August 1998 Volume 10 Issue2
TELEMED-E-ZINE
About Telemedicine • Home Care Telemedicine • Mental Health Telemedicine • Radiology • Rural Health Telemedicine • U.S. Telemedicine • Telemedicine Market • World Telemedicine • Consumer Health Information • Disease Management • Telephone Triage
Conferences & Seminars
The Association of Telemedicine Service Providers (ATSP)
The second annual meeting of the ATSP will be held from September 21st through 23rd, 1998 in Portland, Oregon. The theme is "Getting Down To Business". As a "working meeting," there will be an emphasis on attendee participation, with scheduled topics focusing on business models and regional planning. In addition to talks and break-out sessions, vendors will presenting equipment demonstrations. For more information, visit: www.atsp.org.
Legamed Inc.
As a telemedicine seminar designed to inform a wide range of consultants and providers, The Legal Environment of Telemedicine focuses on important problems currently confronting practitioners. Presentations will address HCFA reimbursement perspectives, insurability of telemedicine, and the status of the Rural Health Care Corporation (the entity responsible for distributing Universal Service funds). The seminar will be held on September 28, 1998 at the Hyatt Regency Crystal City in Arlington, VA. For more information, contact Legamed (Raleigh NC) at 1-800-368-9593. Registration before August 14, 1998 will be discounted by $50.00. The regular cost is $395.00.
About Telemedicine
Definitions and Descriptions
Telemedicine: Although no official definition has been universally adopted, "telemedicine" usually refers to the use of sophisticated communication and information technologies (often with imaging or video capabilities) to support improved access to and delivery of health education and medical practices.
Telehealth: Electronic mail, facsimile, telephone, and videoconferencing tools can all be used to supplement interactions between health care providers and their patients. Some industry participants distinguish telehealth from telemedicine services, with the latter involving physician-to-physician encounters such as diagnostic consultations and the former focusing on patient-centric care and support.
Telepsychiatry: A consultation between a patient and psychiatrist can be conducted using real-time interactive videoconferencing equipment operating at a relatively low bandwidth over ordinary telephone lines. Because sessions generally require audio and visual components rather than high-resolution imaging, relatively inexpensive systems are often used for telepsychiatry applications and have formed the basis for networks in rural settings.
Teleradiology: Teleradiology incorporates telecommunications technologies, specifically for transmission of radiographs from one location to another. Images such as computed tomography, magnetic resonance (digital), or x-ray scans can be digitally displayed or converted to hard copies.
Telephone Triage: There are many terms that describe the provision of phone-based health care advice services. Here, "telephone triage" refers to information that is provided to patients whose phone calls are handled by nursing staff using a computer-based processing system. The results of the phone call can be delivery of a general medical opinion or assessment of the caller’s condition to evaluate the need for a physical visit to a doctor or emergency care facility. Industry participants and other publications may rely upon alternative phrases to describe these same systems and services, such as "demand management," "medical call centers," "nurse advice lines," "nurse phone care," "telenursing," "telephone advice services," "telephone nurse counseling," etc. Standardized usages have not yet been established. For example, "telenursing" may refer to services provided with either telephone or video-based systems.
Telemedicine Applications
While a telemedicine network may initially be installed to support delivery of clinical services, the majority of usage may ultimately involve administrative, educational, or training. Clinical applications have grown to represent a higher percentage of total usage in the past two years, with telemedicine network administrators in the top programs citing an increase from 10% in 1996 to between 40% and 50% in 1998. Demonstrations of live surgeries have also become more routine, with images being sent to other locations within the same facility, across town, or around the world.
This dual use of videoconferencing technologies represents a merging of distance learning and telemedicine applications that has been advanced by Bell Atlantic as the "Cardiac Classroom" at Morristown Memorial Hospital. In the United Kingdom, physicians are able to study for membership in the Royal College of Surgeons by participating in lectures which are provided via satellite television. Tetrasur (Telematics Training for Surgeons) offers a year-long course with 42 modules. The first year of offerings began in April 1998 and will be continued if the pilot program is successful. The benefits of seeing a live operation are considered to be much better than viewing on film because sessions can be interactive and cover a range of topics, rather than predetermined content.
