The Internet enables quick establishment of e-commerce networks for healthcare

By Andy Shaw

The eHealth Solutions Group at BCE Emergis now processes health insurance claims for a lion’s share of the North American market – including the claim transactions of 20,000 hospitals, clinics, and other care-provider groups, as well as 150,000 physicians in the United States. But the roots of this Ma Bell spin-off, headquartered in Mississauga, Ontario, are all-Canadian. Its work continues here at a billion-dollars-a-year clip. The eHealth Group grew from Assure Health, founded by Ron Loucks in 1989, and taken over by BCE just two years ago. Loucks now runs the Group.

“At Assure, we basically took paper-based insurance claims, be they drug or dental, and turned them into electronically adjudicated, real-time claims,” says Loucks. “So now (at the eHealth Group) we have all the pharmacists in Canada and about 9,000 dentists hooked up. Last year, we processed about $750 million worth of drug claims and about $250 million of dental claims on behalf of nine Canadian insurance companies. And that makes us bigger than all of our competitors combined.”

An 800-pound gorilla though it might be in its field, the eHealth Group, since Assure Health was taken over, has been nimbly entering nearby territory.

“We now have a suite of what you might call horizontal products for the whole healthcare market place,” says Loucks. “We’re offering electronic procurement, invoicing, and CRM, that is, customer relationship management services. And for all those new services we bring to market, the Internet is now the base.”

Of course, the old services weren’t based that way, and still aren’t. In pre-Internet days, Assure spent nearly a decade laboriously hardwiring their nation-wide strings of pharmacies and dentists via third-party data transmission services into its shop.

“It took us about seven years to get all our pharmacists on line,” says Loucks. “But one of the first Internet-based applications we devised at Emergis was for optometrists. To get all 6000 of their offices on line, took us only a day.”

Loucks says this ease of establishing lines of communication has placed the Internet squarely at the centre of BCE Emergis’ technical and marketing strategies.

B2B – New Web-based claims system: “We’re currently developing the first Web-based “claims exchange marketplace” in Canada and we will have it launched by the third quarter of this year,” says Loucks. “Unlike the EDI (electronic data interchange) set-up we use to have where you had to have the pharmacist or other provider hooked up to the adjudicator in order to pay a drug claim, insurance companies have now outsourced that to us and claims can be processed entirely electronically at a fraction of the cost.”

Loucks says about 50 percent of such claims are already being processed electronically, but the new Web exchange will also be able to handle the payment end of traditional paper based claims – where an employee might save up a batch of prescriptions in a shoe box before submitting a claim to his or her organization’s health plan office.

“Insurance companies are still maintaining their expensive mainframe set-ups for processing paper claims, but the volume they handle is down by 50 percent so they are now doubly expensive,” says Loucks. When the Web-exchange is up and running, however, you can go the local pharmacy, pay cash for, and get their prescription. The pharmacist will then ask: Do you want to submit this electronically? If so, the pharmacist will give you a code number on the drug receipt. You then go home, visit the company Web site, pull down an electronic claims form, and enter the particulars of the prescription, the code number, and the co-ordinates for your bank account. Soon, back will come an e-mail confirming your claim, the deductible you pay, and the final amount that has just been placed in your account.”

And Loucks says, for those that are not that computer literate, the pharmacist will be able to make it all happen for you too.

This BCE Emergis example alone suggests just how healthy the business-to-business, or B2B, side of electronic healthcare is these days. There’s more uncertainty, however, on the human side of the equation at the B2C, or business-to-consumer end.

B2C – Not the mainstream: Even though a Harris Poll has found that a whopping 70 million people have used the Internet to seek healthcare information, there’s no convincing evidence in yet that the Internet has become a vital medical or wellness tool. As Dr. Gerald Brock, a urologist at the St. Joseph’s Health Centre in London, Ontario, and one of Mediconsult.com’s on-line, fee-for-service “MediXperts” told Family Practice magazine, “Maybe 30 years from now this (seeking professional medical advice over the Internet) will be a mainstream of medical care. I don’t see it that way. I don’t think this will ever replace to any great extent the patient-physician relationship. This is just another part of the healthcare package.”

Establishing more of those profitable physician-patient relationships via the Internet was also the hope of Toronto’s Mount Sinai Hospital. Using a U.S.-based medical “chat” service, Mount Sinai offered up its top people to the world as hosts for on-line discussions with consumers interested in their various specialties. Mount Sinai has since quietly ended its participation in the service.

