Should Facebook Be Considered By Your Search Engine Optimization Company?

sfbusdIf you remember first days of Facebook (as a social network available for citizens), you will have to admit that it was understood as a new type of entertainment. But ask any search engine optimization company and they will explain to you that although it was used for fun in the beginning, Facebook is now a great source for internet marketing. It is often used for promoting online businesses and if you own a company, it would be a good idea that you open a fan page and post there regularly. But opening a fan page is not enough. Facebook now offers many other ways of internet marketing, so serious companies will consider purchasing ads.

Anyone who runs a fan page on Facebook should use it, otherwise fans will be bored and click the “Unlike” button soon. Post not only statuses, but also give links, upload images and arrange giveaways. If you cannot take control over social networking on Facebook, hire some of the many San Diego search engine optimization companies who will to the job instead of you. Indeed, social networking has become a job and the days when people used it for entertainment only are indeed long behind us.

Search Engine Marketing Should Combine Techniques Of Off-Page SEO

Each business that wants to gain success should make a strategy. If a person does not feels capable to make a strategy alone, it is always good to hire a team that can make a good strategy and a business plan. The strategy can be made after thorough analysis about who is potential buyer, what type of competition the business has and similar. Only when the business owner knows the details about present situation, the strategy can be made. These details may include statistics about gender and age of your buyers.

SEO companies are capable to make such analysis and then plan a strategy for your website. After the strategy is being done, the next step is to deal with thorough search engine optimization. A pretty well proven company is All Systems Go Marketing. This strategy includes not only the on-page SEO that is taking care for the website itself, but also many other activities which aim is to build links. In order to make link building, a website owner may use blogs, forums, video marketing on YouTube, news portals, blogs and social networks. It can be discussed which tactic is the best one, but the combination is usually the best.

Now That EMR Is Mainstream, A Look Back

mhTo hear it from a couple of dozen enthusiastic vendors, the concept of putting personal health histories on a safeguarded Internet site is logical and laudable.

Providers get access to vital information in emergencies and better information in the everyday situations that call for all the clues they can get to diagnose a problem.

Personal medical records are appearing on the Internet in various forms and stages of development. The field, which scarcely existed a year ago, is exploding with activity. “It’s very early on, but in a couple of years, we’re going to look at this as (being as) common as the insurance card is now,” Mitchell Gold, M.D., says of personal medical records and other Internet uses that strengthen physician-patient ties. Gold is president and chief executive officer of Elixis, a Seattle-based vendor of software that allows physicians to develop medical records that patients can tap into via the Internet.

To skeptics, however, the usefulness of and demand for personal medical records is largely a matter of speculation, and the success of developers’ vision ultimately depends on buy-in from physicians and health systems as well as from consumers. There’s also a deep philosophical divide between proponents of consumer-maintained health histories and advocates of compiling an edited version of the electronic records created by medical professionals.

Nathan Kaufman, senior vice president in the San Diego office of Superior Consultant Co., doesn’t see a major impact from either type of record in the near term. Kaufman says physicians are adopting electronic medical records very slowly. They’re costly and complex, and they require changes in the way doctors practice. As for do-it-yourself sites, he hasn’t seen any evidence that consumers want to view their medical records or maintain their own versions of records.

“The only thing patients want is to see their doctors when they are sick, and if they are really sick, they want to see the best doctors around,” he says.

Power to the consumer. Intended to give consumers one place to store health records and call up information now in their physicians’ hands, personal medical records are an extension of the consumer-empowerment movement that’s hitting healthcare big-time. After all, healthcare consumerism already is being fueled by the vast and growing array of medical information made easily accessible by the World Wide Web.

At least 25 firms have been identified as developing or already marketing online personal medical records. And in recent weeks, the leaders have gone live on such prominent Web sites as iVillage’s AllHealth.

Developers in the Internet niche say personal medical records have the potential to become valuable health management tools, as well as valuable marketing tools linking consumers and providers.

A universal patient record, documenting a patient’s lifelong health history within and outside the traditional medical system, has been a dream of many healthcare reformers. They say such records would eliminate administrative inefficiencies and result in better medical care by facilitating the transfer of information between providers.

For some firms, however, personal medical records are part of a broader effort to use the Internet to improve healthcare. The health histories are a starting point for delivering targeted preventive health information to the personal Web pages of patients and for automating communications between patients and providers.

A handful of companies focus on the exchange of information between physician and patient. Companies making patient-provider communications a priority include Healinx Corp. of Alameda, Calif., and MediVation, based in Needham, Mass. (See related story, p. 50).

Among firms that focus aggressively on medical records, three types have emerged:

* Those that maintain only emergency medical information provided by the consumer. Security measures vary. Typically, consumers receive wallet-sized cards with a telephone number, a Web site address and, in some cases, the security codes that enable access to the information.

