By David
Bennahum
Wired magazine, Mar 1995
Five years ago, what should have been a smooth surgical
operation turned into a nightmare for Dave Morgan. The senior researcher
at Motorola went to the hospital for surgery on a cancerous kidney. As he
lay on the gurney, the anesthesiologist flipped through Morgan's medical
records, which the surgeon would later need to operate successfully. The
anesthesiologist placed the file on a nearby chair. Minutes later, Morgan
was wheeled into the operating room, anesthesia filling his veins. The
surgeon came in and, failing to find the records on the gurney, asked who
had them. No one remembered where the records were except Morgan. As
everything faded to black, he moaned, "They're on the chair."
Medical records are the first thing a doctor turns to when a new
patient is admitted for treatment. But the records are often unavailable,
or, during emergencies, there's not enough time to retrieve them. So
doctors will fly blind, relying on sheer knowledge and experience rather
than an understanding of the patient's history. Records - some estimate as
much as 10 percent of them - also get lost. Usually, this doesn't cause
any harm, but for some patients, such as those with drug allergies, it can
be fatal. Many people end up in hospitals because drugs have exacerbated
existing medical conditions - 7 to 10 percent of those under 65, according
to the health-care consultants Towers Perrin.
Another problem with medical records: they are costly. Tracking
doctors' procedures and patients' welfare consumes vast amounts of
hospital resources, with back-office staff translating handwritten notes
into databases on networks of workstations that process the information.
According to one study, medical costs could be cut by 15 to 30 percent if
doctors had adequate information when making decisions. With health-care
costs consuming about US$1 trillion dollars a year, paper medical records
could represent billions of misspent dollars.
Come up with a way to radically improve medical record keeping and not
only will you save lives, you could make a few billion.
After his close call in the hospital (the surgeon found his records),
Dave Morgan helped found the Computerized Patient Records Institute, a
group devoted to developing systems for storing and accessing medical
records and influencing the national standard that govern those systems.
Morgan and the institute have found powerful allies in digital technology
and wireless personal digital assistants. Take patient records out of
paper form (where they are hard to copy, easy to lose, and tough to
transfer), and they become virtual patient records - mobile bundles of
bits that can be instantly shipped around the country, from hospital to
doctor to pharmacy to insurance company. Likewise, turn the computer into
a wireless PDA, and it, too, becomes mobile, following the doctor from
patient to patient. Over time, the virtual patient record becomes
increasingly detailed - it forms a complete profile of a patient's medical
history, from birth to death. Combine everyone's virtual records, and an
incredibly detailed model of the nation's health care emerges. Simulations
can then be performed, calculating which treatments work, which are
cost-effective, and why. This is the Holy Grail the health-care industry
has quietly pursued for the past 20 years. With a virtual patient record,
crises like Dave Morgan's would never occur: the doctor would just call up
the medical information on another device. This year, for the first time,
the infrastructure is falling in place: the virtual patient record is
moving from vaporware to hardware.
The virtual patient record
For two decades, hospitals and insurance companies have worked to build
bigger, faster, and far more powerful medical databases to get closer and
closer to the virtual patient record. But the companies have always been
hampered by the conflict between a sedentary mainframe and a highly mobile
physician. With the arrival of PDAs and efficient wireless networks, it's
now possible for records to keep pace with the doctor. The first two-way
wireless network of this kind, linking doctors, hospitals, insurance
companies, and drug labs, is being used in Dearborn, Michigan, where a
small company called
Med-E-Systems Corporation has figured out how to wire
the virtual patient record.
Med-E-System's headquarters is in Tarrytown, New York. A spinoff of
Physicians Online Inc., Med-E-Systems plays yin (recording interactions
between doctors and patients) to the yang (providing doctors with a
universe of general medical information) of Physicians Online. For now,
these databases are separate, but eventually they will reach physicians
through the same hardware. The doctor pulling down a record from
Med-E-Systems on a PDA could, for example, get background information by
looking up the details of a particular drug or disease by browsing the
information available in Physicians Online.
Both companies were founded by a physician, Dr. Christian Mayaud, who
greets me at the headquarters of Physicians Online in full denim regalia,
replete with Harley-Davidson belt accessories and a long, blond pony tail.
Mayaud, in his 40s, is still living out his '60s dream of changing the
world - at least the world of health care, where his dream is to return
decisions about health care to patients and doctors, wresting them from
large insurance companies and health-care bureaucracies.
As the denim doc ushers me into his office, I notice a preponderance of
fine silk neckties and classy suits. Mayaud's staff exudes mostly a
straight corporate style. I get the somewhat strange sense that they all
feel like they're humoring a tenured professor they can't get rid of.
Mayaud explains that he got the idea for Physicians Online and
Med-E-Systems in the mid-'80s, when he was a resident at Lenox Hill
Hospital in Manhattan and helping the hospital install a 24-hour online
reference library. The hospital assumed the physicians would be reluctant
to embrace the new technology, but the doctors took to the resource.