Home Care Telemedicine
Telecardiology Monitoring
Telecardiology is an expanding application within home care telemedicine. Telemetry equipment has been used for years for patients with pacemakers or irregular heart rhythms. A natural progression for the technology is to support more sophisticated capabilities, such as continuous monitoring, to settings outside of hospitals. Specifically, the LifeSigns system from Instromedix Inc. (Hillsboro, OR) has been approved by the U.S. Food and Drug Administration for marketing since since late 1997. LifeSigns is a compact, relatively inexpensive that uses a dedicated telephone line to transmit vital signs data from a remote location to a centralized processing system. Simultaneous data and voice transmissions are supported, with incorporation directly into a patient's medical file. Patients with congestive heart failure or a history of myocardial infarction are groups that can be well-served with this technology. For more information on Instromedix, call 503-681-9000.
Another competitor with a patient monitoring system is Spacelabs Medical (Redmond, WA), which announced availability of the Ultraview Care Network. Vital signs displays incorporate the latest communication, integration, and signal processing technologies to streamline clinician access to patient information. As a monitoring platform, the Ultraview Care Network can serve a variety of care settings, ranging from low acuity areas to sophisticated intensive care environments. Formats can be mixed and matched to provide an optimal arrangement of displays, network connectivity, screen sizes, etc. For more information, call 425-882-3700.
Mental Health Telemedicine
VideoLink of St. Peter’s
The system formerly known as as the SouthWest Montana Telepsychiatry Network (SWMTN) is now VideoLink of St. Peter's. Operations began in in January 1995 with the stated primary mission to "improve access and quality of mental health care services and education in Southwest Montana through the use of an integrated system of communication technologies and collaboration of provider resources." Funding was provided in 1994 when St. Peter’s Hospital Foundation (Helena) received an Office of Rural Health Policy (ORHP; Rockville MD) grant to establish an interactive telecommunications network for rural psychiatric consultation and services.
The original area covered by the network included the twelve counties in Montana Health Planning Region IV, with services being provided over 28,509 square miles for a combined population of 190,000. In 1997, changes were implemented, with Region IV community mental health services being divided among other regional entities based in Billings, Great Falls (for the greater Helena area including Boulder), and Missoula.
For the treatment of mental illness, assistance is provided by family practice physicians and mental health professionals who benefit from a broad scope of psychiatric services made available by health care provider organizations located in Helena. Consult stations at VideoLink of St. Peter’s support interactive video communications at Anaconda, Boulder, Bozeman, Helena, and Warm Springs.
Through a collaborative effort, video connections are offered in 25 communities. One result of this level of access has been expanded pre-admission screening, discharge planning, and family visitation capabilities for Montana State Hospital (Warm Springs) and Montana Developmental Center (Boulder). For the period from January through May, 1997, total usage of the network included 206 direct patient care visits, 60 administrative meetings, 15 educational conferences, and 33 "other uses." This teleconsultation level has remained relatively stable.
While assessment of cost savings can be quite variable depending upon the criteria used, some tangible examples have been identified to date. Cost savings cited by administrators from January through May 1997 were estimated to be $63,343. For the full year in 1996, the network was used a total of 511 times, yielding an estimated savings of $168,191. One of the major benefits of the network involves mental health screenings. Before 1995, patients arrested in Gallatin County were placed for care at St. Peter’s Hospital and had to be transported to Bozeman for scheduled court hearings. The videoconferencing system eliminates the need for deputy escorts and travel time for transport. In the "other uses" category, "televisitation" is an important but unquantifiable component of network usage through which video technology helps support family communication and structure when individuals are being treated in a distant hospital or other location
Educational conferences can help individuals recognize early signs of suicidal behavior to support appropriate intervention. Videoconferencing is also helping mental health providers to overcome climatic and geographic obstacles to deliver a continuum of care services through the network. Optimal convenience and cost benefits still need to be quantified. Use of compressed video has been evaluated, through a project begun by SWMTN and Montana State Hospital. Although there wasn't a large enough sample for statistical relevance, the data was extremely useful internally to the organization.
Equipment at VideoLink of St. Peter’s includes CLI videoconferencing systems. Two units were initially installed in Helena and at the State Hospital in Warm Springs. Collaborative efforts within the community supported addition of a site in Bozeman in the summer of 1995. The network represents efforts made in conjunction with various other organizations, including St. Peter’s Hospital, Gallatin County Commissioners (Bozeman), A.W.A.R.E. Inc. (Anaconda), and the State of Montana Department of Public Health and Human Services (Helena).