Emergency medical technicians, trained to search patients’ wallets, can call to have the emergency information faxed or access it online if the security code is available on the card or provided by the patient. Most companies charge consumers a nominal fee for the service.

* Companies that maintain a full personal health history provided by the consumer, as well as emergency information. Consumers can print portions of the record, such as a child’s immunizations, or give their providers a security code allowing them direct access to the record.

In some cases, providers can upload information into the record through the providers’ information systems. Many developers market the records as part of a package of consumer-interactive tools to Internet portals and to health plans and provider systems. Generally, they charge licensing fees or have revenue-sharing models.

* Electronic medical record firms offering to make a version of the physician-maintained record available online for consumer review. Such records respond to new federal requirements that patients have easy and immediate access to their records and to an audit trail of people who have reviewed their records.

In this case, physicians must be using the larger electronic record and generally must pay a monthly fee to make a version of it available online to patients. These records also often have an emergency information section and are tied to electronic communications, such as online scheduling or prescription refills.

The money is in the second two categories.

The leaders in consumer-maintained health histories include Portland, Ore.-based WellMed, which has deals with eight of the 15 major Internet portals, including iVillage, and hopes to raise up to $25 million in a current round of financing. Columbia, S.C.-based HealthMagic is another top company, with clients such as Walt Disney Corp.’s town of Celebration, Fla., and, although a launch date hasn’t been set for HealthMagic’s debut on the former U.S. surgeon general’s Web site.

HealthMagic argues that its patient record is unique because it can already import data from external systems at hospitals, physician offices and pharmacies. The company is backed by Adventist Health System, which has contributed $35 million to its financing.

Among electronic medical records companies, Hillsboro, Ore.-based MedicaLogic might be the best positioned for growth, with its electronic record in use at 40 of the largest integrated delivery systems and group practices. A pilot program at four healthcare systems, including Houston’s Baylor Health Care System, has been giving patients online summaries of their records, active medical problems and medications.

The company is marketing the product nationally after early data showed that the system appeals to patients and appears to reduce administrative costs with online scheduling, for example, says Christine Egli, MedicaLogic’s director of Internet marketing (See related story, p. 54).

An electronic edge? Electronic medical records companies contend they have an edge over firms marketing consumer-controlled personal medical records.

Elixis’ Gold says physicians will use only records that are tied to their systems, because they don’t trust other information. What’s more, only documents drawn from physicians’ records fulfill legal requirements requiring providers to give patients easy access to their own records. Such requirements are part of the Health Insurance Portability and Accountability Act of 1996, the details of which are expected to be ironed out in the next year to 18 months.

Industry analysts agree with Gold. “To be used for any real medical purpose, a personal medical record has to be related to the actual medical record,” argues Stephen Savas, a vice president at New York-based Goldman Sachs. “Are you going to rely on a cancer patient to tell me what strain of chemotherapy he was given a year ago?”

For their part, companies marketing consumer-controlled records argue that theirs is the way to go. HealthMagic and WellMed, for example, have a long-term goal of drawing medical information directly from providers and consumers. The information will serve as a central repository and will supplement provider-based records.

“If a lifelong record is controlled by a healthcare organization, it can never be a lifelong record,” says Calvin Wiese, CEO of HealthMagic and former chief financial officer at Adventist. “Those types of records will be enterprise-centered, which means they’ll have the same problems we’ve always had,” he says.

“If you build a record that is an extension of a healthcare organization record, it really doesn’t fundamentally change the way information is being managed and maintained.” It won’t be as universally accessible and won’t typically seek out and accept information created outside the boundaries of the organization maintaining the record, he says.

Not only is HealthMagic trying to work with Internet portals, it also has agreements that will bring it to health plans and providers. For example, Pittsburgh-based Managed Care of America has made the HealthMagic record part of its suite of offerings to employers, purchasing groups, providers and insurance companies.

Wiese acknowledges the limitations of a medical record organized by patients. HealthMagic’s long-term goal is to make sure that providers submit information to the record as well, which then can be viewed and used by multiple organizations with the consumer’s permission. He says the company has a strategy to do exactly that but declines to discuss specifics.

WellMed CEO Philip Marshall, M.D., says his work with the electronic medical record for providers convinced him that a consumer version was necessary. Working with Kaiser Permanente on its implementation of an outpatient medical record, Marshall was impressed by how difficult it is to get physicians to adopt such records.

Because the cost of full electronic medical records is so high and the length of time for adoption so long, a consumer-controlled version seemed to represent a faster way to take advantage of the administrative savings possible in having an electronic version available, Marshall says.

“What we are providing is to fill that time gap,” he says.

He argues that a consumer-controlled medical record is as valuable as the provider record if it has the same ability to affect decisions made in the physicians’ office. That will become increasingly true as consumers grow more used to making decisions about their own healthcare based on information that once wasn’t accessible to them. What’s more, the company has spent many years building a system that can easily translate consumers’ information into medical terms that are acceptable and useful to physicians.

