Report 5 The Blue Ridge A C A D E M I C H E A LT H G R O U P e-Health and the Academic Health Center in a Value- driven Health Care System Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Framing Health System Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Health e-Connectivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Findings, Recommendations, and Implementation Guidelines . . . . . . 12 Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Findings, Recommendations, and Implementation Guidelines . . . . . . 17 Health e-Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Findings, Recommendations, and Implementation Guidelines . . . . . . 22 Health Provider Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Findings, Recommendations, and Implementation Guidelines . . . . . . 27 Public e-Health Knowledge and Empowerment . . . . . . . . . . . . . . . . . . . . . . . . 29 Findings, Recommendations, and Implementation Guidelines . . . . . . 33 Universal Coverage and Value-driven Health Care . . . . . . . . . . . . . . . . . . . . . 34 Findings, Recommendations, and Implementation Guidelines . . . . . . 38 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . 40 About the Core Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 About the Invited Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Other Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Reproductions of this document may be made with the written permission of the University of Virginia Health System by contacting: Elaine Steen, University of Virginia Health System, Box 800413, Charlottesville, VA 22908 Fax: (804) 243-6078, E-mail: ebs9g@virginia.edu. e-Health and the Academic Health Center in a Value-driven Health Care System is fifth in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of the University of Virginia. This report is not intended to be relied upon as a substitute for specific legal and business advice. Copies are available at a cost of $10.00 each. To order, see the enclosed form. For questions about this report, contact: Don E. Detmer, M.D., University of Virginia, Phone: (804) 924-0198, E-mail: ded2x@virginia.edu. Copyright 2001 by the Rector and Visitors of the University of Virginia. The Blue Ridge Academic Health Group Report 5 e-Health and the Academic Health Center in a Value- driven Health Care System The Blue Ridge Academic Health Group Mission The Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to identify recommendations for Academic Health Centers (AHCs) to help create greater value for society. The Blue Ridge Group also recommends public policies to enable AHCs to accomplish these ends. Members Paul L. Ruflin, M.B.A., Vice President, Cap Gemini Ernst & Young U.S., LLC David Blumenthal, M.D., Professor of Medicine and Healthcare Policy, Harvard George F Sheldon, M.D., Chairman and . Medical School; Director, Institute for Professor, Department of Surgery, School Health Policy, The Massachusetts General of Medicine, University of North Carolina Hospital at Chapel Hill Enriqueta C. Bond, Ph.D., President, Katherine W. Vestal, Ph.D., Vice Burroughs Wellcome Fund President, Cap Gemini Ernst & Young U.S., LLC Robert W. Cantrell, M.D., Vice President and Provost, University of Virginia Health Invited Participants System Andrew Vaz, Vice President, Cap Gemini Don E. Detmer, M.D., Dennis Gillings Ernst & Young U.S., LLC Professor of Health Management, Judge Institute of Management Studies, Dennis Gillings, Ph.D., Chairman and University of Cambridge* Chief Executive Officer, Quintiles Transnational Corporation Michael A. Geheb, M.D., Senior Vice President for Clinical Programs, Oregon John P. Glaser, Ph.D., Vice President and Health Sciences University Chief Information Officer, Partners Healthcare System Jeff C. Goldsmith, Ph.D., President, Health Futures, Inc. Jordan J. Cohen, M.D., President, Association of American Medical Colleges Michael M.E. Johns, M.D., Executive Vice President for Health Affairs; Director, the Staff Robert W. Woodruff Health Sciences Cap Gemini Ernst & Young U.S., LLC Center, Emory University Danielle Federa, Senior Manager Peter O. Kohler, M.D., President, Oregon Health Sciences University Jacqueline Lutz, Associate Director Edward D. Miller, Jr., M.D., Dean and Sanjay Pathak, Senior Manager Chief Executive Officer, Johns Hopkins Medicine, The Johns Hopkins University University of Virginia Jeff Otten, M.A., M.B.A., Chief Executive Charlotte Ott, Senior Executive Assistant Officer, Brigham & Women’s Hospital Jon Saxton, J.D., Policy Analyst** Mark Penkhus, M.H.A., M.B.A., Elaine Steen, M.A., Policy Analyst Chief Executive Officer, Vanderbilt University Hospital *Chair **Editor Introduction T he advent of the Internet has been many aspects of our culture, from language almost universally heralded. It has been to customs to the meaning of symbols. Its compared to most of the important techno- ubiquity crosses national borders and polit- logical milestones in human history, from ical boundaries. It has created untold thou- the capture of fire to the development of sands of virtual or cyber communities and electricity, the steam engine, and the tele- has forever transformed many real commu- phone. The Internet’s dynamic, even explo- nities. It sparked “irrationally exuberant” sive, growth is often described using activity in the nation’s stock market, cat- biological metaphors (e.g.,“a squirming, alyzing the creation (and more recently protoplasmic nexus of informational activi- some destruction) of new wealth. ty” (Valovic, 2000, p. 24)) that suggest the development of a nascent hypertrophic Novel applications of Internet-based tech- organism of uncertain but highly promis- nologies are found or created almost daily. ing ontogeny. And several public and private initiatives, including the government sponsored Next Indeed, the Internet, as a technology plat- Generation Initiative (NGI) and the form, is having a significant, even revolu- private-sector sponsored University tionary, impact on communications, on the Consortium for Advanced Internet flow of and access to information, on the Development (UCAID) are currently speed and efficiency of many types of working to develop vastly enhanced net- transactions, and on connectivity between working technologies, applications, and and among an ever-growing mass of elec- new Internet platforms for a variety of tronically networked individuals, organiza- commercial, governmental, research, and tions, and systems. It is affecting communications applications (National everything from the behavior of individuals Research Council, 2000). to the conduct of commerce. “The Net” has spawned whole industries and trans- This nascent technology, perhaps some- formed others. It has created new cate- what like a developing nervous system, is gories of jobs and career paths, while vectoring in multiple directions, creating making others obsolete. It has affected new connections through multiple signal- ing pathways, and triggering adaptive (including protective and competitive) responses of many kinds. It is impossible to predict at this early stage what this There is little doubt that within 20 evolving system will eventually look like, how it will function, or even whether it years the Internet will become as will proliferate into an “Internetwork” of ubiquitous and invisible as today’s Internet platforms. It is quite possible that phone or electrical networks. the Internet’s proliferation will be such that it will never be completely compre- – Don Tapscot, Blueprint to the Digital hensible; that what we now call the Economy, 1998 Internet will give way to simply ubiqui- tous connectivity among increasingly intelligent agents endowed with one or 2 another or a combination of continuous, findings and corresponding recommenda- at will, and/or contingent, “with permis- tions and implementation guidelines sion” data sharing. In any case, it is rela- provide guidance for leaders and tively certain that the Internet as a policy-makers seeking to understand and technology platform will continue for the prioritize the evaluation, adoption, devel- foreseeable future to grow and to spawn opment, or enhancement of Internet- unprecedented and increasingly ubiqui- based health care, research, and training tous connectivity among networked users resources with a five to ten year horizon. and systems. Relative to other industries, AHCs and other health care organizations are prov- ing to be slow adopters of Internet tech- nologies and capabilities. Few health care policy-makers or leaders would dispute that the Internet holds great promise for enhancing health care, health sciences research and training, and drug and device development. Yet very few AHCs or other health care organizations have prioritized the development of Internet- based resources or technologies. Most have not identified these as critical to their core missions, competencies, or The Blue Ridge Academic competitiveness, at least over the next Health Group (Blue Ridge Group) three to five years. The Blue Ridge Academic Health Group (Blue Ridge Group) The Blue Ridge Group reviewed a great studies and reports on issues of fundamental importance to deal of evidence and sought the input of improving our health care system and to enhancing the ability of academic health centers (AHCs) to sustain optimal thought leaders concerning these and progress in basic and clinical research, health professions related observations. Convinced that the training, and patient care. Four previous reports described Internet has brought and will increasingly opportunities to improve AHC performance in a changed health care environment and to leverage AHC resources in bring technology and resources of great achieving significant improvements in health system access, value to health research, training, and quality, and cost. The Blue Ridge Group provides guidance care, the Blue Ridge Group provides this to AHCs that can improve financial performance, enhance leadership and knowledge management capabilities. report as a resource to health sector lead- It encourage AHCs to contribute to the development of a ers and policy-makers. more rational and comprehensive, but affordable and value-driven health care system (Blue Ridge Group 1998a, The report first provides a brief context 1998b, 2000a, 2001). In this, its fifth report, the Blue Ridge Group considers the prospects for and barriers to the describing three essential trends in the adoption, development, and deployment of Internet technolo- health care system. It then surveys the gies within the health care sector in general and, in particular, status and trajectory of Internet technolo- in support of the essential mission areas of the AHC. gies, resources, and commerce in the health care sector. Finally, a series of 3 Exhibit 1: Recommendations e-Connectivity • AHCs and other health care organizations should be should embrace health informatics as a full fledged profes- engaged in ongoing, governing board and leadership-level sional specialty in medicine, nursing, and public health. evaluation of operational and administrative capabilities and the opportunities presented by new Web-based technolo- • AHCs and other health organizations should vigorously gies to enhance, revise, or redesign current service and support the efforts of the National Committee on Vital and business processes and patient care capabilities. Health Statistics (NCVHS), the National Committee on Quality Assurance (NCQA), the Data Council of the U.S. • Evaluation, planning, and implementation capabilities for Department of Health and Human Services, the President’s Web-based operational and administrative systems should Information Technology Advisory Committee (PITAC), and be a core competency within all health care organizations. related efforts to create and maintain a national health infor- In the short or near term, health care, research, and training mation infrastructure necessary to the burgeoning demand organizations should prioritize development of Internet- for fast, secure, and reliable information transfer and pro- based capabilities that strengthen local or regional market cessing. position, and services that are reliable, scalable, customer- friendly, and flexible. • AHCs and other health organizations should vigorously advocate for the Department of Health and Human Services • AHC leadership should explore opportunities across to take leadership in overseeing and coordinating informa- and among academic centers for shared investment in, tion technology initiatives aimed at optimal development of a or outsourcing of, Web-based operational and national health information infrastructure for the twenty-first administrative systems. century. Education Public Knowledge and Empowerment • AHCs should actively investigate the opportunities and • AHCs should take a leadership role in identifying, making challenges for the development of online curricular and ped- available, and assuring quality health care information for agogical resources for students and faculty. their patients and the public over the Internet. • Medical and other health professions schools should priori- Universal Coverage and Value-driven Health Care tize strategic evaluation and planning designed to maximize • AHCs and other provider organizations should explore the impact of online curricula and resources for health pro- opportunities to vastly improve relationships with payors fessions training. through online transaction and information processing. AHCs should also explore opportunities to better manage e-Research and/or outsource in-house HR functions. • AHCs should aggressively pursue opportunities for the development or acquisition of online clinical trials design and • AHCs should seek to work closely with payors and management. employers as well as policy makers to ensure that the evolu- tion of consumer directed medical and benefits manage- • AHC faculty must become thought leaders and innovators ment strategies and payment systems track and report in the new environment. information on quality, outcomes, and other metrics of care necessary to informed consumer choice of plan and Provider Empowerment provider. • AHCs should institutionalize and formalize the capacity to support the development and implementation of Internet- • AHCs should continue to advocate for and seek opportu- based technologies that can enhance and extend care. nities to guide public policy that is more supportive of AHCs must conduct trials and demonstration projects and e-health care, including addressing limitations on reimburse- expand their research agendas to facilitate exploration of the ment for telemedicine, state barriers to e-health, and univer- question: How is health care going to be transformed sal access to the Internet. Progress in these areas is vital to because of new Internet capabilities? achieving universal coverage and the transition to a value- driven health care system. • As an important basis from which to expand and assert AHC leadership in Internet health care innovation, AHCs 4 Framing Health System Change Over the last several decades, dynamic These and many other forces are changing forces and trends in three areas have been the health care system and affecting the particularly important in shaping our delivery of care at every level. health care system. The first is the historic transformation of the health care system The second trend is the evolution of the from a predominantly decentralized cot- clinical relationship between physician and tage industry of professionals and related patient from a hierarchical and paternalistic local institutions, relatively insulated from model to one that is more egalitarian and traditional market forces, to a more cen- cooperative. This change corresponds as tralized, bureaucratic industry subject to well to the increasing role of self-care and the forces of a highly competitive market- the fast-evolving possibilities for both better place. This transformation is still in population health management and increas- progress and its end point is not known. ingly customized individual care enabled by E-commerce and the trend towards stan- new knowledge and technologies. dardized market transactions may yet redirect health care away from bureaucra- Over the last five decades, the traditional tization towards organizations and prac- clinical model of the physician as the indis- tices with more varied and permeable putable expert in the provision of care and boundaries. Characteristics of the chang- the patient as a passive recipient of care has ing environment are: been changing. Diverse forces have influ- enced this change. Starting in the 1950s, • The consolidation of large numbers of solo and Dr. Spock’s books on managing child care small group practitioners into large provider and managed care organizations; and health led the popularization and pro- liferation of health and family-care guides • The transformation of many solo and small and programs. The Women’s Health group physicians into salaried workers; Collective