-10 years? I think this is an adoption curve that has started accelerating faster than it has until now. It had a slow and bumpy start, because vendors had been going out of business and that makes it very hard for any organization to adopt a strategy that no longer exists. However, we are now seeing the survivors of that. They are providing solutions and can help hospitals take steps and improve the way they are doing business; there are some leaders that have helped pioneer. If you think of the term The Westward Movement; it started off with a few pioneers and settlers trying to figure how to get across this country. Once some people had made it, it opened the floodgates and eventually the railroad was built and everyone poured into the West. I think we see the railway getting built now, and in the next 5-10 years, we ll see huge changes in digital strategies within hospitals. The infrastructure to make it happen is getting laid piece by piece, and it will lay the conduit for everyone to fall into place. As the companies who are making the solutions become profitable, they ll be able to lower the cost as well. I really think we ll see a transformation of healthcare within the next decade. Gale, thank you very much for this opportunity to and for sharing your thoughts with EP Lab Digest!