In the long run, WellMed wants to be able to have physicians add information directly to its records. Its current focus is on developing a link allowing e-mail communications with doctors to be directly imported into the record.

So far, it’s won some supporters. For example, General Electric Co. is piloting the WellMed product among a sampling of employees as a preventive health tool. National HMO Health Net, based in Woodland Hills, Calif., also has begun making the record available to all its members through its national Web site. The record, which incorporates a health risk assessment and information targeted to the risks, builds on Health Net’s emphasis on wellness programs, says Cindy Keitel, director of health improvement and wellness for the program. “A lot of what we are looking at is providing members with knowledge and giving them more control,” Keitel says.

Of the marketplace in general, she says, “This is a brand-new tool. But the proof is in the pudding. If consumers find it valuable, it will be adopted.”

Is Medical Data Really Safe In The “Warehouse?”

maamaThe American Medical Group Association’s plan to partner with a major pharmaceutical firm and create a national data warehouse is being met with reactions ranging from wholehearted support to wary skepticism.

“I think this is a glimpse into the future, that we can substantially improve the quality of care,” says Molly Joel Coye, M.D., CEO of the Health Technology Center of Menlo Park, Calif., a not-for-profit medical technology assessment group.

“I am skeptical that they won’t be identifying people,” says Betsy Mahoney, coordinator for the Medical Privacy Project of the Maine Civil Liberties Union. “The average American would have the same skepticism.”

The AMGA said Feb. 9 that it had entered into a partnership with Aventis Pharmaceuticals, the U.S. arm of the French pharmaceutical giant Aventis Pharma, to create a national database of information gleaned from its 300 healthcare group members.

AMGA member groups work with 67,000 physicians, the organization says.

In the next five years, the AMGA estimates it will spend up to $42 million to create the database to provide members with clinical and financial information that’s deeper and more broad than what is currently available, says Julie Sanderson-Austin, AMGA’s vice president of quality management and research.

The project will expand on AMGA efforts begun 10 years ago, says Sanderson-Austin. For a decade, AMGA has gathered outpatient clinical information from about 95 member groups and financial information from more than 100, she says. The AMGA reports to member physicians and groups on nine clinical benchmarks.

The data is coded so member groups will be able to identify only their own data, she says.

As yet, few AMGA member groups use electronic medical records systems, Sanderson-Austin concedes, and the dearth of key data gathering technology will create a huge hurdle for AMGA members and project sponsors to overcome, according to technical experts.

“We’re starting with claims data,” she says. “Most of our groups have electronic lab data and, where they have it, pharmacy data.”

Groups will contribute data from patient encounters when available, she says.

The goals of the project are in line with the aims of two Institute of Medicine reports on medical errors and quality of care, which called for creation of regional databases to better track quality of care.

Coye was a member of the IOM committee that produced the reports. A large database is a “critical underpinning to being able to improve quality of care,” she says.

Walter Menning, vice chairman of information systems at the AMGA-member Mayo Foundation, says the Rochester, Minn.-based group analyzes its own clinical data and has worked with the Cleveland Clinic on a joint benchmarking project. His take on the AMGA plan is positive.

“We still look to be able to compare ourselves and see if somebody else has a best practice,” Menning says.

The scope of the AMGA project is enormous, says Michael Millenson, a Chicago-based principal with Mercer Management Consulting and an expert on the use of computer technology to improve quality of care.

“To my knowledge, there has never been that much money dedicated to a national database and that much cooperation,” Millenson says.

Physician support will be a key to success. “Your average working physician is not going to take the time out of his (or her) busy schedule to collect this data unless there is an excellent clinical reason to do so,” he says.

Stewart Gleischman, M.D., vice president for strategic business development of Newport Beach, Calif.-based TriZetto Group, a software and application services provider, says the project is technically feasible but calls it “a question of time, resources and technical know-how.”

In December, the AMA voted to take steps to protect physicians from the use of prescribing pattern information by pharmaceutical companies. AMGA says it plans to track prescriptions and diagnoses, two key data elements for pharmaceutical marketers, but insists it won’t share that information with Aventis.

The AMA declined comment on the AMGA plan.

A further complication is Aventis itself. Last fall, after a congressional investigation, Rep. Fortney “Pete” Stark (D-Calif.) lambasted an Aventis progenitor, the German firm Hoechst, for what he called “fraudulent price representations” for its injectable form of the antinausea drug Anzemet. Aventis was formed in 1999 from the merger of Hoechst and Rhone-Poulanc of France.

Criminal or civil investigations into infusion drug marketing schemes are active at the federal and state levels against several drug companies, though Aventis has not been named in any of those probes.