first published the influential • The closing and consolidation of many local and book, Our Bodies, Our Selves, in the 1960s, regional hospitals and medical centers; helping to empower women to better understand and care for their bodies. • The loss by physicians of many of the perquisites and much of the autonomy of the traditional professional; As the counter-cultural ‘60s and early ‘70s gave way to the increasingly market- • The shifting of risk away from payors/insurers towards providers and consumers via capitation focused ‘80s, public policy favored greater and other risk-shifting practices; individual attention to, and responsibility for, healthy behaviors. Dr. C. Everett Koop • Turbulence in sustaining managed care models, set a new standard for healthy behavior including the failure of major physician management organizations; advocacy in the newly created post of Surgeon General of the United States. A • Increased outsourcing of both clinical and broader patient advocacy movement administrative services; and emerged in the ‘90s in response to prob- • Federal cost reduction policies, especially the lems encountered in the now competitive Balanced Budget Act of 1997, mandating health care market place. Pharmaceutical substantial reductions in payments to hospitals for care services through the year 2002. and other health care and insurance prod- uct and services companies have enhanced 5 the trend towards consumer and patient as the norm for larger employers. The empowerment through new self-care and enactment of the Medicaid and Medicare home health care technologies and the systems in the 1960s served to provide aggressive deployment of direct-to-con- coverage and access for many of the most sumer marketing of drugs and devices. The vulnerable in the population. roles and responsibilities of providers, pay- ors, patients, and consumers continue to Despite these policies and programs, about evolve as new knowledge and technologies 15.5 percent of the population remains enable both broader and more customized uninsured even as the United States has dissemination and utilization of health sustained the highest per capita health care data, information, and technology. spending of any industrialized nation. As a result, problems with health access and A third major dynamic influencing health costs have seldom been absent from local system development is the continuing or national agendas. Following the Clinton struggle over universal access to quality, Administration’s failure to achieve univer- affordable health care. Universal health care sal coverage, neither public policy nor the insurance and the costs to individuals and managed care industry have addressed the society of inadequate access to care are continuing lack of affordable health cover- issues that have occupied American politics age for as many as 43 million Americans and public policy throughout the twentieth (U.S. Census Bureau, 2000). and now into the twenty-first century. Periodic attempts to enact universal insur- The Blue Ridge Group is on record in sup- ance coverage have failed, but important port of policies that can transition our steps have been taken towards expanded national health care system towards a access to quality, affordable care. National value-driven model of universal coverage prosperity in the post-World War II years and population health management, established employer-sponsored coverage through a combination of public and pri- 6 vate mechanisms (see Exhibit 2, Blue Standardization, empowerment, and uni- Ridge Group, 1998b). With universal cov- versalization are principles that the Blue erage for care scientifically proven to be Ridge Group believes can guide health effective, health care organizations could care leaders and policy-makers in evaluat- compete to manage and improve the care ing and employing Internet technologies of populations. This would catalyze the and in leading the transition to a development of new population health value-driven health system. management strategies, drive competition to develop better ways to measure and reward quality and efficacy of care, and create more value for the health care dollar. The Blue Ridge Group believes that the trends described above suggest three fun- damental principles that support progress towards a value-driven health system. These are: • Standardization of health industry data, Exhibit 2: connectivity, and communications, attendant The Value-Driven Health System upon the industry-wide rationalization of provider and payor systems. Cost reduction and A value-driven health system is grounded in the principle productivity enhancements have dominated that a healthy population is a paramount social good. It is a early standardization efforts. Harder to define health system that promotes and improves the health of the and establish, quality and value-driven care and population by providing incentives to health care providers delivery standards – including privacy standards (both public and private), payors, communities, and states – are steadily gaining prominence. to optimize population health status and rewarding cost- effective population health management. Such a health sys- • Empowerment of providers and patients in the tem would achieve better health outcomes and improve the care process through access to new health and health of citizens over the long-term while achieving cost care-related information and technologies, and savings for all stakeholders. the growth of self-care, remote care, and customized care capabilities. Two kinds of incentives exist within a value-driven health system. First, there are incentives for individual citizens • Universalization of health insurance coverage (patients), health care professionals, health delivery organi- for scientifically proven effective treatments, with zations, payors, and communities to seek and maintain ongoing pressure to improve access, quality, health. Health insurance premiums, reimbursement rates, and value of care for all. and grants to communities can all be structured to reward behaviors and strategies that advance health. Second, providers compete for populations to manage on the basis of quality and efficiency (where quality is defined in terms of health of the community or region as well as health of individuals). To do so, however, requires a fully insured population (universal coverage) so that population health management strategies can be implemented. It is antici- pated that in a mature value-driven evidence-based sys- tem, universal coverage will be less expensive than in the current system. 7 Health e-Connectivity T he development and adoption of com- Data sharing and processing is one of the mon standards is vital to the growth and most daunting issues in the changing maturation of most modern industries health care industry. Many record keeping and services. Common standards enable and clinical assessment and reporting sys- multiple actors on a shared platform to tems, including relatively sophisticated add new value and forge competitive computer and software systems, prolifer- advantage. They enable the efficient and ated over the course of the twentieth cen- effective utilization of data and informa- tury. But most developed as proprietary tion necessary to modern commerce and systems and were designed to address communication. local and/or payor specific recording and reporting needs but not to facilitate com- The Internet has emerged as a common munication with other systems. With an platform upon which a vast array of new estimated 30 billion eligibility, claim, lab- communications and connectivity tech- oratory, and referral transactions per year nologies can be developed and deployed. alone, the health care industry is notori- The Web has become the preferred con- ous for the difficulties encountered in nectivity technology because of the early deriving and sharing data among payors, and virtually universal acceptance and use providers, laboratories, and patients. The of standard underlying software lan- rapid transition to a competitive, cost- guages. Hypertext Markup Language driven health care environment acceler- (HTML), and its latest incarnations ates the need for standardized information including Extensive Markup Language systems that can connect and communi- (XML), allow Web sites to be linked and cate ubiquitously and transmit data easily, their contents (digital data) to be trans- efficiently, and securely. The Administrative mitted to one another through a relatively Simplification sections of the Health simple and easy to use Web browser. Insurance Portability and Accountability Browsers can be employed on everything Act of 1996 (HIPAA, P.L. 104-191) repre- from dedicated terminals, to desktop and sent the government’s first attempt to set portable computers, to cell phones and transmission standards for health data other devices, thus enabling unprecedent- whether for government purposes or not. ed and relatively inexpensive communica- tion among users, systems, and sites. The volume of transactions is only the first hurdle. A second major hurdle in the Also important to the power of the implementation of standardized health- Internet as a common platform is the related data systems is the diversity and increasing use of sophisticated database complexity of the records that are created coding. For instance, object-oriented, and utilized in support of the care relational databases enable the discrete process. These include medical histories, labeling and identification of every ele- diagnoses, examination notes, treatment ment in a database. This labeling enables records, prescriptions, test and lab results, the data to be utilized, analyzed, and regulatory compliance reports, insurance manipulated with almost unlimited flexi- eligibility, billing and collection functions, bility and power. scheduling, referral data, hospitalization 8 records, and so forth. Some of these cessing is the need to ensure that new records are generated at dedicated com- computer-based health records and sys- puter-aided patient intake stations, some tems are secure and can provide optimal on paper forms. Some records are jotted safeguards to protect the privacy of down by hand by the health care profes- patient data. Security and privacy of med- sional, and some are transmitted by fac- ical information is and must be a priority simile or dedicated electronic pipeline of both industry and government. HIPAA- from provider to payor. mandated action to establish proper stan- dards either by the Congress or by the The average medical center or health care Department of Health and Human system uses at least six different clinical Services (HHS). HHS has released regula- and administrative systems. The complex- tions that create and enforce standards for ity of the record creation and record keep- obtaining, holding, transmitting, authenti- ing functions, and the multiple cating, and utilizing sensitive health data. administrative and delivery situations that give rise to them, have so far defied stan- dardization. One initiative devoted to tackling this problem is the W3-EMRS Project. It is developing an Internet-based system to access multiple heterogeneous electronic medical record systems (Kohane et al., 1996). The Web is also enabling new capabilities for extending connectivity and care into the Farthest along in electronic transmission home and other remote environments. are insurance-related transactions. Two- thirds of health claims are processed elec- tronically; the majority of these are pharmaceutical claims. Eighty-seven per- cent of hospital claims are submitted elec- tronically. However, many of these are transferred on tape media, and the vast majority flow through dedicated, propri- The HIPAA-mandated rules now force all etary lines and from legacy systems that health care organizations, data handlers, are extremely expensive to maintain and and their business partners and affiliates cumbersome to operate. Even with elec- to adopt stringent policies and technologi- tronic submission, relatively few claims cal safeguards to protect sensitive health can be adjudicated electronically, creating data. Standard transactions and other elec- industry-wide problems with the manage- tronic individually identifiable information ment of billions of denied and delayed transmitted between business partners will claims (Goldsmith, 2000). require encryption. A universal digital sig- natures security system, with tiered securi- A third daunting issue in the development ty access and clearance, likely will be of common standards in health data pro- mandated for use by all individuals with 9 access to covered or potentially sensitive and easy connectivity to payors, employer data, including providers, trainees, staff, benefits plans, and providers also demand patients and their families, as well as complex and failsafe privacy safeguards to employees of vendors, business partners, protect personal health information. and affiliates. The new rules will likely be While HIPAA is designed to help address both technically complex and expensive to such payment system and other structural implement, requiring the employment of impediments to efficient and secure elec- sophisticated technologies and elaborate tronic processing, unequal and often “per- security processes. For the present, the verse” incentives are rife in the health regulations will not affect those who con- system and should not be underestimated tinue to use paper transmission. (Kleinke, 2000). A fourth daunting issue in the develop- The Web, in particular, is spawning a uni- ment of common standards for health verse of devices and capabilities designed data processing is that not all health sys- for use in the recording, processing, analy- tem stakeholders have equal incentives to sis, reporting, and transmission of data in adopt common data processing standards almost every conceivable environment for or efficient connectivity systems. Payors health care practice, administration, often derive financial benefit from delays research, and teaching. Traditional ven- in making payments caused by the com- dors, such as IDX and McKesson/HBOC, plexities and inefficiencies in claims as well as upstarts like Healtheon (created authorization and processing. Providers by the billionaire Internet entrepreneur, have few incentives to establish electronic Jim Clarke and then merged into connectivity to patients that can alter WebMD), MedicaLogic (which recently work flows and increase workloads with- acquired Medscape), Athenahealth, out commensurate remuneration, proper ProxyMed, and MD Technologies, all are staffing, and new mechanisms for risk either migrating existing systems online or management. Patients who desire direct are designing entirely new, Web-based sys- 10 tems for use in all aspects of practice man- Both the proliferation of Web-based tech- agement and administration. New software nologies and the rapid rate of evolution, is increasingly enabling the conversion of improvement, and invention of these new pre-existing or legacy content into the capabilities create planning and deploy- newer standardized code, while more and ment challenges for the health care organ- more original content is being entered and ization. Web-based technologies are in the created online or in digital formats easily early stages of development and will con- migrated online. tinue to develop at a rapid pace for the foreseeable future. While the Web pro- This mass migration towards Web-based vides a common standardization platform, information technologies and systems is there are many vendors and technologies driven by the possibility of significant providing a variety of pathways for system cost savings and productivity gains, with migration, from the incremental to the vastly more effective and efficient record global. Appropriate decision-making con- keeping, including data mining, transmis- cerning the adoption and deployment of sion, and communication among these new technologies requires health providers, payors, and patients, and the care organizations to acquire the knowl- streamlining or improvement of many edge or expert assistance necessary to other elements of the administration and appropriate organizational planning and management of care. The Web is also prioritizing. Most health care organiza- enabling new capabilities for extending tions at this point have some experience connectivity and care into the home and with Internet technology. Most utilize other remote environments. Already, the electronic mail (e-mail) systems and oper- wired world of the Internet is rapidly ate Web sites that serve both in-house and being augmented, and in many areas vir- external connectivity functions. tually replaced, by wireless technologies Information technology (IT) managers that provide sophisticated mobile capabil- and support personnel are virtually indis- ities suitable to the full spectrum of care, pensable to all significant health system teaching, and other non-static and remote operations. environments. Increasingly intelligent systems and devices are aiding all deci- sion-makers, from the patient to the provider to the payor to the researcher, by enabling the conversion of complex data into accessible information and knowledge. As sufficient connectivity bandwidth is installed, the goal of universal connectivity is moving closer to realization. 