“It did not lead to the kind of out-of-country demand for the services of our experts that we had hoped for,” says Lynn Nagle, Mount Sinai’s CIO.

If that Internet strategy failed for Mount Sinai, they are not alone. Though its attempt to reach out to the public was perhaps more imaginative, others have been less so. Writing in the COR Healthcare Market Strategist (www.corhealth.com), Dr. Jeff C. Goldbloom, PhD, concludes: “The Internet and hospitals appear to be creatures of two different geological eras. Like automobile factories, hospitals are very much creatures of the industrial-era ‘old economy’.”

Goldbloom goes on to say that an Internet strategy for most hospitals has amounted to not much more than creating a Web page and re-packaging content from rather shallow commercial databases. Too many hospital Web sites, he says, are full of re-formatted hospital brochures. And comments Goldbloom: “There doesn’t appear to be a large, unslaked thirst for reformatted hospital PR messages.”

On a more upbeat note, Goldbloom observes: “However, progressive hospitals realize that what the Internet represents is a fundamental shift in power toward patients/families, and away from institutions and professionals.”

A Canadian expert heartily agrees. Dr Alejandro Jadad, not yet out of his 30s, has already had a distinguished career in health informatics. The Colombian-born physician, has a Ph.D. from Oxford University. He was one of the first physicians in the world to hold a doctorate in knowledge synthesis. First landing at McMaster University in Hamilton, Ont., Dr. Jadad, or Alex as he prefers to be called, is now at the University of Toronto. There he is a senior scientist in healthcare research, a professor of health administration, and head of the Program in eHealth Innovation.

“Our health system is very conservative because its built on that industrial age model. So it needs to be re-created to match the needs of the information age, says Dr. Jadad. “And there’s no choice about it. We will have to change the system because people want it to change. They know what is possible. So, we need to re-create our relationship with the public because it is expecting more and demanding more.”

The challenge then becomes, adds Dr. Jadad, not whether hospitals and other healthcare providers will get on the B2C Internet bandwagon, but how.

“The change needs to be made efficiently, equitably, and responsibly. But right now we have different projects going all over the world in different directions. There’s lots of duplication, lots of wasted effort, and plenty of missed opportunities for collaboration,” says Dr. Jadad.

As a result, Dr. Jadad is striving to bring order to this global chaos. At the U of T, he’s building up a network of like-minded innovators. “We want to develop a mini-model of the world in Canada. We’ll be working with communities from over 150 countries. We’ll find out what’s working where in a very rigorous and research based way,” says Jadad.

Dr. Jadad’s Centre for Global eHealth Innovation, for which he is now seeking financial and academic partners, will feature labs to conduct experiments in simulated conditions as well as provide support to real-world hospitals, physicians, and community care providers faced with making decision about IT. Generally, the Centre will strive to “accelerate the study of the role of technology in the health system and society, in Canada and worldwide.”

Still nothing like a story well told.

Despite those lofty aspirations, Dr. Jadad has his feet still planted firmly in the reality of how humans actually communicate. He believes the Internet, with its multi-media capabilities, maybe our modern times’ best way to revive an ancient yet still effective way of conveying knowledge – story telling.

“Stories can convey a message, a truth beyond factual truth. Vivid stories and anecdotes are among the most powerful tools that humans use to make decisions,” writes Jadad. “Although there has been some recognition of their importance in healthcare ... they tend to be misused, undervalued and relegated to the bottom of the ‘evidence hierarchy’.”

In the end, however much of a effective story teller the Internet turns out to be for either B2C or B2B communications, Dr. Jadad reminds us of what messages such stories should convey and what facts about human nature they must heed – in an article (The new alchemy: transmuting information into knowledge in an electronic age (see www.cma.ca/cmaj/vol-162/issue-13/1826.htm) he co-wrote while at McMaster’s Health Research Information Centre with Dr. Murray. W. Enkin:

“Phenomena we witness with our own eyes make a greater impression than second-hand data. Face-to-face recommendations are more influential than hard data presented impersonally. Recommendations by a respected colleague are a more powerful force for change in clinical practice than evidence-based guidelines published nationally. Clearly, anecdotal and research evidence should play complementary rather than competitive roles in healthcare decision-making.”