Stark expressed ambivalence about the AMGA-Aventis venture.

“I hope that the agreement includes firewalls to protect the patient and the physician from being steered toward the use of Aventis drugs-drugs which may or may not be the best for the patient,” Stark says. “The data has shown that when a drug company gets involved with doctors, somehow that company’s product sales increase.”

Aventis refused to disclose its equity interest in the venture, as did the AMGA. Aventis did not answer questions on whether it currently aggregates data by physician or has access to that information. Through a spokesperson, Aventis says identifying information about physicians and patients will be stripped from the data before it enters the warehouse.

Aventis says it hopes the venture will provide information on health outcomes and the cost-benefit of therapies to improve patient care as well as help the company improve product offerings and clinical research.

Mahoney, of the Maine ACLU, says “the frightening thing about any information is this stuff isn’t thrown away. Who’s to say what’s going to happen next day, next month and next year?”

However, having patient data compiled in a meaningful way and reported back to physicians can lead to improved patient care, says Sarah Corley, M.D., who has used a healthcare database called Practice Partner Research Net in her two-physician internal medicine practice in Arlington, Va., for six years.

“You get wonderful reports showing how you’re doing on guidelines,” she says. “The more data you have, the better you can practice medicine. It’s a nonthreatening way (to) know you’re not perfect.”

Finally, all the data in the world won’t change patient care if someone isn’t riding herd on doctors at the institutional level, according to Gregory Cooper, M.D., co-author of a study that concluded quality programs need someone in-house to keep physicians using best practices.

“If there isn’t some kind of daily interchange, they (physicians) don’t adhere to them,” he says.

AMA Can’t Escape The Master

amaThe American Medical Association is not about to shut down its lucrative Physician Masterfile, a treasure chest of biographical information on doctors that generates about $23 million in annual revenue for the Chicago-based organization.

As expected, the AMA’s policymaking House of Delegates, meeting last week in Chicago, skirted any action on a resolution to limit the organization’s use of the database, which is used by pharmaceutical firms to target physicians through their prescribing patterns. Filled with personal and professional information on more than 800,000 U.S. physicians, it is the most richly detailed and comprehensive repository of its kind.

The attempt to restrict the use of the Masterfile was one of more than a dozen drug company-related resolutions debated by the 547-member House of Delegates. The topics included a proposal to limit the kinds of gifts doctors may receive from drug-company salespeople and an effort to ban the practice of direct-to-consumer advertising.

The AMA didn’t take dramatic action on any of the high-profile resolutions involving drug companies, but the organization made its point loud and clear, top officials declared.

“Our concern is the impact (of drug costs and advertising) on the physician-patient relationship,” said Randolph Smoak, M.D., the AMA’s outgoing president. “It’s nice to say we’d like certain things to change. But it’s a slow process. I think we’ve made some progress in all these issues.”

Added Leroy Sprang, M.D., the former president of the Illinois State Medical Society: “Clearly, by introducing these resolutions and addressing the issues, (the AMA) is keeping the drug companies on their toes. The `bully pulpit’ approach does make a difference. The drug companies are hearing what we’re saying.”

For instance, rather than asking for the prohibition of direct-to-consumer advertising, a policy considered futile and probably unlawful, the AMA recommended that any such marketing effort include this disclaimer: “Your physician may recommend other, more appropriate treatments.”

AMA representatives also quickly tabled a resolution calling for stricter, more specific limits on the kinds of gifts physicians may accept from drug-company salespeople. Several delegates argued that the policy is already specific enough, restricting gifts to a $100 value and specifying that they benefit patients or are tied to education. The resolution was referred to the board for further consideration.

Other broad proposals involving drug companies also were watered down, tabled or referred to the board of trustees for future consideration. The California delegation’s resolution on the Masterfile, which called for new restrictions on the use of biographical information on doctors, eventually was pulled from consideration and referred to the board of trustees for further study.

But the issue of the public dissemination of personal information, an increasing concern among doctors, triggered some heated discussion.

One delegate denounced the use of the AMA’s database to help drug companies target physicians, calling such detailed profiles “unbelievable and outrageous.” Another characterized the profiling as a hyper-invasive marketing measure. “Patient confidentiality is the issue as well as physician confidentiality,” the doctor declared.

Asked if there was a possibility that the Masterfile would be shut down, D. Ted Lewers, M.D., chairman of the AMA’s board of trustees, replied, “No way.”

“This (Masterfile) is the gold standard,” Lewers said. “It’s a system that’s been in place since 1901. We have the security and we know it’s safe. But if somehow we need to improve it, it will be improved. But there is no evidence at this time that it needs improvement.”

The California delegation’s resolution asked the AMA to provide physicians with a simple way to “opt out” of having their information in the database. Other restrictions would have made it far less attractive to drug marketers.