11 e-Connectivity Findings, Recommendations, and Implementation Guidelines Findings • The Internet, through the World Wide • AHC leadership should explore oppor- Web, provides health care organizations tunities across and among academic with the ability to standardize data uti- centers for shared investment in, or out- lization and transmission, and to inte- sourcing of, Web-based operational and grate disparate clinical and admin- administrative systems. istrative systems. This migration towards a single, standard platform enables Implementation Guidelines unprecedented development of health e-connectivity, communication, and Web-based technologies are sufficiently commerce. advanced that health care organizations can profitably focus on the following • The Web is a technology platform that domains: will become increasingly important to the efficient and effective administration and • Managing internal business and operational processes – there are significant opportunities operation of health care organizations. for cost savings, operational improvement, and The Blue Ridge Group predicts that process reform in the areas of administration, within ten years, Web-based technology human resources, claims processing, customer will be indispensable to the ability of relations, and marketing. health care organizations to operate • Managing internal patient care processes and effectively and competitively in the health improving patient/provider decision-making – care industry. there are significant opportunities for improving capabilities in evaluating the efficacy and Recommendations efficiency of care, and in communicating and sharing data with patients and third-party • AHCs and other health care organiza- payors. tions should be engaged in ongoing, • Managing health data privacy, confidentiality, governing board and leadership-level and security – there will be significant evaluation of operational and administra- requirements for implementation of HIPAA- tive capabilities and the opportunities mandated security standards, processes, presented by new Web-based technolo- technologies, and rules; both legacy health care information systems and newer vendors will be gies to enhance, revise, or redesign cur- important partners in complying with these rent service and business processes and regulations. patient care capabilities. • Evaluation, planning, and implementa- tion capabilities for Web-based opera- tional and administrative systems should be a core competency within all health care organizations. In the short or near term, health care, research, and training organizations should prioritize develop- ment of Internet-based capabilities that strengthen local or regional market posi- tion, and services that are reliable, scala- ble, customer-friendly, and flexible. 12 Health Professions Education Physician training standardized around a skills information to individuals through scientifically and evidence-based curricu- large lecture classes increasingly have lum has been well established since early moved to adopt group seminar formats in the twentieth century, following that allow a focus on individual and group Abraham Flexner’s detailed report of the problem solving. shortcomings of most training programs to that point. Nearly 10,000 randomized Pedagogical approaches also have changed clinical trials results are now published in the clinical setting, which has been annually, providing an ever-growing base made more challenging because of man- of evidence for clinical practice and pro- aged care and changed reimbursement fessional education (Chassin, 1998). scales. With hospitalization rates and Communication of generally accepted lengths of stay falling, medical educators clinical and scientific content has been have been hard-pressed to provide stu- standardized through broad dissemination dents with the patient exposure necessary of a core curriculum and approved texts to ensure thorough clinical training. Many and reference works. Standard pedagogi- schools have experimented with substitut- cal, clinical, and training protocols have ing volunteer and paid actors for real been widely adopted and refined. patients in order to present medical stu- dents with live subjects from whom they One of the most daunting ongoing chal- can learn and practice the many skills lenges in medical education is the amount involved in taking histories and diagnos- of information, skills, and knowledge that ing health problems. must be assimilated by medical students and other health professions students. The Increasingly, students are expected to uti- quantity of scientific and clinical knowl- lize expert information, technology, and edge has grown tremendously over the last decision support systems. There are exper- century. The rate of growth of biomedical iments in training students to learn and knowledge is increasing with advances in share skills and expertise in teams, includ- technology, the growth of the research ing teams where more responsibility is enterprise, and the opening of whole new allocated to skilled and advanced nurses, areas of inquiry, especially in genomics, physician assistants, and other allied structural biology, and many other emerg- health professionals. Biostatistics, epidemi- ing fields. Some fields are advancing so ology, behavioral modification, health quickly that it is difficult to keep pub- services research, and bioinformatics all lished texts, and even journals, up to date. are gaining a more prominent role in health professions education. Along with the increase in the amount and complexity of medical information that The advent of the Internet and growth of must be assimilated, is the pedagogical the Web is transforming medical and health challenge of finding the best methods to professions education. A broad range of facilitate the learning process. Schools that medical and public health information is traditionally imparted basic science and widely available online, increasing the 13 student’s access to new and existing medical schools now offer online courses knowledge. Among the resources readily where physicians can earn CME credits. obtainable from public and commercial The private sector is also playing strongly sources are professional journals, reports, in this field. CMEWeb.com, for instance, and presentations (sometimes live) from now provides more than 1100 hours of professional and scientific meetings, a full online accredited continuing medical edu- range of major medical reference works, cation testing and processing. and databases. In addition, health profes- sions students have access to search Advances are also being made in schools engines that enable extensive and sophisti- of public health and nursing. The Rollins cated information searches, to continuing School of Public Health of Emory medical education courses and materials, University, for instance, has developed as well as to supplies, devices, and equip- eLearnTM, a suite of programs to deliver ment they might require. electronic materials via the Web. The school offers a Career MPH degree, a 42 Medical, dental, pharmacy, and nursing credit-hour program in which students school educational resources increasingly participate in both traditional face-to-face are being moved online. Health sciences classroom sessions and on the Web. The libraries are migrating publications, cata- eLearn system enables students and facul- logues, and most other library resources ty to interact via chat rooms, an electronic and services online. Many schools have whiteboard, and Internet video conferenc- moved significant elements of their cur- ing. The program is designed to allow ricula online for ready access by students working professionals to complete an and faculty. An online private company, MPH degree in approximately two and a medschool.com (www.medschool.com), half years. has staked out a significant Web presence as a self-described “e-learning health care Nursing schools long have been innova- hub and virtual community offering tors in distance learning. Many are rapidly access to the highest quality medical edu- adding innovative and extensive online cation for students, educators, physicians, learning programs. At Duke University allied health professionals and sophisticat- School of Nursing (DUSON), for instance, ed consumers . . . that augments the cur- nurse practitioner and clinical nurse spe- rent medical educational system and cialist students can participate in Web- addresses critical needs in health care based courses and programs, including education.” Additionally, thousands of MSN degrees in Nursing Informatics, Web sites are maintained by medical stu- Health Systems and Leadership dents, organizations and schools, pre-med Outcomes, and Clinical Research preparation companies, medical textbook Management. The DUSON is also one of a publishers, and many others with infor- growing number of schools with an infor- mation on virtually any medical-school matics program, emphasizing clinical related subject or topic. informatics tools for the improvement of patient health outcomes. Similar advances are being made in con- tinuing medical education (CME). Many 14 Most expert observers see these develop- ments as only the very beginning of capa- bilities that will likely revolutionize education and training in the health pro- fessions over the next two decades. The better_health@here.now project of the Association of American Medical Colleges Medical, dental, pharmacy, and nursing (AAMC) is the most sophisticated school educational resources increasingly forward-looking assessment of medical are being moved online. education resources and technologies that are currently deployed, under develop- ment, and projected by experts. This visioning project concludes that medical education in the year 2010 will be suf- fused and enhanced by a host of new resource that combines the capability of a Internet-based technologies and capabili- digital library with a course delivery sys- ties. Among the projections for the future: tem and a curriculum management sys- tem. The Database contains an image • A set of refereed multimedia cases that cover database (e.g., micro slides), course syllabi core medical concepts will be used for instruction at most medical schools. (including some textbooks), video clips, lecture slides with audio, and self-assess- • Lecture time will be replaced by small group ment quizzes to monitor progress. More sessions that build on independent study of Web-accessed information and resources. than 60 percent of the first and second year curriculum is online. An object- • Intelligent information systems will provide oriented database provides flexible, learning materials that continuously adapt to expandable, and integrated content that learners’ needs and accomplishments. can be utilized, searched, updated, and • Procedural skills will be taught first on a digital customized. simulator. • Patient simulations (i.e., virtual patients) will be The Database provides students with inte- core experiences in widespread use for the grated course materials that can be evaluation of clinical skills and medical decision accessed and utilized in a variety of for- making. mats. Faculty and students can build on • Continuing education will be personalized – and refine course materials. All users can delivered by online modules based on physician share materials with one another and with performance needs with his or her own patients. users outside the institution. As the Tufts curriculum and others migrate online, the A Tufts University Medical School project opportunities for sharing and cross- that anticipates many of these capabilities, fertilization in the elaboration of pedagogi- is likely to significantly influence the cal tools and biomedical knowledge and development of online medical education skills will increase exponentially. The resources. Launched in 1995, the Tufts AAMC hopes to form a consortium to online Health Sciences Database is a connect such resources and facilitate their unique and powerful online curriculum fullest development. 15 The Internet’s influence is overestimated for the next two years – but underestimated for the next 10. – Bill Gates, 1999 Internet-enabled enhancements to health What will constitute a school under these professions education will drive educators circumstances? What would it mean to to rethink and even re-conceptualize tradi- matriculate? If much of the basic curricu- tional pedagogical methods. Internet- lum can be conducted interactively online, based curricula will soon be capable of will hospitals or health plans or other providing customized elements of the organizations stake a claim to the neces- basic curriculum that are directed and sary hands-on health professions training? updated by intelligent online teaching sys- If curricular material can be packaged into tems; in fact, most non-experiential learn- intelligent learning systems, will commer- ing is likely to be accomplished over the cial companies, like the Kaplan test prepa- Internet. What will be the implications for ration organization or privately owned faculties and students? Will the education- for-profit professional schools, become al model move from memory-based to leaders in the development of such sys- process-based learning? Will faculties be tems, with a legitimate claim of being able reduced in size? Will faculty size remain to provide or host the training? Could any stable with curricula leveraging online or all of this apply to residency and other learning to enable faculties to spend more advanced training? time providing individualized clinical mentoring and counseling, critically The Blue Ridge Group believes that the assessing and guiding the development of best scenario is that new Internet-based professional values and ethics? Will the capabilities will serve to strengthen the criteria by which students are selected existing system of health professions edu- change to focus differently on certain cation, enriching the curriculum and character traits, intelligence, adaptability, enabling more individually, culturally, and communication skills, leadership attrib- technically nuanced training of a diverse utes, ability to interface both with tech- cohort of students. Faculty can be freed of nologies and between digital and more mundane and repetitive tasks and biological systems? have more time for trainee contact and mentoring, and to pursue unprecedented opportunities for curricular and pedagogi- cal innovation. 16 Education Findings, Recommendations, and Implementation Guidelines Findings Implementation Guidelines • The Internet is a platform that will Medical schools should work closely become integral to medical and health with the AAMC, the Liaison Committee professions education over the next ten on Medical Education (LCME), the years. Universities and an array of Liaison Committee on Graduate Medical organizations and commercial enterpris- Education (LCGME), specialty boards, es will develop online educational specialty societies, and other relevant resources and programs. Most medical health professional education associa- and other health professions schools will tions to maximize the utility of curricular move substantial elements of their cur- innovation and to ensure the integrity riculum online. There will be new compe- and quality of online educational tition from the private sector to provide resources and programs. educational materials and services to the students, universities, the health profes- sions, health care organizations, and the general public. • Increasingly, health professionals will need to know both their clinical special- ties as well as how to utilize information technology in their research and prac- tice. This has implications for how schools must train health professionals and researchers. Recommendations •AHCs should actively investigate the opportunities and challenges for the development of online curricular and peda- gogical resources for students and faculty. • Medical and other health professions schools should prioritize strategic evalua- tion and planning designed to maximize the impact of online curricula and resources for health professions training. 