Amen!

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Major hospitals ready to test MedcomSoft’s electronic patient software

By Jerry Zeidenberg

TORONTO – MedcomSoft Inc. announced that two major medical centres – Toronto’s Sunnybrook & Women’s College Health Sciences Centre and Johns Hopkins Hospital in Baltimore – will soon test its electronic patient-record software.

Moreover, Jim Gordon, the mayor of Sudbury declared at a meeting held here that his city intends to test the software on a community-wide basis, using its new high-speed, fibre-optic system for data communications.

MedcomSoft president and CEO Dr. Sami Aita said the tests are a method of introducing the software to key users and of raising its credibility. He predicted that 10 to 20 hospitals across North America will experiment with the software this year.

Medcomsoft’s software – called MedWorks – is the first complete system to make use of the Medcin database, which was developed by Medicomp Systems Inc. of Chantilly, Va. Medcin contains 200,000 data elements, including symptoms, tests, diagnoses and therapies that are logically linked.

For its part, Medcomsoft used the Medcin software as the core of its own medical record system, and created a user-friendly application and platform around it.

Overall, the software is said to be much faster and easier for doctors to use than other systems on the market. Dr. Aita claims a patient encounter can be documented in 1.5 minutes instead of the 15 minutes typically needed when using traditional patient record software.

That’s because the software will automatically display a series of pop-up choices for the physician to drill through and create a record of the encounter. These pop-up choices can be quickly checked with a stylus or on a keyboard.

The result is an extensive, computerized, text record for the physician. What’s more, the Medcin database is updated every six months, thereby presenting the physician with the latest diagnoses and therapies.

If a doctor is unfamiliar with any of the new information, web links can connect him or her to appropriate sites on the Internet or on a hospital-based Intranet.

The system can also be used for hospital or region-wide outcomes analysis. Information from multiple encounters could be loaded into a data warehouse, showing healthcare managers the best medical treatments, and their costs.

“We can verify the outcome of various therapies, so we understand whether we’re doing the right thing,” said Dr. Aita. “We can then adjust the therapies.”

He said this will reduce the cost of delivering medical care more than de-listing services, one of the current strategies used by healthcare systems.

Dr. Aita also announced that MedcomSoft has struck an agreement with Mytec of Toronto, to build biometric security into the system. Medcomsoft will make use of Mytec’s fingerprint authorization software and readers to safeguard access to the medical record system.

MedWorks also makes use of other security procedures, such as digital certificates and encryption for the transfer of information. “It will log the users, as well, to determine who accessed a record, and who looked for longer than 15 seconds,” said Dr. Aita. “It can also lock the data after a certain number of days, whatever the local laws are, so that data can only be added and the original data cannot be changed.”

One of the features about MedWorks that doctors appear to like is the ability to customize it. Instead of searching through all 200,000 data elements in the system, templates or ‘protocols’ can be made for various specialties, such as orthopedics.

Indeed, Johns Hopkins will be testing the advanced electronic medical system in connection with the centre’s orthopedic clinic.

“We’ve found the software to be open, malleable, expandable,” said Dr. Peter Evans, director of orthopedic research at the Johns Hopkins Bayview Medical Center. He said the goal is to use MedcomSoft’s system to create “a total orthopedic electronic medical record.”

Dr. Evans, originally from Canada, is now moving to the Cleveland Clinic. He plans to implement the MedcomSoft software there, as well.

Meanwhile, Toronto’s Sunnybrook hospital this year launched the Centre for Applied Health Informatics with start-up funding of nearly $1 million. It will test electronic medical records, and the intention is to examine MedWorks to see if it is effective across the various specialties of the hospital. That will include departments such as surgery, orthopedics, critical care, long-term care, and the various medical clinics run by the hospital.

“We want to see the results from a broad perspective,” said Dr. Glen Geiger, director of the new center, “from many departments, and from people who have various levels of commitment [to using electronic patient records].”

Sunnybrook will look at the effect of the electronic patient record on information flow and patient care. “A neo-natal ICU might have just two hours to prepare all the documentation to discharge a baby. We want to see, for example, if they’re better off using electronic systems, and what the difference actually turns out to be.”