Meantime, delegates took another step toward adding the first nonphysician to the 20-member board of trustees, approving a change in bylaws that will allow for a vote on the new representative within the next year. Smoak and others believe the addition of a “public” trustee will add to the organization’s credibility.

In other action, the delegates affirmed their support for the AMA’s 2-year-old labor union affiliate, Physicians for Responsible Negotiation, which has had difficulty organizing new members for collective bargaining despite receiving more than $3 million in loans from the AMA.

Plunging Into The Eap

In a global economy where the competition for the best and brightest workers is perhaps even more intense than the competition for new customers and markets, the health and safety of employees and workplaces are critical to the success of any organization. EAPs, under the direction of or in cooperation with occupational physicians or medical directors, can help employers manage the health of their workers and worksites and promote greater employee productivity.


My own experience in this area is instructive. As a plant physician several years ago, and later as regional medical director, I helped administer an occupational health program that provided both injury and illness treatment as well as preventive health services at the worksite, such as health screenings and initiatives for blood pressure monitoring, hypertension control, and diabetes education and detection. Many of these activities and initiatives eventually were folded into what evolved as a joint labor-management preventive health program called LifeSteps.

At one location, I was responsible for the health and safety of about 15,000 employees, most of whom were hourly production workers represented by the United Auto Workers (UAW). During that time, I oversaw the evolution of our employee assistance program from a very small concern with one full-time staff member to a three-shift-a-day program with both hourly and salaried support staff. The growth in staff was accompanied by a growth in services: The EAP evolved from being mainly a substance abuse (primarily alcohol-based) program with an in-house 12-step effort into a program that addressed concerns well beyond substance abuse, such as psychological and emotional issues, family concerns, or other problems that underlay performance problems at work.

As the EAP evolved, it began to play a more prominent role in our ability to identify and resolve potential employee health problems. As various employee concerns–financial difficulties, child and elder care, stress, and so on–surfaced at work, EAP staff sometimes were able to discern underlying issues that might affect workplace health and productivity To help address these issues, we initiated a worksite mental health program that incorporated a psychiatrist who would visit one day each week. The psychiatrist would talk to employees who had been in contact with the EAP to assess their emotional health and determine what steps should be taken to prevent their condition (if any) from becoming more severe. Supervisors and others also got involved as necessary.

The EAP spearheaded a very active effort to educate supervisors how to recognize individuals with possible mental health problems and refer them for assessment before their problems resulted in long-term absences or discharges from work. In conjunction with my office and local facilities and organizations, our EAP team conducted self-help programs to help people recognize whether they might have problems that needed attention.

In these and other areas, such as helping coordinate training for employees and union officials in addition to supervisors, our EAP proved extremely effective in identifying and helping resolve potential health problems. Whenever EAP staff saw specific health issues that required their attention, they got involved and assumed responsibility for necessary activities.

One thing I noticed as I watched our EAP evolve and play a larger role in our occupational health efforts was that the more knowledgeable and professional the employee assistance personnel, the more effective the employee assistance program. Someone assigned to the EAP staff who didn’t have a lot of interest in employee assistance tended not to have the same level of effectiveness as someone who had been trained and had acquired expertise in the field. Our joint program made sure that our EAP personnel got that training, both the union representatives and the salaried people as well.

Handle on Costs

The need for training and professionalism is even more imperative today because there’s been such a strong move in the direction of outsourcing EAP services. As that process has continued, the level of direct involvement between the medical director and the EAP has significantly decreased, although the need for that involvement is as great as ever because many problems that come to the attention of EA professionals require confidentiality and a health expertise that people in the human resources area may not possess. The physician needs to be made aware of these problems.

The outsourcing of EAPs has been accompanied by another development that’s having a profound effect on occupational health–the rise of the Internet. I see a great future in this area with respect to health services for employees, especially as organizations and the economy become more global. The range and incidence of problems that affect a global workforce will exceed anything we have ever seen before, and employers will recognize that increasing the knowledge base of their employees–in particular, by providing low-cost access to the Internet–is a cost-effective method to assist in addressing and preventing these problems.

Within the next year, I think we’ll see more and more Internet access afforded to employees, even to the point where they can access it from home. Some companies like Ford have actually provided low-cost computers–they’re literally giving them away–to employees to increase access to the Internet. Other companies are addressing this in different ways, but all companies, I think, are finding that it pays to facilitate easier access to the Internet for their workforce.

In addition to providing employees access to the Internet, I expect employers, through their EAPs, to begin using the Internet aggressively to educate workers on preventive health concerns. But even the Internet, with its unparalleled reach and breadth, is no panacea for occupational health problems. Even with the Internet, we’ll still have drug abuse–the drug itself may change, but the problem won’t go away. And we’ll still have workers who have problems with stress and family issues. These problems may, if I can look forward with wishful thinking, decrease in terms of both degree and frequency, but I think they’re still going to be there.