17 Health e-Research T hrough the first seven decades of the intense pressure to provide better admin- twentieth century, basic biomedical istrative support and vastly improved effi- (including behavioral) and clinical ciency and industrial responsiveness for research were almost exclusively the their clinical trials and technology trans- province of AHCs and their affiliated hos- fer capabilities. Most AHCs have not been pitals, a few private hospitals and treat- able to achieve the levels of operational ment centers, and philanthropically effectiveness and productivity in clinical supported care and research centers. The research desired by industry. pharmaceutical industry also conducted and sponsored basic and clinical research, Into this competitive fissure grew a new but focused primarily on applying discov- industry of contract research organiza- eries to the drug development and mar- tions (CROs) competing to provide the keting process. Over the century, biotechnology and pharmaceutical indus- standards for the conduct and reporting of tries with efficient and effective drug and research were developed through the aus- device development services. Many in the pices of the National Institutes of Health biotech and pharmaceutical industries (NIH), the National Science Foundation also added new research and development (NSF), and other federal agencies, profes- capabilities, and all hired leading scien- sional societies and associations, and pri- tists and some of the most promising vate foundations, all of whom have younger scientists away from traditional cooperated to ensure the quality and academic careers. As universities have integrity of the research enterprise. As struggled to improve industry-sponsored popular trust in and support for biomed- development and clinical research services, ical research grew, so did federal dollars the new CRO and biotechnology indus- allocated to the NIH, NSF the Department , tries have proven effective competitors. of Defense, and other agencies to support While universities conduct the vast sponsored research. majority of sponsored basic research, it is estimated that universities now conduct Beginning in the late 1970s, the explosive only about 30 percent of industry-spon- emergence and growth of the biotechnolo- sored clinical research, down from 70 per- gy industry signaled the maturation of cent two decades ago (Rich, 2000). The biomedical science to the point where it rapid development and consolidation of could generate and support a national and the highly competitive and well capital- international marketplace with a constant ized biotechnology, pharmaceutical, and and widening spectrum of new products. CRO industries continues to put a premi- As the biotechnology and pharmaceutical um on improving the efficiency and effi- industries captured unprecedented financ- cacy of drug and device development. ing and found or created huge new mar- kets, competitors increasingly looked for The Internet is proving to be a very com- ways to accelerate, lower the costs, and pelling and promising medium through improve the efficiency of the drug and which to expand and further enhance bio- device development process. The tradi- medical research and the drug and device tional university-centered biomedical and development process. In basic research, clinical research enterprise came under the Internet has been widely employed by 18 researchers to increase the speed and effi- ciency of the transfer and sharing of infor- mation. Collaborators can more easily and quickly share data, feedback, and results. Peer review panels now save weeks or more in the manuscript review process by being able to post reviews and otherwise The Internet provides a robust platform streamline study section administrative for addressing and managing virtually all processes online. Bioinformatics appears aspects of clinical trials. poised to assume a larger role in academic medicine, nursing, and public health. Significant programs now exist at Boston University, Northeastern University, Stanford University School of Medicine, University of California at Santa Cruz, and Washington University in St. Louis, among others. E-Biomed, for the posting and disclosure The Internet is also serving as an excellent of both peer and non-peer reviewed platform for databases that allow research results and papers (Varmus, et researchers virtually unlimited access. al., 1999). The proposal envisioned an Major online databases include the international repository where researchers National Library of Medicine’s MEDLINE, worldwide could share results and discov- an index of the entire biomedical serial lit- eries with unprecedented speed, receive erature since 1966; PubMed, a search feedback, respond to queries and criti- engine hosted by the National Center for cisms, and in many other ways open-up, Biotechnology Information; GENBANK, accelerate, and improve the research pub- the major database of DNA sequences, lication, review, and dissemination hosted by the National Institutes of Health; process. While well received by many and OMIM, Online Mendelian Inheritance researchers, the proposal was met with a in Man, hosted by Johns Hopkins torrent of criticism from many others and University. Many other important databas- from journal publishers, professional soci- es are available online, both free and by eties, and other quarters. Much of the subscription. These online resources have criticism stemmed from the fear of the become basic tool sets and forums for col- damage such speedy dissemination could laboration in biomedical research and for do to the integrity of the research review rapid growth in the field of bioinformatics, process and to public trust in the research where AHC leadership is central. enterprise. A scaled-down version of the original proposal is now being imple- Yet, the research community struggles mented. Researchers and policy experts with the implications of this efficient new are monitoring the program carefully to medium. For instance, in 1999 Harold learn if and how the research review and Varmus and colleagues at NIH proposed dissemination process can be enhanced the creation of an Internet repository, through such a repository. 19 While academic researchers and physi- of pharmaceuticals development are a cians continue in their vital role at the matter of some uncertainty. AHCs have leading edge of discovery research and lost significant ground in their traditional clinical innovation, the pharmaceutical role of conducting clinical trials to test industry is assuming unprecedented lead- the efficacy of therapeutics. As suggested ership in defining and driving the future above, AHCs have been only partially and of treatments for disease and disability. inconsistently successful in improving Research and development spending by their capacities to reliably conduct effi- the pharmaceutical industry, which cient and effective clinical studies. Most reached $26.4 billion in the year 2000, is centers are plagued by administrative dif- now 50 percent higher than the $17.8 bil- ficulties, especially in recruiting and lion sponsored research budget of the NIH retaining sufficient trials participants, in (Drews, 1996). Pharmaceutical industry records management, and in timely man- spending will accelerate clinical research agement of human subjects and other reg- and drug and device development over the ulatory requirements. Nevertheless, AHCs next ten years. The industry has approxi- remain a compelling locus for such stud- mately 500 biological targets for drug ies, if they can solve the critical adminis- development. With advances in molecular trative and process issues. AHC faculties biology and the successful mapping of the are well suited to the complex challenges human genome, within a few years there of arbitrating and translating information will be up to 10,000 such targets, vastly to and from clinical practice. expanding the universe of treatable condi- tions and the efficacy of treatments. The Perhaps most compelling is the gradual industry is targeting currently untreatable but unmistakable shift from in-hospital conditions, especially cancer, and lifestyle treatments as the dominant site for dra- drugs, such as Viagra. matic improvements in life expectancy to outpatient management where medica- The roles that AHCs will play and the tions taken chronically help the greatest extent of their participation in the surge numbers. Indeed, with joint replacements 20 and similar treatments the hospital is now Project management modules, extensive increasingly the site for quality of life data mining capabilities, automated news improvement and palliative treatments and reporting functions, comprehensive rather than life-saving care. The new security and privacy safeguards, all con- medicine will increasingly be “high-tech, nected to data warehouses, will accommo- low-touch.” date the needs of investigators, patients, payors, and sponsors. This system will The Internet provides a robust platform also be able to support and integrate with for addressing and managing virtually all other functions up and down the produc- aspects of clinical trials. A partnership tion chain, from research, to development, between Quintiles Transnational to sales, to quality control and assess- Corporation and WebMD to develop clini- ment. The implementation and refine- cal trials capability in a Web environment ment of this system is expected to have a illustrates the ability of the Internet to significant impact on the costs, manage- support new levels of connectivity, collab- ment and success of clinical trials. oration, and commerce in medical research and pharmaceuticals develop- The development of this level of online ment. The Quintiles/WebMD partnership capability is beyond the reach of most is creating an integrated set of Web por- AHCs and other health care organizations. tals that will enable online design and But AHCs can partner with organizations management of clinical trials. Web portals building such capabilities if AHCs acquire dedicated to patients, investigators, and or create appropriate electronic or research sponsors enable customizable Internet-based administrative and data connectivity and collaboration among any management capabilities. and all participants. These portals will manage: • Recruitment of physicians and patients; • Feasibility assessments; • Study design and protocols; • Data collection, processing, and management; • Labs and clinical supplies ordering and tracking; • Real time information on status of trial and access to educational materials, news, and study documents; • Clinical monitoring and audits; • Ethics, human subjects, and regulatory requirements; • Adverse event reporting; and • Online training, including Web casts. 21 e-Research Findings, Recommendations, and Implementation Guidelines Findings AHCs have been unable to achieve lev- els of operational effectiveness expected by industry and have lost significant ground to contract research organiza- tions in their traditional role of conduct- ing clinical trials in support of drug and device development. New models show that the future of clinical trials design and management is online. AHCs can remain strong research and development part- ners if they aggressively acquire relevant Internet-based administrative and opera- tional capabilities. Recommendations • AHCs should aggressively pursue opportunities for the development or acquisition of online clinical trials design and management. • AHC faculty must become thought leaders and innovators in the new envi- ronment. Implementation Guidelines AHC leadership should seek strategic partnerships for online connectivity and collaboration with contract research and pharmaceutical organizations. 22 Health Provider Empowerment A s reviewed above, the Internet is As a group, physicians have been slow to spawning Web-based technologies with adopt Internet-based technologies in their unprecedented capabilities for connectivi- clinical practice – or to adapt clinical ty and data exchange between providers, practice to new Internet-based or payors, patients, and other parties. enhanced technologies. Surveys of physi- Integrated Web-based practice manage- cian Internet usage vary, but on the whole ment programs, in use by some physi- indicate that anywhere from 50 to 85 per- cians and organizations, are expected to cent of physicians now have access to migrate to a majority of providers by the computers at home or in the office. The year 2010. Online practice management vast majority utilize the Internet, but not should enable the realization of signifi- to support of clinical care. Typically, cant efficiencies and cost savings in the physicians use the Internet the way others utilization and transmission of care- do – for e-mail, news, entertainment, and related data. Providers and payors will for information searches on both profes- achieve new levels of accuracy and timeli- sional and personal topics. Measures of ness in the processing of eligibility and physician utilization of the Internet for insurance claims. Providers and provider clinical or patient-related topics show organizations will realize new levels of usage to be relatively low. administrative effectiveness in the man- agement of medical records and patient A recent online survey conducted by flow. Patients should reach new levels of WebSurveyMD.com sampled a cohort of customer satisfaction with easier and physicians with online access. Only 27 per- more reliable scheduling, billing, and cent believed that the Internet would help medical record keeping, and with reduce health system costs over the next enhanced connectivity for the purposes of five years. Fewer than 50 percent believed communicating with or accessing that the Internet would help improve resources and information from providers physician-patient communication. Twenty and payors. percent use the Internet to communicate with patients, 19 percent to consult with The complexity and diversity of health colleagues. Of most interest to those sur- care practices hinders the development veyed, was the potential of Internet-related and adoption of a broadly accepted or technologies to extend care to patients at indispensable model for care delivery and remote sites (WebSurveyMD, 2000). management. Instead, the Internet is serv- ing as a common platform for the devel- Many analysts attribute low physician opment of a wide spectrum of new Internet utilization to practitioners’ indi- proprietary clinical care and process relat- vidual and collective reticence to change ed capabilities. Since they are being devel- long-standing practices, resistance to new oped on a common platform, they will be technology, or even professional arro- able to share data and connectivity in the gance. These explanations miss the point. delivery and management of care among Limited utilization of the Internet for providers, payors, pharmacies, patients, care-related activities is primarily a func- and other parties. tion of the lack of demonstrated utility 23 and value of Internet technologies to the and clinical practice guidelines become care process. To date, only a few Internet increasingly sophisticated. Decision sup- or Web technologies have been developed port in medicine requires an extremely that seem capable of providing the physi- complex set of capabilities, including cian with new capabilities, efficiencies, computer terminals or appliances that are practical benefits, margins on productivi- easy to use, portable, and can access and ty, or cost savings in the actual provision display data and patient records in real of care that would justify their adoption. time. Also required are extensive and Among these, Allscripts (allscripts.com), sophisticated databases that include up- ephysician (ephysician.com), and several to-date research and clinical findings and other vendors have pioneered the devel- protocols. Rendering all of this informa- opment of portable or hand-held wireless tion available and useful to diagnosis and electronic prescription capabilities that treatment requires search engines and enable physicians to create electronic pre- software that can process and analyze the scriptions in the exam room. data in ways that are useful to the clini- Prescriptions can then be sent electroni- cian in the clinical setting. cally to the local retail, mail order, or Internet pharmacies, printed in the office, Several organizations and companies tar- or for the most commonly prescribed get specific diseases and conditions for medications, dispensed in the physician’s clinical decision support and guidance. office. On a separate track into the physi- The diagnosis, treatment, and manage- cian’s workflow, MDeverywhere ment of conditions such as asthma, heart (mdeverywhere.com) and Pocketcode disease, and diabetes are supported by (pocketcode.com) have developed wire- increasingly sophisticated products and less charge capture devices for use by applications. I-Trax (Itrax.com) has had physicians at the point of care. some early success with pediatric provider adoption of its Asthma Watch System. Many other technologies promising in- Health plans are increasingly looking to office and care-extending benefits are being such solutions for monitoring and guid- developed. Providers are likely to get prod- ing the care of their members. The man- ucts that enhance care delivery, but only aged care company, Humana, Inc., has incrementally, because of operational, tech- begun