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Ottawa announces CHIPP awards for telehealth, EMRs

By Jerry Zeidenberg

Ottawa has started to announce the winners of its CHIPP awards, the telehealth and electronic medical-record program that has been eagerly anticipated by hospitals, health regions and vendors alike. The government-run program will pump $80 million of federal money into the development of distance-medicine and EMR projects across the country.

As a shared-cost program, the winners are required to provide matching funds. Overall, the infusion of cash and government expertise is expected to re-energize the telemedicine sector, which has been in a lull for the last year as project organizers waited to see if they would qualify for CHIPP funding.

“It’s going to have quite an impact,” predicted Sandra Chatterton, a senior policy advisor with the Canada Health Infostructure Partnerships Program (CHIPP) in Ottawa. She stressed that Ottawa will not only contribute cash to the projects, but will also lend management consulting expertise.

Over 180 projects applied for financing through CHIPP, requesting more than $500 million worth of financial support. Under the terms of the program, the applicants must be not-for-profit or government organizations engaged in healthcare delivery.

The government selected about 30 winners, and by early April, had publicized five of them. There has been no official launch event in Ottawa or elsewhere in the country. Instead, local members of parliament and senators have been holding smaller meetings in their ridings.

There are a few reasons for the low-key approach. First, the exact number of winning projects has not yet been determined, as some of the consortiums given the go-ahead did not receive as much funding as they expected. These groups are still deciding whether to proceed with their plans.

Second, Health Minister Allan Rock has been recovering from prostate cancer surgery, and during his recovery has been unable to make major announcements, Chatterton explained.

Details about five projects given the green light can be found by searching the Health Canada web site.

In brief, they are:

• Ottawa will invest $8.5 million in the Northern Ontario Remote Telecommunications Health (NORTH) Network, allowing it to move into its second phase of implementation. NORTH plans to expand the number of sites that are linked by videoconferencing and remote medical instruments. The project will connect rural and remote communities in northern Ontario, and referral centres such as Thunder Bay and Sudbury, to academic health science facilities in southern Ontario and Winnipeg. The NORTH network will provide residents in rural and remote communities with access to over 30 medical specialty services, including cardiology and dermatology.

• The federal government will contribute over $3.86 million to Manitoba community health and research initiatives. (In this case, CHIPP is one of several organizations providing funding.)

• Up to $3 million for development of the British Columbia Telehealth Program in partnership with the Health Association of B.C. The expansion of the B.C. Telehealth Program is designed help deliver more accessible healthcare to communities across the province. In particular, the goal is to provide care closer to home. Partners include the Children’s and Women’s Health Centre of B.C., Canuck Place, the Vancouver Hospital and Health Science Centre, and the University of British Columbia’s Faculty of Medicine.

Participating communities include the Okanagan-Similkameen Health Region, the East Kootenay Community Health Councils, the Capital Health Region, Northern Interior Health Region, Northwest Area Community Health Councils, and child development centres.

Provincial and national supporters include the B.C. Children’s Commission, B.C. Research Institute for Children’s and Women’s Health, the B.C. Medical Association, and Dieticians of Canada.

CHIPP is also providing up to $410,000 to develop the Okanagan-Similkameen Health Region’s HealthLink initiative. This integrated information system is designed to assist seniors and their care providers in accessing community services from home, and allow nursing staff to coordinate health services for HealthLink’s patients.

• $3.7 million to develop an information technology network in partnership with the Nunavut Department of Health and Social Services. The investment in the Ikajuruti Inungnik Ungasiktumi (IIU) Network, which in Inuktituk means a tool to help people who are far away, will enable Nunavut to expand telehealth services to all communities. The program will establish links with the Northwest Territories, Alberta, Manitoba and Ontario to provide improved access to services for Nunavut residents. The primary roles of the IIU Network are to establish a comprehensive telehealth program and support the delivery of health care and related social services to Nunavut residents, such as diagnosis/care, telepsychiatry, teleradiology, dermatology, mental health counseling and education, and prenatal and family visits.

Chatterton noted that the projects were assessed “strictly on merit” and that no attempt was made to spread the winners evenly across Canada. “The review process was not about regional development,” she said.

She added the government plans to assess the impact of the projects as they proceed, to determine whether they result in healthcare improvement and technological innovation. “We want to see if the public uses the technologies, if they adapt them to their lifestyles or see them as intrusive,” said Chatterton. “We’ll measure whether the systems have improved healthcare delivery, and by how much.”

