Online Health Management Gets a Start

In southeastern Minnesota, the residents of little Winona are being besieged by messages from the future. On the radio and in newspapers, on billboards and handouts, the town's approximately 27,000 residents are being exhorted to join a pilot program that will put their individual health management information online. Going well beyond mere E-mail communication between physician and patient, the Winona Health Online1 project foreshadows a not-too-distant time when many Americans will have personalized health details at their fingertips in an electronic format. "I think people will be demanding this more and more within three years," predicts David Sides, director of implementations for IQHealth, a division of Kansas City-based Cerner Corp., which is a leading provider of electronic health management systems. IQHealth is running the pilot program in partnership with Winona organizations that spearheaded a local Internet access drive in the early 1990s. As a result, 60 percent of the town's residents are online today, about 20 percent more than the national average. An initial phase of Winona Health Online involving less than 200 patients began last year and is now being expanded to embrace as much of the populace as possible. About 80 percent of the community's 50 primary care physicians will participate to varying degrees, according to Sides. Each patient using the online service has a personal Web page. The patient's health record "self-populates," to include new details such as lab and diagnostic results with interpretations by the primary care provider, upcoming appointments, and discharge summaries. New prescriptions can be checked for drug-to-drug interactions, there are links to sources of information concerning the patient's disease, and secure E-mail correspondence can be conducted between doctor and patient. The E-mail currently has four templates, to help reduce the possibility of long or confusing communications. The patient can ask about medications, request a renewal or refill, make an appointment, or query about the last visit. Winona family practitioner William E. Davis notes that at his clinic, the physician reviews lab results before sending them onward. If the result is normal, it goes to the patient, but if it's abnormal, a message is sent asking the patient to contact the doctor. David M. Rind, a Harvard University assistant professor of medicine in the clinical computing center at Beth Israel Deaconess Medical Center, points out that doctor-patient E-mail should conform to guidelines established by the American Medical Informatics Association. For example, it should not be time-sensitive, bring bad news, or inform patients of privacy matters. Beth Israel Deaconess also offers online health management for patients and doctors. Among its capabilities are secure E-mail, selected lab results, a calendar and diary, billing and insurance details, a search engine, and relevant web links.2 Rind comments that one reason such services remain unusual is that many healthcare facilities do not have electronic access to this range of medical detail. Measuring Outcomes Success for the Winona pilot program will speed expansion into other communities. Accordingly, a scientific advisory board has been assembled to oversee a five-year study of the program's outcomes, the first results from which are expected next year. "This is one of the most challenging projects we've ever done," observes advisory board member David B. Nash, founding director of the office of health policy and clinical outcomes at Thomas Jefferson University. He notes that the technology is unique, the sample size will be large, and both access and outcomes must be measured. "The punch line is that no one has ever tried to do this." One difficulty in measuring outcomes will be to minimize self-selection bias. "People who choose to use the Internet to manage their health care are a very different group from people who don't," explains Winona's Davis. For example, he suggests that patients with diabetes who poorly manage their insulin requirements are unlikely to access the Internet for health care information. The outcomes study will include two subgroups of sufferers from chronic conditions, diabetes and congestive heart failure. Patients in these subgroups will be randomized to "online" or "no online" disease state management, although Sides points out that patients will only be asked, rather than told, not to participate in the online program. Four key areas will be measured: access to healthcare information and healthcare; service and satisfaction; utilization and cost; and clinical quality. Privacy is Paramount Harvard's Rind believes that privacy in online health management remains an important issue, although Cerner Corp. and its several competitors in the budding field encrypt their messaging. Other safeguards such as passwords and personal identification numbers also are used, and Rind says that lessons learned from Internet financial transactions help to ensure the security of medical information transmissions. However, moving patient records from one facility to another creates many privacy hurdles. "For the emergency room, we still have not figured out a great way to do this, even across the city," he admits. At Cerner, Sides comments, "As far as we're concerned, the patients own their medical record, and it's up to them to decide who they give it to." In December, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which includes detailed standards to protect the privacy of individually identifiable health information. Even as companies gear up to provide new services that stem from HIPAA's mandate for better connections between patients and health plans, there is some concern that compliance with the Act will dwarf Y2K compliance.3 The effects that cyber-assisted medicine might have on the frequency and quality of face-to-face meetings between doctor and patient is still undetermined. One notion rejected by Cerner IQHealth medical director Doug Pousma is that patients might use their increased information to attempt dangerous self-treatment. "Some doctors are threatened by people becoming more knowledgeable about their health," he declares. "But the danger is, there's a lot of unreliable information out there, and there has not been a great way to make it personal, for one specific case." Rind says, "Currently, I believe on our site we are not sharing HIV results or pathology results." He adds that there is debate over the usefulness of those restrictions, while conceding, "Another thing doctors think about is, 'Do I have any patients I definitely don't want on this system?'" But he affirms, "I'm far on the side of giving patients as much access to information as possible." Ross D. Silverman, who holds assistant professorships in medical jurisprudence and medical humanities at Southern Illinois University, agrees that the opportunity for increased patient information is "a wonderful advantage." Yet, he's concerned about physician licensing when these interactions cross state lines. For example, diagnosis or treatment by E-mail could infringe state medical board regulations. He mentions cybermedicine, in which virtual consultations are conducted with physicians unknown to the patient.4 "I think it's going to be difficult to bring about a federal statute in the near future, because these areas are so traditionally held by the states that it's a power they will be unwilling to give up." In 1999, estimates of Americans accessing the Internet for health information ranged between 30 million and 70 million, while another study estimated one-third of physicians E-mailed to their patients, a figure up more than 1000 percent from two years earlier.5 Nevertheless, Rind acknowledges, "Being overwhelmed with E-mail is always a concern doctors have." And regarding the future of online health management, Nash warns, "I think, frankly, the biggest challenge will be to achieve acceptance by physicians." Steve Bunk (sbunk@uswest.com) is a contributing editor for The Scientist. References 1. See www.winonahealthonline.org 2. For a tour, see https://patientsite.caregroup.org 3. D.A. Hastings, "Foreword: the changing face of law and medicine in the new millennium," American Journal of Law & Medicine, 26:135-41, 2000. 4. Groups may use doctors licensed in states where the patients live. See http://www.cyberdocs.com 5. R.D. Silverman, "Regulating medical practice in the cyber age: issues and challenges for state medical boards," American Journal of Law & Medicine, 26:255-76, 2000.

Online Health Management Gets a Start

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