Appropriate technology choices can significantly contribute to the potential success of a telepsychiatry network. Critical features are:
- • Good resolution and image quality
- • Real-time video capabilities to catch subtle visual cues associated with adverse effects of inappropriate medication dosages
- • The ability to move the line of vision from a person’s face to his or her whole body
- • Integration of equipment from various vendors into a single network
Individuals with a great deal of enthusiasm for telemedicine are also needed to encourage community participation and financial support.
Most recently, VideoLink of St. Peter’s officially became part of the Information Services department at the hospital. In other news, there were a total of 120 direct patient care visits conducted during the period from January 1st - March 31st, 1998. In Spring 1998, officials with A.W.A.R.E. Inc. (a participant of the VIdeoLink of St. Peters network) announced plans to apply for Universal Service funds to off-set mileage costs for use of the videoconference site in Anaconda.
Radiology
Filmless And PACS Environments
Data storage and enterprise-wide access to images can be accomplished through incorporation of a picture archive and communications systems (PACS). Radiology departments in hospitals and medical centers throughout the United States have adopted PACS technologies and options that support other functions, such as automated tape libraries, disk arrays (instead of optical media), and digital teaching. PACS usually represent one of the earliest steps toward establishing a filmless environment, which will be accomplished to an even higher degree in the future when x-rays are processed using direct digital radiology systems.
Various competitors offer PACS and radiology equipment. In July 1998, there were several new developments. In support of a filmless radiology initiative in Manitoba, Canada, Pulsecom (Herndon, VA) is providing the WavePacer DSL Solution for high-speed transmission of images over ordinary telephone lines. The goal of the project is to process digitized images within a network which will streamline access and distribution, while also reducing costs and delays in diagnosis. A total of five hospitals and one clinic will be integrated as a result of the three-year pilot project, with extension throughout Winnipeg expected in the future. Imation Corporation (Oakdale, MN) is providing the PACS technology using asymmetric digital subscriber lines (ASDL). A filmless environment is expected to generate significant cost savings, since the current expenditures for radiology film, administration, and transport is approximately $2.0 million a year.
In Central and South America, sales of medical imaging systems will be advanced through an agreement recently signed between Elscint Ltd. (Haifa, Israel) and Healthcare Systems Finance S.A. (Westport, CT). A significant share of the computed tomography and nuclear medicine segments in Brazil is already held by Elscint, which is also demonstrating improved positioning in magnetic resonance imaging.
In other news, marketing clearance for the iiRAD system from Sterling Diagnostic Imaging Inc. (Greenville, SC) was granted by the U.S. Food and Drug Administration (FDA; Rockville, MD) in early July. The system incorporates DirectRay technology to enable direct digital image capture. An investment of nearly $60 million has been made by Sterling Diagnostic in the DirectRay technology over an eight-year period. Several leading hospitals and medical centers are expected to purchase commercially-available iiRAD systems in the second half of 1998, which will be co-marketed by Sterling Diagnostic Imaging and Fischer Imaging Corporation (Denver, CO).
At the American Healthcare Radiology Administrators annual meeting held in Las Vegas, Nevada at the end of July, a digital x-ray detector currently under development was demonstrated by Philips Medical Systems (Shelton, CT). The system is in the beta testing stage and can be used with Bucky tables already in radiology departments to improve productivity and reduce operational costs. FDA marketing clearance is still pending.
In the teleradiology segment, INPHACT (Nashville, TN) offers on-line services to process computed tomography, magnetic resonance, and other images for clinics, health care systems, and hospitals located in different parts of the United States. The latest customer supported by INPHACT is Atoka Memorial Hospital (Atoka, OK). In 30 minutes, a digital image can be sent via the Internet to be read and diagnosed, allowing more immediate treatment of patients. For smaller hospitals that can't afford a full-time staff radiologist, these services help physicians provide patients with better care.
Rural Health Telemedicine
Improved Access To Health Care
Leaders in rural communities encounter difficulties when trying to recruit primary care physicians or highly specialized health care professionals. There has been a chronic shortage of doctors and mid-level practitioners in these areas, which has been coupled in recent years with the closure of many small hospitals. The solution to this problem is not easily found, even though studies have been funded to specifically develop incentives to 1) encourage physicians to serve in rural communities and 2) subsidize the economic health of community hospitals. Since the early 1990s, however, telemedicine has often been viewed as a viable alternative, ensuring access to quality health care services via interactive and store-and-forward technologies.