She added that a successful outcome could result in further rounds of CHIPP funding for telehealth and development of electronic medical records. “We’d like to see it go beyond its two-year lifespan,” said Chatterton. “It could become a ten-year-long program.”

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Wireless Ethernet soars, but vendors are late with Bluetooth

By Issie Rabinovitch, PhD

Several months into 2001, it has become clear that the focus of attention in IT is shifting. Many formerly interesting topics have receded into the background. For example, a major U. S. networking publication has decided that the annual review of 10/100 Mbps Ethernet cards in the current issue will be its last.

It’s not that this category of equipment is unimportant. Far from it. The reason is simply that it has become a commodity. The differences between the dozens of brands on the market have disappeared, to the point where a comparative review is pointless.

What’s hot? In 2001, anything that’s small, portable, and wireless qualifies. In fact, just being wireless is enough. Case in point? Wireless Ethernet.

Until the IEEE ratified the 802.11b protocol for Wireless Ethernet in 2000, wireless networks were risky and expensive.

With Wireless Ethernet, all that has changed, although prices are still on the high side. Compatible products supporting 802.11b are available from 3Com, LinkSys, DLink, SMC, and IBM, to list a few. I’ve installed a 3Com Wireless Gateway in my house. It can accommodate up to 35 wireless clients, so it is a solution for small networks wherever they may be.

Since I already had a 100 Mbps Ethernet network, I connected the 3Com unit to my existing hub. Now I still have one network, and all of the computers that connect to it have access to the same resources. Some connect via an Ethernet cable at 100 Mbps, while others (with a wireless Ethernet card) connect from wherever they are in the house or backyard without the need of a cable.

Wireless Ethernet is rated at 11 Mbps at a range of up to 100 metres indoors and 300 metres outdoors. Whereas I can confirm the bandwidth, the range specifications seem a bit optimistic. I took my notebook with me for a brief walk. The strength of the signal dropped once I was about 40 metres from the house. On the other hand, I have an 11 Mbps connection to my network wherever I wander in the house and in the backyard.

There is no widespread deployment of wireless Ethernet in Canadian healthcare. I have spoken to consultants who specialize in healthcare technology. They are aware of a sprinkling of small pilot projects, but nothing more for now. In business, the acceptance of wireless Ethernet has been dramatic in the short time it has been available. There is no reason to expect that the situation will be any different in healthcare.

It is well known that cell phones cannot be used in hospitals. Are there any prohibitions against wireless networks? It turns out that there is no problem with wireless Ethernet, since the energy put out by an entire network of 802.11b devices is much less than that of a single cell phone. Even though wireless Ethernet uses the 2.4 GHz frequency, which is used by other equipment in many hospitals, I have been assured by several experts that there is no conflict. I have not been able to confirm this from a sufficient number of independent sources to feel totally confident.

There’s another wireless protocol on the way, called Bluetooth. I’ve written about it in this column. It is supported by every company of any significance in computers and communications, from IBM, HP, Compaq, Microsoft, Nokia, Motorola, and Ericsson all the way down to companies no one has heard of. Bluetooth is very much like a low-cost wireless Ethernet. It is much cheaper, with about 1/11 the bandwidth and 1/10 the range. It is designed to allow devices like phones, headphones, PDAs, printers, MP3players, and networks to communicate when they are in close proximity.

After several years of basically upbeat news from the Bluetooth consortium, the message has recently turned negative. It turns out now that the original specification was inadequate. Version 1.1 was ratified in February 2001,pushing back the launch of usable products into 2002. The first Bluetooth devices to appear will be headphones, which don’t solve really important problems, in my opinion. They may reach the market later this year.

Of greater concern than this delay is the possibility that Bluetooth, which also uses the 2.4 GHz frequency, may interfere with wireless Ethernet. I have yet to get my hands on a Bluetooth device (outside of a trade show, and then only for a few minutes), so I have no direct experience in this matter. I’ve heard opinions on both sides of this issue, but I expect to be able to offer more information in a future column.

A few days ago I received a new IBM ThinkPad notebook computer to test. It came with integrated wireless Ethernet. I unpacked it, did two minutes of configuration, and immediately I was able to connect to my network, open files, and browse the Internet through my broadband Internet connection. That’s the beauty of 802.11b and similar communications standards. They work.

Issie Rabinovitch, PhD, is a Toronto-based computer consultant and writer.

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