Mayaud next imagined an online service that delivered timely medical
information to doctors around the country. In 1991, he worked part time in
an emergency room and created Physicians Online with his life's savings.
As wireless PDAs appeared on the market, he built Med-E-Systems. Today,
the two companies employ about 150 people.
Library in a box
Fifteen thousand doctors use Physicians Online; Mayaud claims the
number of new subscribers grows by 200 a day. Part of its success lies in
Mayaud's strategy: Physicians Online is free to doctors. It is completely
funded by online advertising, much like broadcast television. Its
sponsorship was partly in response to the earlier failure of Medline, a
similar product compiled and maintained by the
National Library of
Medicine in Bethesda, Maryland, and funded by the
National Institutes of
Health. Medline, which provided doctors with electronic access to
thousands of medical journals, proved popular with doctors. A network of
private resellers appeared, offering Medline data and charging up to $30 a
search. Doctors, faced with rigid spending brackets instituted by
insurance companies, had a difficult time justifying the cost. "This led
to the question, Is the patient worth the search?" Mayaud says. He set out
to convince pharmaceutical companies to sponsor access to the data. In
return, they would be able to run interactive ads for their drugs. With
the average doctor controlling $1 million in medical spending a year,
advertising to physicians could bring in a substantial amount of revenue.
Yet pharmaceutical companies were initially reluctant to support
Physicians Online. Medical advertising is conservative and fairly
unimaginative, and this thing called "interactive advertising" sounded
frightening. But not for long. Today, sponsors include the largest
pharmaceutical companies, including
Astra/Merck,
Pfizer,
Sandoz, and
Marion Merrell Dow. Their commitments add up to millions. A host of
advertising agencies, most of which specialize in forms of medical
advertising, collaborate with the pharmaceutical firms. Companies like
Nelson Communications,
Medicus Intercon International, Ferguson
Communications Group, and
Dorritie Lyons & Nickel are designing the interactive advertising.
Everything on Physicians Online is point-and-click and fairly
intuitive. Libraries of medical data are available, and doctors can search
for diseases and treatments. (The company plans to add "forums," where
doctors can post messages on various topics, creating a kind of
specialized Usenet for physicians.) The online advertising is tasteful: it
scrolls along the bottom fifth of the screen. You can ignore it and
continue working, or, if something interesting comes by, click on the ad
and enter an interactive tutorial explaining the product's use. I clicked
on an ad for Prozac, and it expanded to fill the screen; it moved along
quickly, flashing FDA charts (mandatory in all drug advertising) and funky
icons. I was offered a free sample, which, sadly, I couldn't order (after
all, I'm not a doctor). The next ad offered was for Cardizem. The ads were
ever-present and almost comforting.
Dr. David Zalut, a nursing home director and family practitioner in
Voorhees, New Jersey, has used Physicians Online since it started up last
summer. He sees the advertising as a necessary evil, a price he's willing
to pay for the medical information he receives on pediatric illnesses.
Zalut says the information from Physicians Online has revealed alternative
therapies he was not aware of, and confirmed the validity of measures he
intended to take, as was the case with a new measles treatment. Physicians
Online is working. But Physicians Online's spinoff, Med-E-Systems, faces a
much tougher climb if it's going to become successful. So far, just 20
doctors are using the service in Dearborn, where the company has signed a
contract with Value Health, a leading managed-care company.
Portable physicians
Med-E-Systems is across the hall from Physicians Online. Its chair and
CEO, Dr. Jonathan Edelson, looks like a management consultant: short hair,
glasses, white shirt, and tie. Today he's suffering from hoof-and-mouth
disease and can't shake my hand. Being a doctor, he's prescribed himself
the necessary medication, which he carries with him in a Ziploc bag.
Edelson is a managed-care specialist, formerly a senior executive at Value
Health, which provides pharmacy benefit services for major employers such
as Ford Motor Company. Mayaud brought in Edelson to give Med-E-Systems
someone insurance companies and HMOs could be comfortable with. The styles
of the two docs couldn't be more different. Mayaud is happy to digress and
discuss the philosophy of science; Edelson is all business. He pulls out a
nondisclosure form for me to sign as I sit down.
Edelson's current challenge: to get physicians sufficiently wired. He's
found an ally in insurance companies, which will provide doctors with PDAs.
The companies' investment is expected to more than pay off as the device
is projected to cut insurance costs by encouraging doctors to prescribe
cheaper brands of medication. Med-E-Systems projects the return on an
insurance company's investment will be 11 to 1 in the first year alone,
and will climb to an even higher return rate in the second and third
years.