The factors affecting quality health care in rural areas are different from those in urban centers. Because the decision-making process depends upon an urgent need, there can be a higher degree of anxiety and an absence of viable alternatives for patients in rural communities. Restricted access to medical information may also lead to an over-reliance on the judgment of the treating physician regarding health care options. The doctor therefore takes on a dual role in regulating both the demand and supply of health care services. Economically, the volume of services in rural regions is comparatively low, and the decision to practice outside of an urban area is also affected by geographic isolation, which (without telemedicine technologies) restricts physician-to-physician consultations.
U.S. Telemedicine
Electronic Pharmacy Systems
A variety of new technologies are being used to track prescribed medications. For example, a program has been implemented at CVS Corporation drug stores to mail reminder notices to customers. As with telemedicine, there are confidentiality and privacy issues raised by this type of practice, but the large percentage of hospital admissions due to improper use of prescriptions (20%) seems to justify more aggressive monitoring. The American Pharmacy Alliance (Lexington, KY) is a consortium of 16 software companies that supports compliance monitoring through the Prompt Rx system, which forwards information to a central processing company to send out reminder notices. As a pharmacy, this company is bound by patient confidentiality, and enrollment is voluntary, creating a transparent service for customers.
Internet-Based Telemedicine
The WebPro package from Acuson demonstrates how telemedicine can be added to the desktop. A personal computer is used by a physician to evaluate an entire ultrasound examination with images and patient data. Clinics and hospitals can easily be linked to improve productivity and turnaround times. With WebPro, image management is provided at a much lower cost than with more complex systems, with each workstation priced at between $8,000 and $10,000. Internet-based offerings involve a modest investment in hardware and software to enable teleradiology or teleconsultations. Another major advantage is for data and images to be transferred using ordinary telephone lines. For on-call staff, information can also be reviewed on home computers.
Military Telemedicine
A system known as Desert Care enables the diagnosis and tracking of military personnel at deployed locations. The collection and instant use of data serves as a force protection tool, with information being accessible through an electronically integrated network. Since the system was implemented in 1997, there have been more than 33,000 medical visits recorded. Additional modules will support processing of environmental and laboratory data.
Robotics And Telesurgery
Remote technologies used in telesurgery focus on minimally invasive operations which rely upon information and visualization systems. Computers and robotic devices enhance control and performance for surgeons, especially for cardiac microsurgical procedures. Alliances have been formed between companies such as Computer Motion Inc. (Santa Barbara, CA) and Karl Storz (Tuttlingen, Germany) to provide innovative surgical instrumentation with robotic components such as specialized handles to filter tremors. A total of eight patents have been issued to Computer Motion to cover robot-enhanced endoscopic surgery. Future developments in the field are expected to include more visual display aids to improve the images seen by the surgeon. Another advance is use of scanners to provide a detailed electronic image during the operation. Other companies involved in this segment are Integrated Surgical Solutions (Sacramento, CA) and Vista Medical Technologies (Carlsbad, CA).
Telemedicine in the Air
As the leading competitor with in-flight emergency medicine systems, MedAire (Phoenix, AZ) offers the MedLink system. In 1997, a total of more than 1,700 calls had been handled by the Company, and statistics indicate that 70% of incidents involve neurological, gastrointestinal, or respiratory problems. An additional 20 categories account for the remaining 30%. The system allows crew members to speak directly with a board-certified physician by radio to provide diagnoses, initial treatment advise, and medical recommendations regarding diversion of the flight. Each incident is tracked to conclusion. From inception through mid-year 1998, more than 5,000 remote emergency calls have been processed by MedAire. With more airlines signed up for the service, the number of calls per year has increased substantially. The need is becoming greater as more people fly and as the average age of flyers becomes older. Ten commercial airlines are being served by MedAire, with the latest addition being Virgin Atlantic Airways. This particular airline may also add other technologies, such as vital sign monitoring devices.
Telemedicine Market
Overseas Consulting
Direct telemedicine revenues from overseas consulting are slowly increasing in well-established programs at academic medical centers. Two examples are Massachusetts General Hospital (MGH; part of the Partners HealthCare System based in Boston, MA) and the New England Medical Center (NEMC; Cambridge, MA), which has just merged with Lifespan (Providence, RI) and created Lifespan International to provide global health care services in conjunction with Brown University (Providence, RI) and Tufts University (Boston, MA). The two original participants (MGH and NEMC) have been offering international telemedicine services for two years or more, with MGH generating between $300,000 and $500,000 annually. Although this level of revenues seems low, operating costs for the telemedicine program are generally offset by patient referrals, with 10% resulting in an inpatient or outpatient transfer to the medical center.