I also think we’re going to have a greater need for early intervention, because early intervention is necessary if we’re to get a better handle on costs. That’s one thing we’re setting out to do in all of industry–get a better handle on all health-related costs, either by eliminating them or reducing their prevalence to the point where they’re far less frequent and we have far fewer complications to address. EAPs and other preventive health efforts are critical to early intervention, so they need to be able to show, over time, the impact they have on health costs. That’s where EAPs and other efforts are going to pay off. But I don’t see these problems going away. It’s just the nature of the human beast.

Clinical Information Vendors Ready To Serve It Up

civrClinical information will have to be computerized before it can be used to manage care systematically, and most healthcare facilities have a long way to go to get their data off charts or clipboards.

But that’s only the beginning, say experts on using information in clinical settings. Once computerized, the data have to become part of an overall effort to coordinate the contributions of many departments toward patient diagnosis and treatment.

For example, if pharmacy information is not easily integrated with lab results, medical history or nursing documentation, a doctor might not get a complete picture of why a patient is taking a turn for the worse.

The best approaches to clinical information technology allow data from perhaps dozens of different computer applications to be swapped and sorted as if they came from the same system, says Thomas Handler, M.D., a research director in the healthcare group of Gartner, a Stamford, Conn.-based information technology research and advisory firm.

It’s a complicated technical undertaking for healthcare information systems companies, much more extensive than just patching fundamentally different systems together through interfaces. In the past several years, some companies have spent many millions of dollars to rebuild their computer architecture in a bid to tightly integrate specialized applications serving a variety of clinical purposes. The result is a truly workable computerized patient record.

A handful of vendors have made that integration strategy a mark of differentiation in the market. But Handler says the differentiation is beginning to blur as competitors race to retool along the same lines.

“Three years ago there was a clear dividing line between integrated vendors and nonintegrated vendors,” he says. “Almost all the visions of all the vendors are coalescing.”

The upshot is that “the vision of an integrated CPR is no longer a differentiation,” Handler says. “The big difference is who can deliver it when, and how well will it work.”

With an integrated electronic record of physician orders and patient treatment data as the technological foundation, IT vendors have big plans to build into clinical care the kind of efficiency that was out of reach a few years ago.

Clinical opportunities

Foremost among the envisioned advances is a combination of physician order entry and a triggering of clinical data and suggested practices in support of ordering decisions.

Computerized physician order entry has attracted a lot of recent attention as a means of preventing medical errors, but proponents also talk up the organizational logic behind getting doctors to enter orders and building an integrated series of communications and responses to the orders.

A physician order “drives a lot of activities throughout the clinical process, and they have to be integrated,” says Harvey Wilson, chairman and chief executive officer of Eclipsys Corp., Delray Beach, Fla. “We’re just beginning to scratch the surface where the clinician is the primary user of the system and institutes the beginning of a process.”

Physicians are regaining control of the healthcare process after years of heavy managed-care intervention, and that changes the priorities of IT, says Paul Taheri, M.D., chief of the trauma burn center at University of Michigan Hospitals and Health Centers, Ann Arbor.

Much of the computerization to date in healthcare organizations has concentrated on the intricacies of insurance reimbursement and on moving patients through a hospital stay, which are important but have little to do with actual patient care, Taheri says. “The core transaction in a healthcare system is still between the doctor and the patient.”

All other digitizing of data emanates from that point, he says. And the new approaches of clinically oriented information systems have that in mind not only in physician order entry but in other opportunities to bring discipline, interactivity and efficiency to the many support activities.

Here are some of the more ambitious objectives:

* Reducing labor costs through automation. When orders are entered electronically by clinicians and the results disseminated to the appropriate places automatically, the healthcare organization doesn’t need to pay clerks to type in orders or runners to deliver the reports.

* Better use of scarce healthcare professionals. A significant portion of the work day for pharmacists and nurses is devoted to typing orders into pharmacy systems, scribbling clinical notes and counting out medications for patients. Automating those duties allows high-priced employees to spend more time on their essential care-delivery functions, ultimately reducing the number of hard-to-find professionals required to meet a healthcare operation’s demands and improving retention rates.

* Maximum use of existing assets. When capacity becomes strained in surgery, the intensive-care unit or the emergency department, the usual response has been to seek additional capacity by investing in new construction. But managers often have more capacity than they realize-the existing facilities aren’t used to their fullest because of rampant inefficiency, says Mikael Ohman, associate principal with McKinsey & Co. By rethinking key routines with the aid of sophisticated computer management techniques, hospitals can make better use of the current space, he says.