utilizing an online coronary artery nical, legal, and professional hurdles. disease (CAD) management product Technologies that enhance clinical care will developed by CorSolutions, Inc. (ecorso- gain momentum among providers and pay- lutions.com). ors, and are likely to become integrated within clinical practice environments over Taking a more general approach, Stanford the next decade. Examples include clinical University created and spun-off as a pri- decision support and care monitoring, vate company, e-SKOLAR.com, a Web- especially to remote environments. based clinical care support site that it describes as a “knowledge service Clinical decision support will become provider.” The site is designed for use by technically feasible as both search engines physicians and other providers to conduct 24 rapid searches across multiple medical Internet-based or enhanced telemedicine references. Users can access the most up- capabilities are poised to move from the to-date medical information and clinical status of esoteric technologies of marginal decision support at the point of care. utility, to mainstream care management e-Skolar.com also promotes the concept tools. Already, many pathology and radiol- of physician-initiated in-context learning, ogy practices routinely employ the providing the opportunity to earn contin- Internet to transmit images and data. uing medical education credits in a Various telemedicine systems are “learning while doing” model. employed to connect providers to patients e-SKOLAR.com grew out of Stanford in homes, assisted living and skilled nurs- SKOLAR, M.D., a powerful search engine ing facilities, and correctional institutions. developed by an interdisciplinary team of faculty members and students from the schools of computer science and medicine. Another start-up, EBM Solutions (ebmsolutions.com), in a partnership with Vanderbilt University’s medical center and five other AHCs, developed a package of Web-enabled evidence-based Limited utilization of the Internet for disease-specific practice guidelines care-related activities is primarily a designed for use by both the professional function of the lack of demonstrated and the patient. Guidelines allow both utility and value of Internet technologies provider and patient to view care options to the care process. best supported by reported research and evidence compiled and reviewed by the six AHC partners. Connectivity tools are being designed to facilitate communica- tion and information exchange, including Home health care is beginning to emerge compliance reporting between patient and as a market with increasingly sophisticated provider. and practical technologies of interest to payors, providers, and patients. Remote A number of companies provide and are monitoring and other connectivity prod- developing diagnostic and testing devices ucts have the potential to reach millions for use at the point of care and remotely. of patients, especially those with chronic I-Stat (I-Stat.com) provides blood analysis diseases and conditions who represent the tools built into a portable device for use at highest cost cohort in the health care the point of care. IGEN International system. Cyber-Care (cyber-care.com), (IGEN.com) is a well-established diagnos- American TeleCare (americantelecare.com), tic and life sciences company developing Medtronic (medtronic.com), and several a product capable of performing a wide other companies have developed and are range of diagnostic tests both at the point refining systems that connect the home of care and remotely. and other remote locations to the 25 provider. Terminals enable audio, visual, all require payment adjustments and and digital communication, as well as the accommodations by both public and pri- reading, monitoring, and transmission of vate payors. New technologies will require health metrics such as blood pressure, and enable unprecedented quality assess- blood oxygen levels, weight, heart rate, ment and assurance measures for use by glucose levels. Regularized, ongoing mon- providers, payors, employers, regulators, itoring of these and other metrics, along and patients alike. with visual and voice communications, should allow providers to better manage Growing employment of the Internet for patients’ health, increase patient compli- clinical care will require ongoing research ance, and help prevent both over and and investment in a national health infor- under-utilization of care. mation infrastructure that includes tech- nologies and standards that provide for While these and other initiatives are pio- vastly increased capacity, speed, reliability, neering new ground in health e-care, and security for data analysis, processing, there are significant technical, opera- utilization, and transmission (National tional, legal, privacy and security, reim- Research Council, 2000). At the national bursement, and quality assurance issues level, several entities have begun to ana- with which both vendors and e-care uti- lyze and project these needs and to make lizers must contend. Migration of clinical recommendations for meeting them. decision support and other clinical func- These include: the National Committee tions online can be accomplished only on Vital and Health Statistics (NCVHS), with operational accommodations in all the National Research Council (NRC), the clinical settings. Hospitals, physicians, National Committee on Quality other providers, administrators, and staff Assurance (NCQA), the Data Council of must be open to incorporating new capa- the U.S. Department of Health and bilities, learning new skills, adjusting Human Services (HHS) the President’s patient flow, and helping to test and refine Information Technology Advisory new technologies. Committee (PITAC). Lacking, however, is an official body, office, or individual that Electronically enhanced or extended care can provide overall leadership or coordi- creates legal issues and responsibilities in nation of national policy and resources for the areas of professional licensing, a national health information infrastruc- provider, vendor, and payor liabilities, pri- ture (National Committee on Vital and vacy, reimbursement, ethics, and other Health Statistics, 1998). HHS is widely areas (Silverman, 2000). HIPAA rules now seen as the appropriate locus for strategic regulate all health-related electronic data. leadership of health IT issues, particularly All health sector participants must devel- “aggressive involvement in the area of op capabilities for compliance. Remote national networking” (Shortliffe, 2000). consultation, technologies enabling new diagnostic and treatment options, and practice innovations of many kinds will 26 Provider Empowerment Findings, Recommendations, and Implementation Guidelines Findings Recommendations • Internet and Web-based technologies • AHCs should institutionalize and for- that can enhance or extend clinical care malize the capacity to support the devel- are still in early stages of development opment and implementation of Internet- and adoption. Internet-based technolo- based technologies that can enhance gies as yet do not provide practical solu- and extend care. AHCs must conduct tions that address the needs of the vast trials and demonstration projects and majority of providers overburdened by expand their research agendas to facili- administrative tasks and with too little tate exploration of the question: How is time to spend with patients – though health care going to be transformed many technologies are gaining incre- because of new Internet capabilities? mental acceptance. Over the next decade, such technologies are likely to • As an important basis from which to become increasingly sophisticated, expand and assert AHC leadership in enabling AHCs and other provider Internet health care innovation, AHCs organizations to improve care-related should embrace health informatics as a operational processes, clinical decision- full fledged professional specialty in making, patient, provider, and payor medicine, nursing, and public health. connectivity, and the efficiency and effectiveness of care. • AHCs and other health organizations should vigorously support the efforts of • Significant technical, operational, legal, the National Committee on Vital and privacy and security, reimbursement, Health Statistics (NCVHS), the National and quality assurance issues remain to Committee on Quality Assurance be addressed by federal and state (NCQA), the Data Council of the U.S. authorities, vendors, and those who Department of Health and Human would employ e-care solutions. Services, the President’s Information Technology Advisory Committee (PITAC), • AHCs have much to contribute as and related efforts to create and main- centers for innovation, collaboration, and tain a national health information infra- nationwide advocacy in the development structure necessary to the burgeoning of Internet-based capabilities that can demand for fast, secure, and reliable enhance or extend care. information transfer and processing. • AHCs and other health organizations should vigorously advocate for the Department of Health and Human Services to take leadership in overseeing and coordinating information technology initiatives aimed at optimal development of a national health information infra- structure for the twenty-first century. 27 Implementation Guidelines • AHCs should create high-level working groups to identify and support on an ongoing basis, the evaluation, develop- ment and testing of Internet-based clinical capabilities within and between their cen- ters. Clinicians, departments, and/or clini- cal delivery services that are willing and positioned to participate should be identi- fied and enlisted in these efforts. Appropriate IT, legal, and administrative resources must be committed to these efforts. • AHCs should begin by identifying processes that need to be fixed or strengthened within the overall clinical and business strategy. AHC leaders should not allow strategy to be con- trolled or driven by technology. AHCs are most likely to make progress in this arena by focusing on basic and incre- mental steps while working with new technologies to improve quality, cost, and delivery of care. 28 Public e-Health Knowledge and Empowerment From the point of view of the patient connectivity to other professionals. and the public, there has been remarkable As market trends and consumer interest development of Internet-based health care escalated, Medscape partnered with the resources. The Internet is providing access television network, CBS, to create CBS to health information in unprecedented Healthwatch.com, a portal for customers volume, depth, and breadth. But beyond and patients. simply providing information, hundreds of online commercial and non-commercial It is WebMD, however, that has come to initiatives are deploying new capabilities epitomize the commercial health care portal. for health care services that enable indi- Through a series of major strategic viduals to engage more effectively in man- alliances and acquisitions, WebMD has aging their health, insurance coverage, achieved an unparalleled size, scope, and and care. As these capabilities become market presence across almost the entire more broadly and equally accessible, spectrum of e-health services and capabil- patients and health consumers are ities. But WebMD’s ambitions to become increasingly empowered to participate in the major portal through which all forms managing their care. The Blue Ridge of health care information, data, and Group also predicts that over the next ten transactions will flow have also become a years, there will be dramatic increases in significant management problem that the growth of patient competence in self- recently caused the company’s share price care and remote care. to plummet and its leadership team to experience significant turnover. It remains The first stage of patient and public access to be seen whether this model of health por- to health information came with the tal and transactional gateway can flourish. explosive growth of consumer-focused health information portals. Among the Also sponsoring major Web-based health early leaders with a strong academic pedi- information portals are many governmen- gree were Intelihealth (originally a joint tal agencies (e.g., the National Institutes venture of Johns Hopkins Medical School of Health; nih.gov/health/ and and Aetna U.S. Health Care), clinicaltrials.gov), professional associa- DrKoop.com (with health care content tions (e.g., the American Medical provided in part by the Dartmouth Association; ama-assn.org), pharmaceuti- College Medical School), and the Mayo cal companies (e.g., drugstore.com), Clinic’s own Health Oasis site. Among the health maintenance and other provider private concerns that emerged strongly and payor organizations (e.g., Kaiser were HealthCentral, HealthGate, and Permanente; KPOnline.org), philanthrop- OnHealth, each of which has developed a ic and policy organizations (e.g., the significant portal that provides a broad Kaiser Family Foundation; kff.org), and range of easily navigable resources and university medical centers. HealthWise, a information. Another leading portal, non-profit health-promotion organization Medscape.com, began as a physician- and publisher of popular self-care guides, focused site providing professional news, has become a leading vendor of online articles, and research resources along with consumer oriented, evidence-based self- 29 care guidelines and information, which communicate with health care profession- can be licensed by managed care als, insurance companies, health plans, or organizations, health plans, hospitals, and employee benefits managers. employers for use with their members and employees. For example, DiabetesWell.com and DiabetesManager.com provide integrated A different model, and equally important packages of information and services to to the diffusion of better health knowl- diabetes patients. Both provide: e-mail edge and the empowerment of patients access to medical professionals; daily e- and the public, has been the development mail updates and news; local lab referrals of online communities of interest centered or online help for testing and complica- around diseases and conditions or tions; online glucose monitoring with cohorts. Online communities have a wide data displays and graphs; a secure Web variety of sponsors, from individuals to page to track treatment; medication; dedicated, disease-specific advocacy access to a personal food plan developed organizations, to the major health portals. by a registered dietitian; a personal fitness These online communities have played plan created by an exercise physiologist; very important roles in the evolution of and online education. Both sites encour- expectations for health knowledge acqui- age the patient to pull their physicians sition and interactivity both between into online care management through providers and patients and among these dedicated online services. patients and others with shared disease or other health-related experiences and Women’s Health Interactive (womens- interests. health.com) is typical of Web sites provid- ing health information for specific cohorts Yet research shows that consumers want (other widely targeted cohorts include the even more. In most other service and con- elderly, children, and teens). This site pro- sumer industries, the level of information- vides information, research, chat rooms al access that has been achieved in health and a variety of related resources on the care has been supplemented with impor- range of women’s health issues. Resources tant follow-on transactional capabilities include guidance and links to clinical, that enable levels of service and commerce insurance, and other services. that have so far not developed in health care. As a result, health portals continue to Beansprout.com is an example of the move towards consumer customization trend towards integrating both health and and the integration of health-related prod- related services to particular cohorts of ucts, services, interactivity, and informa- consumers. Beansprout is targeting par- tion. Consumers increasingly can go ents of young children with an online online with any of the major portals not service that connects parents, pediatri- just to find information, but to purchase cians, child care professionals, and dedi- health products and pharmaceuticals, cated childcare resources. The American maintain personal and family health data, Association of Retired Persons sponsors a track and assess personal health status, Web site providing comprehensive cover- join discussion forums, and identify and age of issues of importance to senior 30 citizens, including a health site, Quackwatch.com is a nonprofit organiza- aarp.org/healthguide. Seniors can find a tion with a Web site run by a physician wide range of articles, books, research, whose purpose is to identify and debunk and legislative advocacy materials on health-related frauds, myths, fads, and