Electronic image transmissions and interactive sessions have been conducted with personnel in medical facilities in Africa, the Middle East, and South America, largely through an ongoing relationship with World Care Inc. (Cambridge MA). Academic centers such as the Cleveland Clinic (Cleveland, OH), Duke University (Durham, NC), and Johns Hopkins (Baltimore, MD) have also successfully integrated overseas services into existing telemedicine programs.
The obvious factor supporting demand is access to the best possible medical care for individuals who live in regions of the world where similar levels of expertise may not be available. Also, as governments begin to establish economic growth in developing countries, one of the first goals is to improve health care services, to the potential benefit of telemedicine consulting programs. In the past, sending physicians and specialists to a medically-underserved area has been the normal means of filling the need, but now telemedicine allows expertise to be sent via advanced telecommunications technologies. Ideally, coordination between treating physicians located overseas and specialists in the United States can enhance patient management and, in many cases, be sufficient to eliminate the need for transfers. Through Lifespan, links are planned in Buenos Aires, Argentina; El Jazeira Hospital in Abu Dhabi, United Arab Emirates; and Hamad Medical Corporation in Doha, Qatar. In a separate development, Lifespan is helping construct hospitals and the infrastructure to deliver telemedicine services in Ghana.
Other facilities are just beginning to add global teleconsultations. For example, Rush-Presbyterian-St. Luke's Medical Center (Chicago, IL) is also using videoconferencing technologies to deliver services on a worldwide basis. For patients who require interventions beyond the capabilities of local doctors, the only solution is transfer to a U.S.-based facility. Such has been the case in Russia, with the latest surgical techniques in pediatric cardiology. Connectivity through telemedicine links will also support training to better evaluate and perform electrocardiograms. Fees for services provided to Russian physicians will be deeply discounted at Rush, with one of the goals being increased name recognition for the institution.
World Telemedicine
International News
Desktop Telemedicine in the United Arab Emirates
At Hamad Hospital (Dubai, United Arab Emirates), an asynchronous transfer mode (ATM) network from FORE Systems (Warrendale, PA) is supporting desktop telemedicine applications. Images are easily transmitted among medical professionals, enhancing access to second opinions and overseas specialists. Advantages of an ATM network include accuracy and reliability during transmissions, as well as operation of a variety of other applications, including client-server functions and radiology management. Bandwidth and scalability were two of the reasons cited for choosing the ATM product from FORE Systems.
Beyond clinical health care, there are opportunities for distance learning and medical education. The large network installed at Hamad Hospital is the first in the Middle East with a redundant load-sharing backbone. An estimated 300 doctors have 155 Megabyte/second connectivity, while desktop systems are used by 1,000 individuals. An additional 23 remote health care centers are also being linked through the network.
Government Support for Telemedicine and Information Technology Development in the United Kingdom
In early July, U.K. officials announced establishment of a fund within the National Health Service to incorporate information technology solutions. During the past three years, a relatively simple telemedicine system (personal computer, digital camera, ISDN line, and videocard) at the Royal Free Hospital (London) has already enabled consultants in remote locations to interact with patients via videoconferencing. A general practitioner is present to perform the exam under the guidance of the specialist. To date, six practices have been connected to ten specialists' offices, and a total of 54 teleconsults have been conducted.
NeuroMate Systems Sold In Japan
Integrated Surgical Systems (Sacramento CA) sold the first NeuroMate computer-controlled robotic surgical system in the United States during early 1998. Although the size of the U.S. market is not necessarily known, the estimated 4,000 hospitals with computed tomography scanners represent an important customer group for the NeuroMate system. During the same quarter, an exclusive distribution agreement was signed with Imation-Japan which resulted in an order for two ROBODOC systems. Penetration of other Asian and Pacific Rim markets is planned for the near future.
TANDBERG and TELUS Form Partnership
Officials with TANDBERG (Montreal, Quebec) agreed in July 1998 to extend a previous co-development agreement with TELUS Corporation (Calgary, Alberta). In addition to distance education and telemedicine products, the new arrangement will also cover videoconferencing applications. TELUS, the third largest telecommunications company in Canada, will resell the complete line of TANDBERG solutions, including the TANDBERG Educator, TANDBERG Health Care System III, and Vision portfolio of videoconferencing equipment.