* Productive assimilation of medical knowledge. New medical findings and local consensus on best practices are continually offered for physician consumption, but the information has to be systematically incorporated into the ordering process to have an impact on medical and cost decisions, says William Stead, M.D., a leader in the development of computer systems for medical practice at Vanderbilt University Medical Center, Nashville. Vanderbilt is collaborating with McKesson Information Solutions to make introduction of best practices a simple matter at the point of physician decisionmaking.

* Vigilance against workflow foul-ups. Computers can economize the process of healthcare and inject important information at the point of electronic ordering, but the smooth running of healthcare operations depends on the coordination of many tasks triggered by clinician treatment decisions during the course of a patient stay, says Frank Lavelle, president of Siemens Medical Solutions Health Services Corp. The Malvern, Pa.-based information services business, formerly Shared Medical Systems, introduced a new push last month to computerize the complex interplay of departments and professionals in care delivery (Modern Healthcare, Oct. 29, p. 20). The aim is to synchronize all the activities scheduled on behalf of patients and eliminate the crossed signals that delay treatment and waste resources.

Clinical complications

The vision of medical management is tantalizing, but the decisions surrounding it involve financial risk and technological gambles, observers warn.

Prospective buyers of clinical-care IT systems will have to consider not only what they want and can afford but also how the new applications fit into their existing tangle of computerization.

Information systems for reporting laboratory, pharmacy and radiology results are essential components of a clinical-management infrastructure, and healthcare facilities likely have made million-dollar investments in those systems already.

And nearly all hospitals and healthcare networks have workhorse financial and patient-accounting systems, which supply both patient demographic information and the cost data that round out the detail necessary to manage care delivery.

Until the importance of integrating information became apparent, healthcare applications were selected to satisfy a particular department rather than their ability to share and consolidate information with other applications and the healthcare system as a whole.

Sometimes healthcare organizations intentionally chose systems for their individual attributes knowing they had to be brought together as a system through extensive interface development. This so-called “best of breed” philosophy created some major integration problems, says Perry Pepper, CEO of Chester County Hospital, West Chester, Pa.

The same type of challenge was going on at several healthcare information services companies during a period of product acquisition and consolidation in the middle to late 1990s. HBO & Co., now McKesson Information Solutions, acquired more than 20 applications to broaden its product line for the full range of provider and payer operational needs. But then it faced reconciling a hodgepodge of disparate methods for creating, trading and storing data among them.

Now the healthcare industry is about to add a new wave of clinical computerization and with it a potential slew of new integration problems. Companies that have invested in integrating systems through a common computer foundation say their approach is the only one that can work.

For example, Per-Se Technologies markets a broad and interlinked set of applications that was built from scratch around a centralized database, designed to assure continuity of information on an episode of patient care, says Karen Andrews, president of Per-Se’s application software division. “It’s not bolted together through acquisitions,” she says.

In addition to fundamentally identical design among component applications, the benefits of ground-level integration include superior computer response time, says Judith Faulkner, president and CEO of Epic Systems Corp. “In the end, a clinical system will fail because of poor response time, because doctors will not use it,” she says. “Then the promise of clinical decision support is unfulfilled.”

Working around what’s already there

McKesson and Siemens, however, are holding on to an advantage over their competition: the thousands of healthcare organizations that already run their information system products and have an existing multimillion-dollar investment to consider in their future decisions.

So while the two biggest IT companies acknowledge the need for integration of diverse healthcare applications-and are busily developing new product lines with that in mind-they’re working to add new clinical computerization to their existing mix in the meantime.

McKesson last year launched development of a new integrated line called Horizon, designed to eventually spread throughout a provider organization but also to connect sources of information from older information systems to hospital users via Web technology.

Siemens is seeking to re-invent itself with a new line of information technology “built from the ground up with workflow at the center of its design,” Lavelle says. But it plans to incorporate the workflow software in a series of small steps for existing customers and also try to sell to new customers based on a study of what systems they already have.

Chester County Hospital, one of the first test sites for the Siemens line, is willing to go the gradual route with new technology surrounding the older installed investments, Pepper says. Despite historical difficulties with interfacing disparate systems, “We’re beginning to make the machinery work together better than we have before,” he says. “This couldn’t have been done as successfully five years ago.”

Privacy And Patients: Having Patience With Change

Successful analysis of the rule will require time and attention from staff in virtually all departments in a health care organization that handle identifiable medical information. Because of its scope, the rule will affect virtually all areas in an organization. That’s because the rule requires the development of privacy protection procedures and the training of all employees to comply with the procedures.

HHS officials issued the proposed privacy rule because Congress failed to enact a national privacy law, authorized under the Health Insurance Portability and Accountability Act of 1996. The proposed rule governs only the confidentiality of identifiable electronic health information and paper-based information printed from electronic sources. HIPAA gives only Congress the authority to enact a privacy law that covers all medical records.


HHS faces a Feb. 21, 2000, deadline for publishing a final privacy rule, which would go into force 26 months after publication for most health care organizations. But few industry observers expect the department to meet that deadline.