fal- health care, fitness, nutrition and well- lacies. This site works with volunteers to ness, care giving, health insurance, investigate questionable claims for med- Medicare, Medicaid, managed care, long- ical procedures, cures, products and out- term care, and other issues. comes as well as misleading or illegal health products marketing. Patients and One of the greatest challenges for patients those interested in health can receive reg- and the health-interested public is evalu- ular e-mail updates on various issues and ating the quality of health information concerns, submit questions, or report and care they receive. An increasing num- questionable claims and practices. ber of health care portals are providing information and guidance in evaluating Sites such as these are now augmenting providers and the quality of care. the thousands of informal networks of individuals who share experiences, anec- DoctorQuality.com and Quackwatch.com dotes, gossip, rumors, facts and informa- are two examples of initiatives to provide tion of all kinds in Web site chat rooms guidance on health information and care. and forums. Many health care organiza- DoctorQuality.com is a growing online tions and providers are well aware of the service that provides information and importance and power of such informal resources of use to providers, payors, and networks in affecting patient and public the public in understanding and improv- perceptions and steering patients towards ing quality of care. For consumers, this particular therapies, practitioners, or site gathers and provides data on doctor institutions. ratings and hospital errors, and provides patients with best practice guidelines to help in understanding and managing dis- ease. DoctorQuality.com has collected public data for all U.S. hospitals, including volume of cases, regulatory and accredita- tion status, and services available. For U.S. physicians, DoctorQuality.com collects An increasing number of health care portals data including physician’s background and are providing information and guidance in eval- training (such as board certification), uating providers and the quality of care. years in practice, and any sanctions against their license (such as convictions, substance abuse, or fraud). Reported per- formance data is collected from physi- cians, hospitals, third-party sources (such as managed care plans), or publicly avail- able state or federal data. 31 The World Health Organization (WHO) ing, tracking, measuring, and assessing is pursuing a novel course to enhance the health claims and information, profession- credibility of health information offered al competence, patient compliance, and worldwide. The WHO applied to the clinical outcomes. Nevertheless, the objec- Internet Corporation for Assigned Names tive of defining, measuring, and enforcing and Numbers (ICANN) to become the standards in all of these areas has long registrar of a new top level domain been embraced. Professional societies, (TLD)– health. Within the ICANN frame- national and state regulatory and accredit- work, new top level domains may be ing bodies, and not uncommonly, the restricted or unrestricted. A restricted TLD, courts, all have had a role in developing, empowers the sponsoring organization to promulgating, evaluating, and enforcing set policy on how the TLD is allocated professional ethics, truth in advertising, and used, including who may apply for a product safety, and practice standards. registration within the domain, and what Individuals and communities too have uses may be made of those registrations. always formed opinions and points of view As registrar of the .health domain, the about practitioners, institutions, products, WHO would have the ability to require and information. That the Internet is now domain name holders to adhere to a serving as a platform for the migration and common set of standards for online health further development of this process online content and services. Though not yet suc- should not be surprising. The vast data- cessful, this effort illuminates the importance generation and -handling technologies of establishing worldwide standards of care. coming online guarantee that there will be unprecedented, ongoing development Efforts such as these to promote standardi- of resources to assess quality, safety, per- zation and evaluation of care are contro- formance, outcomes, and other health versial and complex, but inevitable. There care metrics. are many unresolved difficulties in defin- 32 Public e-Health Knowledge and Empowerment Findings, Recommendations, and Implementation Guidelines Findings The proliferation of Internet health care information provides patients and a health-interested public with extraordi- nary new access to health-related infor- mation that can be used to better understand health and improve patients’ participation in the management of their health and care. However, few patients or consumers have the knowledge or experience to assess the quality and util- ity of much of this information. Research suggests that patients and the public need and prefer local, hospital or provider recommended sources of reli- able health information. Recommendations AHCs should take a leadership role in identifying, making available, and assur- ing quality health care information for their patients and the public over the The vast data-generation and -handling Internet. technologies coming online guarantee that there will be unprecedented, ongoing Implementation Guidelines development of resources to assess quality, AHCs should create or seek partner- safety, performance, outcomes, and other ships in a Web site or sites that provide health care metrics. their patients and public with relevant, reliable, timely and trustworthy health information and educational materials. AHCs not yet ready or able to create their own sites can often partner in the editorial and quality control of e-health content for Web sites otherwise available to patients and the public. 33 Universal Coverage and Value-driven Health Care The Internet enables significant advances vulnerable in the population. Employer- in standardization and empowerment in based health insurance systems provide health care. Standardization allows data to coverage for most of the non-poor and be shared across systems, users, and sites, non-elderly employed and their families. contributing to the de-balkanization of Yet, consistently since the 1960s, about 15 health care. This, in turn, enables the percent of the population has not been development of unprecedented improve- covered by any of these programs. In its ments in the speed, accuracy, and cost of most recent report, published September health care, information utilization, and 28, 2000, the U.S. Census Bureau reported care management. The empowerment of 42.6 million uninsured at the end of 1999, patients and providers through the cre- down from 44.3 million in 1998 – a drop ation of new technologies and the diffu- of 3.8 percent. This was the first drop sion of new knowledge provides recorded by the agency since it began opportunities for gains in professional- counting the uninsured in 1987, lowering directed and self-managed health and the percentage of uninsured Americans care. Both are necessary to progress from 16.3 to 15.5 percent. The bulk of the towards a more cost effective and effica- decline was attributed to the expansion of cious health care system. employment-related health insurance. Nevertheless, projections suggest that the By themselves, standardization and empow- number of uninsured could grow signifi- erment are not sufficient to the develop- cantly during a substantial downturn in ment of a health care system that provides the economy (U.S. Census Bureau, 2000). quality, affordable health care services for the entire population. The actuarial, The rapid transition over the last decade resource utilization, and other metrics from the traditional fee-for-service insur- required to provide the best value and out- ance system to a managed care model has comes in managing health services for a served, if nothing else, to provide unprece- group or population depends upon the abil- dented public and professional exposure ity to define, measure, and then work with to the choices and trade offs necessitated the group. Both nationally and locally, a by a more cost-sensitive health care mar- progressive, value-driven health system ket place. Managed care organizations and remains unworkable absent an inclusive self-insured employers have developed system of universal coverage for health increasingly sophisticated systems for services. Although the Internet as a plat- managing utilization, population health, form may or may not help catalyze move- patient education, and actuarial risk (often ment towards universal access to affordable shifting it to providers). Providers are health insurance coverage, it is proving to learning more efficient utilization, patient be a platform upon which both public and education and care, and risk (including private payors are learning a great deal population health) management. Patients about value-driven health services. and consumers are becoming more aware of the costs and consequences of Since the early 1960s, the Medicare and unhealthy behaviors and environmental Medicaid programs provide coverage for conditions; they are becoming more health care services for many of the most informed buyers of health care products 34 and services; and they are becoming more manage. Many payors are working to active participants and advocates in man- manage this conflict by leveraging the aging their health and care. Internet to develop health coverage that provides new levels of information and Despite these gains, it is fair to say that choice to consumers and patients. About few providers, payors, or patients are very 20 percent of payors currently enable happy with the state of the health care sys- members, employers and/or providers to tem. Providers have had to cope with new conduct online transactions (First productivity and efficiency demands and Consulting Group, 2000). Along with sometimes drastically reduced payments greater information and choice, it is likely for services. Health care workers and pro- that payors are also going to introduce fessionals universally report less satisfac- new coverage models that require and tion and more stress in their work enable consumers to assume increased environments. Both payor and provider responsibility for managing the costs and organizations have been forced to engineer administration of their care (Goldsmith, significant changes in benefit plans, prod- 2000). uct lines, payments systems, regulatory and compliance rules. Many payors and providers have had to reorganize, reduce, or eliminate services, infrastructure, and staff. Patients and the public have been The Blue Ridge Group believes that the wide- dissatisfied with many cost reduction poli- spread dissatisfaction from all quarters with cies that sacrifice provider choice and per- the existing system indicates that the health haps service quality. All have been affected care system must and will continue to change. by rising drug and device prices. Making all of these challenges and changes more difficult is the absence of clear policies or system goals, except perhaps the goal of cost containment, to guide planning and decision-making at the national or even Blue Cross/Blue Shield of California regional or local levels. (blueshieldca.com) subscribers can access health benefits information, research The Blue Ridge Group believes that the providers’ backgrounds, choose care widespread dissatisfaction from all quar- providers and provide quality assurance ters with the existing system indicates that and customer satisfaction feedback. Their the health care system must and will con- MyLifePath.com site also offers the full tinue to change. Absent significant nation- range of consumer health news and infor- al policy initiatives, the market place and mation. Blue Cross/Blue Shield of South consumer pressure are likely to be the two Carolina provides online access to a vari- strongest drivers of system change. ety of information and functions for HMOs, insurers, self-insured employers, members, employers, providers, and bro- and other payors face challenging and kers. Members can use the online My conflicting cost control and consumer Insurance Manager to check claims status, pressures that are increasingly difficult to inpatient and outpatient eligibility and 35 authorization status, the status of bills, the retail banking industry put the costs and how much they have paid towards for manual teller transactions at $1.07 per their deductible. Payors like Highmark transaction. Moving transactions to the Blue Cross/Blue Shield of Pennsylvania Internet reduced these costs to $.10 or less. (highmark.com), are also starting to sell Traditional paper systems for claims pro- health insurance directly to consumers cessing cost an average of $7 per claim to online, thereby removing the middle submit. The same claims submitted over man/insurance brokers (many of whom are the Internet cost $.30. Potential savings scrambling to Web-enable their businesses). from electronic management and transac- Employer-payors are increasingly taking tions for the payor industry have been esti- advantage of the Internet to manage or out- mated to be $18 billion (Darlington, source human resource functions. 1998). By moving these capabilities online, payors As payors and employers Web-enable sub- can use the Internet platform to further scriber information and functions, they customize information, services, and are looking for opportunities to meet con- functions while collecting, tracking, and sumer demand for choice while bolstering analyzing extraordinary new data their own risk management strategies. resources by which they can reduce costs The traditional model for employee health and manage care. They can customize and benefits is built around employers provid- deliver interactive disease management ing a finite set of benefits options (some- resources to high-risk subscribers, track times only one) from which their variability in patient risk and cost in employees can choose. Employees often delivery systems, and promote informed are not satisfied with the limited choice of choice concerning invasive versus non- coverage and providers. A new model invasive or alternative therapies. By link- would have employers simply providing a ing patients with their physicians, either defined contribution to the costs of cover- with automatic alerts or manual querying, age (plus perhaps catastrophic coverage), they can head off emergency room visits empowering the employee to pick and and other costly inefficiencies or mis- choose from a broad menu of benefits and takes. And of course in connecting direct- options offered by an employer retained e- ly with providers and employers, payors broker, or to go out into the market place can accelerate claims and eligibility and choose their own plans. Health plans review, instantaneously make payments, would compete for employees’ dollars as and automatically bill patients’ credit employees build custom-designed virtual cards for co-pays. health plans or choose among health net- works on the Web. By employing an Internet platform, payors have an opportunity to introduce improved The theoretical appeal of defined contri- efficiencies and new levels of customer sat- bution systems is hard to argue with, isfaction. Based on estimates from other since it appears to fit both consumer industries, e-enabling administrative and desire for empowerment and payors’ and transaction processes could yield cost sav- employers’ desires to control costs and ings in the billions of dollars. For instance, share or shift risks to those who incur 36 the costs. Nevertheless, this will not be an expectations. It is possible to foresee a easy system to implement. Among the variety of future developments. complex issues to be addressed are: For instance, the example set by employ- • The implications of risk pool fragmentation, er contributions could be extended by and whether new concepts of risk and new group-identity structures must or can be popular demand to federal and state pay- developed; ors. There are already many advocates for the creation of Medicare and Medicaid • Affordability and cost stability for consumers; defined contribution programs, for the • The future of medical management and ability expansion of the Federal Employees to track utilization, claims, and other data; Health Benefits Program (FEHB), and for tax credits for individual and family • Customer service and consumer protection; health coverage purchases. Unexpected • Identifying incentives to improve care complications and problems with estab- coordination; lishing fair and open markets in coverage • The cost of catastrophic umbrella/out of options could create a consumer backlash network coverage; and against the market-based approach. Would the generalization