Consumer Health Information
Survey Summaries And Benchmark Prioritization Systems
Despite sentiment to the contrary, what consumers think of their health care providers does matter. Administrators at an estimated 40 hospitals and major medical centers have already made the financial commitment to purchase systems specifically designed to assess consumer preferences. The ability to measure delivery and management of services is important to create patient profiles and to improve performance to ensure a continuum of care. Even though lowering health care costs is a primary concern, these organizations must still make every effort to attract and retain customers who may otherwise choose another provider for their medical care needs.
From a technology standpoint, a viable system must integrate consumer priority assessments with clinical and financial data to identify problem areas. The ViewPoint Interactive System from Solution Point (Dallas, TX) performs these types of functions using a decision-support framework that allows comparisons with other health systems. To date, an estimated 230 customers have chosen the ViewPoint system to evaluate and monitor consumer priorities.
Health care provider concerns regarding consumers is apparently justified according to a Health Confidence Survey issued in late April 1998 by the Employee Benefit Research Institute (EBRI) and Mathew Greenwald & Associates (MGA), both of which are located in Washington DC. In general terms, individuals in the United States are extremely confused about health insurance. A limited number understand what managed care involves: More than half of the survey respondents who were enrolled in a private health insurance plan didn't know that their coverage qualified as managed care.
There are other areas of confusion as well, as indicated by conflicting two conflicting opinions. On the one hand, there is agreement among the majority that changes are needed in the existing health care system. Alternatively, the same percentage (60%) appear to be happy with the quality of current care. Private non-managed care plans, however, account for a greater degree of satisfaction than managed care (71% versus 57%). Despite there being stable or small increases in the cost of health care in recent years, survey respondents felt that health care had become more expensive since 1993.
Financial factors also influence the confidence level each person has regarding access to quality health care in the next five year, and approximately 42% of participants in the survey were worried about their ability to afford such services during the next ten years. Members of minority groups more often rated health care in the United States in the "poor" to "fair" range when compared with the responses of Caucasians. Similarly, men are less satisfied than women, and younger individuals (under 35) are more optimistic than those who are middle-aged and demonstrated the least confidence among all respondent age groups. For more details on the survey, visit: www.ebri.org/hcs/.
Disease Management
Health Profiles And Economic Impacts
If information is to be gathered and analyzed, patients will need to consent to profiling. For individuals with chronic diseases that require self-management, there are significant incentives to provide data about their conditions (for use on an aggregate level) in exchange for opportunities to access a "community" of others with the same health care problems. Through a partnership formed between iVillage (New York, NY) and WellMed (Portland, OR), the Health Quotient risk profiling tool has been made available on the Better Health Web site. The goal is to facilitate delivery of personalized health information, and Health Quotient allows participants to receive a report based on each person's unique health status. As one of the most accurate such risk profiling systems currently available, a questionnaire is used to cover family history, general overall health, and lifestyle. The degree of abnormality and interaction among risk factors in a given profile help determine the likelihood of developing a chronic disease, using algorithms and a continuously updated library of medical data. Within the industry, the benefits to consumers is empowerment to become better health care decision-makers. For more information on Better Health, visit: www.betterhealth.com.
The result of gathering data about individuals with a particular disease is to compare and contrast treatment outcomes. Costs, pharmaceutical effectiveness, quality of life issues, and socioeconomic impacts are some of the factors that can be analyzed to hopefully improve future options. For example, Alzheimer's disease is an extremely costly disease which is expected to account for an increasingly large amount of health care expenditures worldwide. A conference was held in late July 1998 in Amsterdam to examine pharmacoeconomics (cost and impact studies). The goal is to establish a dialog and share information on a global basis. Presentations included aggregate patient data from Canada, the United Kingdom, and the United States.
Administrators at health care provider organizations are making the financial commitment to incorporate electronic patient records (EPRs) into existing health information processing systems. One factor contributing to increased confidence in EPR technologies was the publication of proposed rules by the Department of Health and Human Services (HHS; Washington DC) to create a unique identifier to be used for claims filing and reimbursement by each third-party payer. Other proposed regulations are still pending to develop other standards for electronic transactions (including claims submissions). All this activity is the result of two administrative simplification steps mandated by the Health Insurance Portability and Accountability Act of 1996. Use of electronic processing is likely to save up to $1.5 billion during the first five years, according to HHS estimates. Among the advantages for everyone will be faster turnaround times, improved staff productivity, and reduced paperwork.