Each doctor will receive the device preloaded with software that can be
customized to reflect his or her specialty - internist, pediatrician,
obstetrician. Using a pen and the touch-sensitive screen, the device keeps
a record of the "encounter" between the doctor and patient. With an
interface similar to Windows' (drop-down menus, radio buttons, and so on),
the doctor uses a pen to select options instead of typing. He or she fills
out an onscreen form detailing the patient's complaint and the diagnosis.
If the doctor decides to refer the patient to a specialist for more tests,
the device will give out an immediate list of physicians within the
health-care alliance. Often, Edelson explains, harried doctors refer
patients to a specialist without checking whether that doctor is part of
the patient's health-maintenance organization. Doctors also use the device
to prescribe drugs. If there is a cheaper alternative, the device informs
the doctors. They can then agree, disagree, or decide that they need to
get more information.
The next step for Med-E-Systems will be to phase in entire diagnostic
procedures, such as X-rays and CAT scans. Over time, as more and more data
is captured from different parts of a health-care alliance, a virtual
patient record comes to life.
The hoped-for revolution
Edelson envisions Med-E-Systems and its network as the health-care
equivalent of a national banking network. Just as banks use automatic
teller networks like Cirrus to dispense cash, Med-E-Systems gets a small
commission on each data burst in and out of a device (they are all
wireless, connected to either Ardis, Ram Mobile Data, or Metricom
networks, depending on the area). But much of Med-E-Systems's value lies
behind the scenes. The company has created a series of translators that
can interface between different databases, say the X-ray lab in a hospital
and the drug benefit company in another state. These translators are
custom-designed for each health-care provider that joins the Med-E-Systems
network, creating a kind of Rosetta stone for medical information. The
next step is to expand the pilot program to Philadelphia, Chicago, and San
Francisco and possibly beyond. The payoff? Edelson thinks the system will
reduce prescription costs by at least 20 to 40 percent.
It's difficult to judge Med-E-Systems's promise. One of the 20
physicians testing the system, Dr. Eliezer De Leon, is part of the Oakman
Medical Group in Dearborn. He and six colleagues there are all walking
around with PDAs. De Leon uses his to fill out prescriptions. He's
nonplused by the technology. For him it's just a convenience - much more
efficient than dealing with paper. But he doubts that other doctors will
be as willing to change their habits and embrace the new system.
Alec Ellison, who focuses on medical companies for
Broadview
Associates, a firm specializing in mergers and acquisitions of
information-technology companies, agrees and disagrees with De Leon.
Ellison thinks the Med-E-Systems technology makes sense, and sees doctors
as the perfect demographic for this project. "Physicians are highly
mobile, and they control a lot of spending," Ellison says. "Any savings in
that spending quickly adds up and easily covers the cost of installing the
new technology." But, like De Leon, Ellison is more skeptical when it
comes to wiring doctors: "The clear issue is getting beyond the inertia of
doctors, making them comfortable with the system."
The greatest obstacle on Med-E-Systems's horizon may not be the
obstinacy of doctors. It may be privacy concerns of the patients. For now,
your medical records exist in a file cabinet, probably in your doctors'
offices. Physicians control access to the records, and, if they sell their
practices, they can transfer the records to the new owner. Laws protecting
confidentiality spring from an existing technology - paper. What happens
when the records go digital and can be accessed from many locations? If
insurance companies want to run simulations on the data, what right do you
have to control whether you're included in the test? Is the virtual
patient record yours?
Robert Spena, a charter member of Computerized Patient Records
Institute and the director of Clinical Information Management at the
American College of Physicians, doesn't think so. "The notion of
proprietary information is an archaic model. We should share information
for the benefit of everyone," Spena says. "Medical-record information
belongs to the patient, but you have to allow the individual to share it
within an agreement. We need to overcome the barriers of confidentiality
and privacy so the record goes from commodity to utility."
Ownership is a thorny issue. At first, Dr. Eliezer De Leon insisted
that the patient record was his; then he paused, rethought, and shifted
his position: "The data belongs to me and the patient. Patients have the
right to their records, and I have the right to hold them."
Another interest group pushing this debate is the American Medical
Informatics Association, which takes a similar position to De Leon,
emphasizing the benefits of computerizing records along with the need to
create standards for managing them. Dr. Clement McDonald, former president
of the American Medical Informatics Association and professor at Indiana
University School of Medicine, explains: "There's a tension between
computer-stored medical-record systems and confidentiality. If you want to
have absolute security, you burn all the records. Once you say you want to
have the data available, there's less-than-perfect confidentiality. On the
other side of it, patients can die because someone doesn't know what their
medical state is."
Lost in the debate is the voice of the patient - there is no advocacy
group solely devoted to representing patients and ensuring
confidentiality. While the technology helps the health-care industry
pinpoint which treatments are most likely to work, the personal details of
patients' histories - their psychiatric treatments, their weak hearts,
asthma, and HIV status - could flow into the wrong hands.
David
Bennahum is a freelancer writer based in New York.