of the defined • Information and data management challenges contribution model result in increased in supporting an open benefits market. cooperation or competition between pub- lic and private sector payors and pro- So while there is a significant opportunity grams? How much of a regulatory for payors to recast their businesses, for framework would be required and how employers to reduce their benefits costs, truly “free” could or would such a market and for employees to achieve new levels be? These and many other critical public of health market choice, there are also policy issues would have to be addressed daunting implementation challenges. before a defined contribution model These challenges ensure that there will be could be implemented. an incremental transition towards defined contribution, employee and consumer The movement towards a defined contri- choice coverage models, likely extending bution model is also likely to refocus and through the next decade. perhaps intensify the continuing debate on universal coverage. It could well lead Nevertheless, change in this direction also to the development of new knowl- could have significant implications for the edge and new information systems that health care system. Progressively empow- will provide the online technical and data ering consumers with increasingly sophis- foundations for revolutionizing under- ticated information systems by which to writing and creating new mechanisms for participate in a competitive market place extending coverage universally. for health care coverage could have a sig- nificant impact on consumers’ and patients’ knowledge, experiences, and 37 Universal Coverage and Value-driven Health Care Findings and Recommendations payors and employers as well as policy- makers to ensure that the evolution of consumer directed medical and benefits Findings • Payors and employers, along with spe- management strategies and payment cialized vendors and other health care systems track and report information on organizations, are using the Internet to quality, outcomes, and other metrics of provide new levels of information, service, care necessary to informed consumer and functionality to consumers, patients, choice of plan and provider. providers, and others in the manage- ment of health care and insurance cov- • AHCs should continue to advocate for erage. There will be gradually increasing public policy that is more supportive of opportunities for AHCs and other e-health care, including addressing limi- provider organizations to adopt or out- tations on reimbursement for telemedi- source HR and benefits management cine, state barriers to e-health, and capabilities for their employees. Internet access issues. Progress in these areas is vital to achieving universal cov- • In order to better manage risk and erage and the transition to a value-driven cost, payors and employers are explor- health care system. ing “defined contribution” strategies that leverage advancing information technol- ogy and consumer/employee desire for maximum choice of benefits and providers. • While it is impossible to predict with certainty, the trajectory of payor and employer online technologies, capabili- ties, and strategies suggests that many new and important tools could be creat- ed for use by both public and private payors to enhance the technical and data foundations necessary for progress in extending coverage universally. Recommendations • AHCs and other provider organizations should explore opportunities to vastly improve relationships with payors through online transaction and informa- tion processing. AHCs should also explore opportunities to better manage and/or outsource in-house HR functions. • AHCs should seek to work closely with 38 Conclusion The Internet is rapidly becoming a major force in the transformation of health care. It enables the standardization of health industry data and allows con- nectivity for transactions and communica- tions. It empowers providers and patients in the care process and is likely to con- tribute significantly to the development of insurance coverage that provides univer- sal access to quality healthcare. For AHCs, the Internet and Internet- based technologies serve many functions and can be employed to support core mis- sions in research, education, and patient care. In turn, AHCs and their faculties are well positioned to play critical roles in shaping and enhancing online health resources and capabilities. The Internet is spawning many of the tools and technolo- gies necessary to the establishment of a value-driven health care system. AHCs and other health care organizations are well advised to take full advantage of this extraordinary opportunity. It is not the strongest of the species that survives, not the most intelligent, but the one most responsive to change. – Charles Darwin 39 About the Blue Ridge Academic Health Group seasoned, active leaders with a broad range of experience in and knowledge of The Blue Ridge Academic Health Group academic health centers in the United seeks to take a societal view of health and States. Other participants are invited to health care needs and to make recommen- Blue Ridge Group meetings to bring addi- dations to academic health centers to help tional expertise or perspectives on a specific them create greater value for society. The topic. Blue Ridge Group also recommends pub- lic policies to enable AHCs to accomplish Blue Ridge Group members collectively these ends. select the topics to be addressed at annual meetings. Criteria for selection of report Three basic premises underlie this mis- topics include relevance to AHCs’ opera- sion. First, health care in the United tions, consistency with AHCs providing States is experiencing a series of transfor- value to society, the likelihood of being mations that ultimately will require new able to make specific recommendations approaches in health care delivery sys- that will lead to productive action by tems, education, and research. Second, AHCs or other organizations, and the the recent upheavals in health care have ability to frame useful recommendations been largely driven by financial objec- during two-day meetings. tives. Yet the potential exists for funda- mental changes in health care to improve Before each meeting, an extensive litera- health and manage costs. Analysis and ture review is conducted. During the evaluation of the ongoing evolution in meeting, participants reflect on emerging health care delivery must address this trends, share experiences from AHCs, and impact on the health of individuals and hear presentations on specific issues. Most the population, as well as on cost. Third, of the working session is dedicated to a AHCs play a unique role in the U.S. discussion of what AHCs can and should health care system as they develop, apply, be doing in a particular area to achieve and disseminate knowledge to improve visible progress, or a discussion of what health. In so doing, they assume responsi- public and private policy and philanthrop- bilities and encounter challenges other ic organizations can do to facilitate the health care provider institutions do not efforts of AHCs to fulfill their societal mis- bear. As a result, AHCs face greater risks sion. The results of the group’s delibera- and opportunities as the U.S. health care tions are presented in brief reports that are system continues to evolve. disseminated to targeted audiences. The Blue Ridge Group was founded in March 1997 by the Virgina Health Policy Center (VHPC) at the University of Virginia and the Health Market Unit lead- ership at Ernst & Young, LLP (now Cap Gemini Ernst & Young, CGE&Y). Group members were selected to bring together 40 About the Core Members services researchers. David Blumenthal, M.D., M.P.P. Enriqueta C. Bond, Ph.D. Director President Institute for Health Policy Burroughs Wellcome Fund The Massachusetts General Hospital Professor of Medicine and Professor of Dr. Bond is the president of the Burroughs Health Care Policy Wellcome Fund. She formerly held a Harvard Medical School number of research and administrative positions at the Institute of Medicine, Dr. Blumenthal is director, Institute for National Academy of Sciences; Health Policy and physician at The Department of Medical Sciences, Southern Massachusetts General Hospital/Partners Illinois University School of Medicine; Health Care System in Boston, and the Biology Department at Chatham Massachusetts. He is also professor of College. Dr. Bond also serves on several medicine and professor of health care pol- advisory committees and boards, some of icy at Harvard Medical School. Dr. which include the Council of the Institute Blumenthal previously served as senior of Medicine and the National Center for vice president at Boston’s Brigham and Infectious Diseases, Centers for Disease Women’s Hospital, as well as executive Control and Prevention. She has authored director of the Center for Health Policy and co-authored more than 50 publica- and Management and lecturer on public tions and reports in science policy. policy at the John F Kennedy School of . Government at Harvard. Dr. Blumenthal Robert W. Cantrell, M.D. is a member of the Institute of Medicine Vice President and Provost of the National Academy of Sciences and University of Virginia Health System serves on several editorial boards, includ- ing The New England Journal of Medicine, Dr. Cantrell is vice president and provost American Journal of Medicine, Journal of for the Health System at the University of Health Politics, Policy and Law, and the Virginia. He is the former president of the Bulletin of the New York Academy of American Academy of Otolaryngology- Medicine. He serves on advisory commit- Head and Neck Surgery. As a captain in tees to the National Academy of Sciences, the U.S. Navy, he served as chair of the Institute of Medicine, the National Otolaryngology-Head and Neck Surgery at Academy of Social Insurance, and several the Naval Regional Medical Center in San foundations. He is currently executive Diego, California. Dr. Cantrell was also director for The Commonwealth Fund the Fitz Hugh Professor and chair of the Task Force on the Future of Academic Department of Otolaryngology-Head and Health Centers and Chairman of the Neck Surgery at the University of Virginia board of the Massachusetts Peer Review School of Medicine. He also has been a Organization. Dr. Blumenthal is also the consultant to the Surgeon General of the founding chairman of the Academy for U.S. Navy and to the National Institutes Health Services Research and Health of Health (NIH). Dr. Cantrell is a member Policy, the national organization of health or fellow of 33 otolaryngological societies 41 and has taken an active leadership role in many, including the American College of Surgeons, the American Society for Head Michael A. Geheb, M.D. and Neck Surgery, and the American Professor of Medicine and Senior Vice Broncho-Esophagological Association. Dr. President for Clinical Programs Cantrell received the Mosher Award for Oregon Health Sciences University clinical research, has published numerous articles, and lectured nationally and inter- Dr. Geheb is professor of medicine and nationally. senior vice president for Clinical Programs at Oregon Health Sciences Don E. Detmer, M.D. University. Dr. Geheb has also served as Dennis Gillings Professor of professor of medicine, and was the first Health Management director and chief executive officer of the Director University of Alabama at Birmingham Cambridge University Health Health System. Prior to that, Dr. Geheb University of Cambridge was associate dean for Clinical Affairs, and director of Clinical Services at the Dr. Detmer heads the health policy and State University of New York at Stony management center within the Judge Brook University Medical Center. Dr. Institute of Management at Cambridge Geheb’s professional associations include University’s business school. He chairs the the American Federation for Clinical Board on Health Care Services of the Research; the Board of Directors of the Institute of Medicine and is a board mem- University Hospital Consortium; and the ber of several organizations, including the American Board of Internal Medicine’s China Medical Board of New York, the Board of Directors. Dr. Geheb is co-editor Nuffield Trust in London, and the of the textbook Principles and Practice of American Journal of Surgery. He has Medical Intensive Care and authored numerous scientific publica- co-editor for the Critical Care Clinics tions. Dr. Detmer earned his medical series. He also speaks frequently to degree at the University of Kansas after national audiences on health care policy undergraduate studies there and at issues related to academic productivity Durham University of England. He con- and financial models for academic clinical ducts his work with the Blue Ridge Group enterprises. through a professorship at the University of Virginia where in the past he served as Jeff C. Goldsmith, Ph.D. vice president and provost for Health President Sciences and University Professor. Health Futures, Inc. Dr. Goldsmith’s consulting firm assists a wide range of health care organizations with environmental analysis and strategy development. He is a director of Cerner Corporation, a health care informatics 42 firm, and of Essent Healthcare, a hospital clinical institutions and programs in the management firm, as well as a member of health sciences and is a professor in the the Board of Advisors of Burrill and Department of Surgery. A former dean of Company, a private merchant bank in the Johns Hopkins School of Medicine, he biotechnology and health sciences. He is was professor and chair of the currently an associate professor of med- Department of Otolaryngology-Head and ical education at the University of Neck Surgery at Johns Hopkins. Before Virginia. He is a former lecturer in the that he was assistant chief of the Graduate School of Business at the Otolaryngology Service at Walter Reed University of Chicago. He has also lec- Army Medical Center. Dr. Johns is a tured on health services management and member of the Institute of Medicine, and policy at the Harvard Business School, the the Executive Council of the Association Wharton School of Finance, Johns of American Medical Colleges and a fel- Hopkins, Washington University, and the low of the American Association for the University of California at Berkeley. Dr. Advancement of Science. He serves on the Goldsmith has served as national advisor Governing Boards of the National for health care for Ernst & Young LLP, Research Council and the Clinical Center was director of Planning and Government of the National Institutes of Health, and Affairs at the University of Chicago on the advisory committee of the director Medical Center, and special assistant to of the Centers for Disease Control and the dean of the Pritzker School of Prevention. He is the president of the Medicine. Dr. Goldsmith has written for American Board of Otolaryngology, editor the Harvard Business Review and has been of the Archives of Otolaryngology-Head and a source for articles on medical technolo- Neck Surgery, and a member of the Board gy and health services for The Wall Street of Trustees of Genuine Parts Company. Journal, The New York Times, Business Dr. Johns received his Bachelor’s degree Week, Time and other publications. He is a and continued with graduate studies in member of the editorial board of Health biology at Wayne State University. He Affairs. He earned his doctorate in earned his M.D. at the University of Sociology from the University of Chicago Michigan School of Medicine. in 1973. Peter O. Kohler, M.D. Michael M.E. Johns, M.D. President Executive Vice President for Health Affairs Oregon Health Sciences University Emory University Director Dr. Kohler is president of Oregon Health The Robert W. Woodruff Health Sciences Sciences University. After holding posi- Center tions at the National Institutes of Health Chairman of the Board and Chief Executive (NIH), he became professor of medicine Officer and chief of the Endocrinology Division Emory Health Care at Baylor College of Medicine. Later, he served as chairman of the Department of Dr. Johns heads Emory’s academic and Medicine at the University of Arkansas 43 and then as dean of the Medical School at the University of Texas Health Science Center in San Antonio. Dr. Kohler has Jeffrey Otten, M.A., M.B.A. served on several boards. He has been President chairman of the NIH Endocrinology Brigham and Women’s Hospital Study Section and chairman of the Board of Scientific Counselors for the National Mr. Otten is president of Brigham and Institute of Child Health and Human Women’s Hospital where he previously Development. Currently, he is chairman served as executive vice president and of the Institute of Medicine Task Force on chief operating officer. Before joining Quality in Long-term Care and past-chair Brigham and Women’s, Mr. Otten was of the Board of Directors of the chief operating officer for the Hospital of Association of Academic Health Centers. the University of Pennsylvania in Dr. Kohler received his B.A. from the Philadelphia and associate director and University of Virginia and earned his M.D. chief financial officer at UCLA Medical at Duke Medical School. Center in Los Angeles. He has also served in senior management positions at Los Edward D. Miller, Jr., M.D. Angeles County – USC Medical Center Dean and Chief Executive Officer and Harbor – UCLA Medical Center. In Johns Hopkins Medicine addition, he has been a consultant in health care strategy and financial manage- Dr. Miller is chief executive officer of ment. He has held teaching positions at Johns Hopkins Medicine. His former California State University Los Angeles, posts include chairman of the Department UCLA, Wharton, and the Harvard School of Anesthesiology and Critical Care of Public Health. Mr. Otten is the immedi- Medicine; Interim dean of the School of ate past chairman of the Massachusetts Medicine; professor of anesthesiology and Hospital Association (MHA). He is direc- surgery and medical director of the tor of corporate development of the Surgical Intensive Care Unit at the Massachusetts Heart Association, chair- University of Virginia; E.M. Papper elect of the Board of Trustees of the Professor at Columbia University; and Greater Boston Food Bank, a member of chairman of the Department of the Boston 2000 Consortium, and vice Anesthesiology in the College of chair and executive committee member of Physicians and Surgeons. Dr. Miller has University Healthsystems Consortium. authored and co-authored more than 150 Mr. Otten also serves on the Board of the scientific abstracts and book chapters. He Council of Teaching Hospitals at the received his A.B. from Ohio Wesleyan Association of American Medical University and his M.D. from the Colleges. He received a Master of Arts University of Rochester School of degree in 1975 and a Master of Business Medicine and Dentistry. Administration degree in 1983 from the University of California at Los Angeles. 