In July 1998, several provider organizations announced the addition of EPRs, including East Carolina University (ECU; Greenville, NC) and New York University Medical Center (New York, NY). Administrators at both institutions chose the Logician system from MedicaLogic (Hillsboro, OR). Three of five pilot site clinics at ECU reported improvement in office workflow and physician productivity. One concrete example of time-saving benefits is direct delivery of lab results to a physician via his or her desktop computer. Expansion will include installation of Logician in 80 clinics for use by 250 physicians. An important component has been the ability to integrate Logician with existing information processing systems to support consultation notes, discharge summaries, and pathology reports to be posted in the EPR.
With approximately 600 independent practices, the New York University Medical Center is incorporating advanced information technologies to support a growing managed care network. EPRs are an important component of the system, especially since competitiveness is driving provider organizations to improve patient and physician satisfaction levels. Within a network, immediate access to medical histories is a factor in patient perception of quality services. Providers also see less duplication of tests and prescribing of conflicting medications because of instant access to all necessary information in a single place. Evaluation of practice details is another benefit, especially when managed care contracts are involved.
Another EPR system known as Praxis 98 is available from Infor*Med Medical Information Systems Inc. (Los Angeles, CA). Operating in Windows-based platforms, the software supports a flexible EPR which automatically documents procedures for reporting purposes to private and public insurance payers. The "concept processing" technology incorporated in Praxis 98 improves in time as the physician-user's patterns are established. Interfaces are also being developed for billing, laboratory reporting, and practice management functions.
For more information on Infor*Med, visit: www.inform-med.com. To contact MedicaLogic, visit: www.medicalogic.com.
Telephone Triage
Company News And Review of QUEST Legislation
During the past month, there have been several new developments for two of the leading competitors in the medical call center or telephone triage industry. A new health measurement tool, the Health Needs Questionnaire, was introduced by CareWise Inc. (Seattle, WA). As a self-administered survey, health plan administrators can better identify individuals with behaviors that may impact utilization. Another measurement determines willingness to change, an important factor for implementing successful interventions. An initial test of the Health Needs Questionnaire with 8,000 participants compared results with existing claims data collected during a three-year period. the Health Needs Questionnaire demonstrated predictive reliability and a strong correlation of "poor health perceptions" with higher utilization.
More recently, the PhyCor Inc. (Nashville, TN) acquisition of CareWise Inc. was completed through a pooling-of-interests transaction. CareWise serves more than 2.0 million worldwide with a variety of health care decision-support programs and services. PhyCor Inc. operates 61 multi-specialty clinics and offers practice management services to an estimated 26,000 physicians in 36 markets.
In other acquisition news, Access Health Inc. (Broomfield, CO) announced completion of the purchase of InterQual (Marlboro, MA), a leading source of clinical decision-support criteria and systems. The goal is to extend care management capabilities available from Access Health to serve health care providers and insurance companies. In addition to this growth strategy, the integration of both firms is expected to help "redefine" health care delivery.
The Internet is also becoming a source of nurse and physician advise services. A new investment by Premier Research Worldwide Ltd. (Philadelphia, PA) and two other companies will support America's Doctor Inc. (Owings Mills, MD), the source of "Ask A Doctor" services available on the World Wide Web. The goal is to provide health and medical information, real-time discussions with physicians, and referrals. The site will be a health page anchor tenant with America On Line.
The Health Care Quality, Education, Security and Trust Act (QUEST) legislation introduced by Senator James M. Jeffords (R-Vermont) received support from the American College of Emergency Physicians (Washington, DC) in March 1998. The goal was to establish a "prudent layperson" standard to guarantee health and medical coverage based on presenting symptoms rather than the final diagnosis. This and other health care legislation still under consideration by members of Congress. For example, a "responsible" managed care bill has been proposed by Senator Trent Lott (R-Mississippi) as a "bill of rights" which would address disclosure requirements, grievance procedures, and tax incentives to support health insurance coverage. Senator John Chafee (R-Rhode Island) has outlined a bill allowing the Department of Health and Human Services (HHS; Washington DC) to impose fines on managed care plans if denials of coverage seriously jeopardized an individual's health or life. Most current managed care legislation is not expected to be addressed until after the August recess.
