Docs for Docs

Wired 3.03, March 1995

HIGHLIGHT: This is the breakthrough the health-care industry has chased for 20 years. It's called the virtual patient record. And it's going to change medicine and health care forever.

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."

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The Privacy Issue

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.

by David S. Bennahum