44 Mark L. Penkhus, M.H.A., M.B.A. Paul L. Ruflin, M.B.A. Chief Executive Officer and Vice President Executive Director Health/Managed Care Consulting Practice Vanderbilt University Hospital Cap Gemini Ernst & Young U.S., LLC Mr. Penkhus is chief executive officer and Mr. Ruflin leads the health/managed care executive director of Vanderbilt University consulting practice for Cap Gemini Ernst Hospital. Prior to joining Vanderbilt, Mr. & Young U.S., LLC (CGE&Y) and is Penkhus was a partner and business unit responsible for all business development leader for Healthcare Consulting (Mid- and service delivery to CGE&Y’s provider, Atlantic area) in Washington D.C. for managed care, and health/technology Ernst and Young LLP, and served as a clients. He has over twenty years of health national leader for academic health cen- care consulting experience with a focus ters. During his career, he has worked on developing and implementing strate- with a variety of organizations as an inno- gies to transform health organizations vator, and change agent with a special including major providers and academic emphasis on strategic, operational, and medical centers. He previously served as financial performance improvement. Mr. director for business transformation serv- Penkhus received a B.S. degree from Iowa ices for the health consulting practice State University, a master’s degree in where he had national responsibilities for Hospital and Health Care Administration operations improvement, merger integra- from the University of Iowa, and an tion, turnaround, medical management, M.B.A. from Rensselaer Polytechnic physician practice management, supply Institute in New York. He is also a gradu- chain, clinical improvement, and benefits ate of the Advanced Management realization services. Mr. Ruflin is a CPA, Program, Wharton School of Business, at and holds a M.B.A. from Bowling Green the University of Pennsylvania. He is a State University and a B.A. in Accounting fellow of the American College of from Walsh College. He is a member of Healthcare Executives (ACHE), a fellow AICPA, Ohio Society of CPAs, Hospital in Project HOPE, Washington D.C., and a Information Management Systems Society, member of the Johns Hopkins University and Healthcare Financial Management School of Hygiene and Public Health, Association. Department of Health Policy and Management. Mr. Penkhus serves on sev- eral non-profit and for-profit boards in Tennessee and nationally. 45 George F. Sheldon, M.D. Katherine W. Vestal, Ph.D. Chairman and Professor Vice President Department of Surgery Health Consulting Practice University of North Carolina at Chapel Hill Cap Gemini Ernst & Young U.S., LLC Dr. Sheldon’s background in graduate Dr. Vestal leads the academic health cen- medical education spans four institutions: ter sector for Cap Gemini Ernst & Young’s Kansas University, Mayo Clinic, University (CGE&Y) health consulting practice of California at San Francisco, and where she focuses on large-scale organiza- Harvard University. He is currently chair- tional change for a wide range of health man and professor, Department of Surgery care delivery organizations. Prior to join- at the University of North Carolina at ing CGE&Y, Dr. Vestal held several exec- Chapel Hill and was formerly professor of utive positions in academic health centers surgery in the Department of Surgery at and taught at the graduate level at the the University of California, San University of Texas. Her background Francisco. He has held several national includes over 25 years of operations man- appointments, including: president of the agement and consulting in the areas of American Surgical Association and chair- business transformation, post merger inte- man of both the American Board of gration, and clinical management. She Surgery and Council on Graduate Medical speaks nationally on issues of organiza- Education. He is currently chair of the tional improvement and is a Malcolm Association of American Medical Colleges. Baldrige National Quality Award He was past president of the American Examiner. Dr. Vestal received a B.S.N. College of Surgeons, and past chair of the from Texas Christian University, an M.S. Council of Academic Societies of the from Texas Women’s University, and a Association of American Medical Colleges. Ph.D. from Texas A & M University. She He has published 195 articles and book is a Fellow of the Johnson and Johnson chapters and co-authored eight books. Wharton School of Finance, American College of Healthcare Executives, and the American Academy of Nursing. 46 About the Invited Participants Jordan J. Cohen, M.D. Special Medical Advisory Group of the President and Chief Executive Officer Department of Veterans Affairs. In 1994, Association of American Medical Colleges Dr. Cohen was named a member of the National Academy of Sciences Institute of Dr. Cohen’s career in academic medicine Medicine. He is a graduate of Yale spans almost 40 years. Most recently, he University and Harvard Medical School served as dean of the medical school and and completed his postgraduate training professor of medicine at the State in internal medicine in Harvard service at University of New York at Stony Brook, the Boston City Hospital. He completed a and president of the medical staff at fellowship in nephrology at the Tufts-New University Hospital. Prior to serving as England Medical Center. He is the author dean at SUNY-Stony Brook, Dr. Cohen of more than 100 publications and is edi- served as professor and associate chair- tor of Kidney International’s Nephrology man of Medicine at the University of Forum. Chicago-Pritzker School of Medicine, and physician-in-chief and chairman of the Dennis Gillings, Ph.D. Department of Medicine at the Michael Chairman and Chief Executive Officer Reese Hospital and Medical Center. He Quintiles Transnational Corporation has held medical faculty positions at Harvard, Brown, and Tufts universities. Dr. Gillings began providing statistical Dr. Cohen is also a former president of consulting and data management services the medical staff at the New England to pharmaceutical clients in 1974 during Medical Center Hospital in Boston. He his tenure as professor of biostatistics at has held a wide variety of leadership posi- the University of North Carolina in tions in almost all aspects of academic Chapel Hill. Quintiles grew from his con- medicine, including chair of the American sulting activities and was incorporated in Board of Internal Medicine and the 1982. Today, Quintiles has 19,000 Accreditation Council for Graduate employees in 38 countries around the Medical Education, as well as president of world. It is the global market leader in the Association of Program Directors of helping pharmaceutical, biotechnology Internal Medicine. A member of the and medical device companies develop, American College of Physicians since market and sell their products. Dr. 1978, he has served as vice chair of its Gillings devotes much of his time to Board of Regents and Chair of its strategic planning for continued interna- Education Policy Committee; he was tional expansion of Quintiles. In addition, awarded a mastership from the college in he oversees day-to-day operations of the 1993. Concurrent with his leadership of company. Dr. Gillings has consulted for the AAMC, Dr. Cohen also serves on the the pharmaceutical and biotechnology Board of Directors of the Foundation for industries and has worked with a number Biomedical Research and of agencies, including the National Research!America, and is a Trustee of the Cancer Institute, the National Institute for Educational Commission for Foreign Dental Research, and the Institute of Medical Graduates. He is a member of the Medicine. He has published widely in 47 scientific and medical journals. Dr. Gillings’ of the advisory board of Counterpart research interests include statistical meth- Capital, and a fellow of HIMSS and ods in the analysis of clinical trials and CHIME and a member of the American mathematical models to improve the College of Medical Informatics. Dr. Glaser delivery of health services in fields such as has been awarded the John Gall award for cancer, perinatal care, cardiovascular dis- health care CIO of the year. Partners ease and rheumatology. Dr. Gillings serves Healthcare has received several industry on several boards and councils, including awards for its effective and innovative use the University of North Carolina School of of information technology. Dr. Glaser has Public Health Dean’s Advisory Council; been a member of National Academy of the Graduate Education Advancement Sciences studies on the role of the Board of the Graduate School of the Internet in health care and health care University of North Carolina at Chapel confidentiality and security. He is on the Hill; North Carolina Institute of Medicine; editorial boards of CIO Magazine, ICAgen, Inc., Triangle Pharmaceuticals, Healthcare Informatics and Topics in Health Inc., and Healtheon/WebMD. Dr. Gillings Information Management. He has pub- received a diploma in Mathematical lished over fifty articles and a book on the Statistics from Cambridge University in strategic application of information tech- 1967 and a Ph.D. in Mathematics from the nology in health care. He holds a Ph.D. in University of Exeter, England, in 1972. He Healthcare Information Systems from the served for more than 15 years as professor University of Minnesota. at the University of North Carolina at Chapel Hill. Andrew Vaz Vice President John P. Glaser, Ph.D. National Health e-Commerce Practice Vice President and Chief Information Officer Cap Gemini Ernst & Young U.S., LLC Partners HealthCare System, Inc. Mr. Vaz is vice president managing the Dr. Glaser is vice president and chief National Health eCommerce practice for information officer, Partners Healthcare Cap Gemini Ernst & Young U.S., LLC. He System, Inc. Previously, he was vice presi- leads the development of the firm’s dent, Information Systems at Brigham and methodology and intellectual capital in Women’s Hospital. Prior to Brigham and the areas of e-Commerce and business Women’s Hospital, Dr. Glaser managed strategy for both the provider and payor the Healthcare Information Systems con- sectors. Mr. Vaz also holds responsibility sulting practice at Arthur D. Little. Dr. for the firm’s health care “dot com” prac- Glaser was the founding chairman of the tice and health new ventures initiatives. College of Healthcare Information Prior to his current role, he was the man- Management Executives (CHIME) and is aging partner of Ernst & Young’s past president of the Healthcare Northeast U.S. health practice and the Information and Management Systems national director of the Canadian health Society (HIMSS). He was the founding co- care practice. Mr. Vaz’s consulting career chair of the Affiliated Health Information has spanned strategy and business plan- Networks of New England, is a member ning, business transformation and the 48 management of change. His client base has included academic medical centers, large integrated delivery systems, managed care companies and most recently, “dot coms” in the health care space. He has successfully led the development of e- Commerce strategies for world class health organizations, enterprise wide business transformation and re-engineering of aca- demic medical centers in Canada and the U.S., facilitated numerous mergers and joint ventures, and developed leading edge strategies for organizations in the provider, payor and life sciences sectors. 49 References Blue Ridge Academic Health Group. First Consulting Group. 2000. Survey: 1998a. Academic Health Centers: Getting Health Plans on the Road to e-Health. Down to Business. Washington, D.C.: Cap Gemini Ernst & Young. Goldsmith, J. 2000. The Internet and managed care: a new wave of innovation. Blue Ridge Academic Health Group. Health Affairs 19 (6): 42-56. 1998b. Promoting Value and Expanded Coverage: Good Health is Good Business. Kleinke, J.D. 2000. Vaporware.com: the Washington, D.C.: Cap Gemini Ernst & failed promise of the health care Internet. Young. Health Affairs 19 (6): 57-71. Blue Ridge Academic Health Group. Kohane, I.S., Greenspun, P., Fackler, J., 2000a. Into the 21st Century: Academic Cimino C., Szolovits, P. 1996. Building Health Centers as Knowledge Leaders. national electronic medical record systems Washington, D.C.: Cap Gemini Ernst & via the World Wide Web. Journal of the Young. American Medical Informatics Association 3 (3) 191-207. Blue Ridge Academic Health Group. 2001. In Pursuit of Greater Value: Stronger National Committee on Vital and Health Leadership in and by Academic Health Statistics. 1998. Assuring a Health Centers. Washington, D.C.: Cap Gemini Dimension for the National Information Ernst & Young. Infrastructure. A Concept Paper presented to the U.S. Department of Health and Chassin, M.R. 1998. Is health care ready Human Services Data Council, October for six sigma quality? Milbank Quarterly 14, 1998. 76 (4): 565 – 591. National Research Council. 2000. Darlington, L. 1998. Banking without Networking Health: Prescriptions for the boundaries: how the banking industry is Internet. Washington, D.C.: National transforming itself for the digital age. In Academy Press. Blueprint to the Digital Economy: Creating Wealth in the Era of E-Business. Tapscott, Rich, R. 2000. Personal communication. D., Lowy, A., and Ticoll, D., eds. New York: McGraw Hill. Shortliffe, E.H. 2000. Networking health: learning from others, taking the lead. Drews, J. 1996. Genomic sciences and the Health Affairs 19 (6): 9-22. medicine of tomorrow: commentary on drug development. Nature Biotechnology Silverman, R.D. 2000. Regulating medical 14 (11): 1516-8. practice in the cyber age: issues and chal- lenges for state medical boards. American Journal of Law and Medicine 26 (2000): 255-276. 50 Tapscott, D., Lowy, A., and Ticoll, D., eds. 1998. Blueprint to the Digital Economy: Creating Wealth in the Era of E-Business. New York: McGraw Hill. U.S. Census Bureau. 2000. Health Insurance Coverage: 1999. (P60-211). http://www.census.gov/hhes/www/hlth- in99.html. Valovic, T.S. 2000. Digital Mythologies: The Hidden Complexities of the Internet. New Brunswick, New Jersey: Rutgers University Press. Varmus, H., et. al. 1999. E-BIOMED: a proposal for electronic publications in the biomedical sciences. http://www.nih.gov/about/director/pub- medcentral/ebiomedarch.htm. WebSurveyMD. 2000. Update on Physicians and the Internet. July 12, 2000. http://Websurveymd.mt01.com/Update_ Physicians_Internet.shtml. 51 Other Sources Bernard, S. 2000. Evolution of the Lathrop, P.J., Ahlquist, G.D., and Knott, e-health space. Pharmaceutical Executive D.G. 2000. Health care’s new electronic (Supplement) March 2000. marketplace. Strategy and Business 19: 34-43. Bernard, S. 2000. Health plans take net steps. Internet Healthcare Strategies July Wurster, T.S. 1999. Getting real about 2000: 8-9. virtual commerce. Harvard Business Review November/December 1999: 84-95. 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