Congress can at any time enact a privacy law that would supersede the rule. Sen. James Jeffords (R-Vt.), chair of the Senate Health, Education, Labor and Pensions Committee, has vowed to continue working toward passage of a bill, but lawmakers are far from reaching the consensus necessary for approval of such a bill.

The proposed privacy rule is separate from a final federal rule, also mandated by HIPAA and expected to be published this month, to ensure the security of all electronic health data. The privacy rule-or a privacy law enacted by Congress-will govern how patient-identifiable health information is used and disclosed. The security rule, on the other hand, will govern how confidentiality is protected by ensuring the security and integrity of electronic health data.

Confusion reigns

The core principles behind the proposed privacy rule are three provisions common to virtually all privacy bills before Congress. These are: the requirement of informed patient consent to release identifiable information beyond what is necessary for payment, treatment and health plan operations; the right of patients to examine their medical records and request corrections; and requirements to track information disclosures.

Some provisions in the proposed rule are quite clear, such as the definition of what constitutes “electronic information. Many provisions in the rule, however, are vague and confusing.

For instance, the definition of “health plan operations” is quite broad. Health plan operations are oversight activities, such as case management and outcomes analysis, that payer organizations say are necessary to increase the quality of care while keeping costs in line.

But Donald Palmisano, M.D., a New Orleans surgeon and trustee of the Chicago-based American Medical Association, calls the definition “a dangerous catch-all” that may permit banks and insurance companies to share medical information without patient consent.

Legislation awaiting President Clinton’s signature would permit financial institutions and insurers to merge. Clinton has said he will sign the bill.

The proposed privacy rule is confusing in how it seeks to ensure that business partners of providers and payers protect patient confidentiality. One section requires business partners-including attorneys, auditors, consultants, clearinghouses and billing firms-to sign contracts agreeing to comply with the privacy rule. But another section indicates there are no restrictions on business partners.

The proposed privacy rule includes a fiscal impact analysis that estimates implementation will cost between $1.8 billion and $6.3 billion over five years.

That’s far below a $43 billion implementation price tag resulting from a recent analysis for the Blue Cross and Blue Shield Association. Both analyses used conservative projections and acknowledge that the real price tag could be considerably higher.

Saving money

But the department’s analysis also calls for cost savings resulting from individuals getting treated faster for medical conditions because of higher confidence that their medical records will remain private. For instance, the nation could save $208 million to $1.67 billion annually due to early treatment of mental health disorders, according to the analysis.

“Confidentiality is a key component of trust between patients and providers, and some studies indicate that a lack of privacy may deter patients from obtaining preventive care and treatment,” according to the HHS analysis. “For these reasons, traditional approaches to estimating the value of a commodity cannot fully capture the value of personal privacy.”

Proposed Privacy Rule Provisions

Covers identifiable medical records created by health care providers, insurers and claims clearinghouses that are either transmitted or maintained electronically. Paper printouts created from these electronic records also are covered under the rule.

Requires covered entities to disclose only the amount of information necessary for the intended purpose.

Permits a covered entity to use and disclose information stripped of identifiers in any way, as long as it does not disclose the key or other mechanism that would enable the information to be reidentified. A covered entity could use or disclose a key only as it could use or disclose the underlying information.

Preserves state privacy laws that are more stringent and enables states to enact stronger laws in the future. Leaves intact state laws governing parental rights to health information about minor children.

Prohibits conditioning treatment, health plan enrollment or payment on a requirement that an individual authorize use and disclosure of their psychotherapy notes.

Specifies procedures law enforcement agencies must take to obtain identifiable health information. Previous recommendations from the Clinton Administration included no restraint on law enforcement access to information.

Requires all researchers-public and private-to receive approval from an institutional review board before using identifiable information. This expands the Common Rule-which governs how federally funded research projects must protect the confidentiality of identifiable information- to also govern privately funded research.

Permits provider and payer organizations to disclose to financial institutions, without patient authorization, identifiable information necessary for processing payments for health care and health care premiums. Financial institutions offering specialized services to the health care industry, such as claims management and billing support, must comply with the privacy provisions.

Defining Electronic Information

“Electronically transmitted information” includes information exchanged with a computer using electronic media, such as the movement of information from one location to another by magnetic or optical media, or by transmissions over the Internet, extranets, leased lines, dial-up lines, private networks, telephone voice response and faxback systems.

“Electronically maintained information” means information stored by a computer or on any electronic medium from which information may be retrieved by a computer, such as electronic memory chips, magnetic tape, magnetic disk or compact disc optical media.

The definitions do not include paper-to-paper faxes, person-to-person telephone calls, video teleconferencing or voice mail messages. The key concept that determines if a transmission meets the definitions is whether the source or the target of the transmission is a computer.