Netting’ healthcare’s future - where to find information
By CYNTHIA DRAKE
Healthcare InfoTech Contributing Writer
SAN DIEGO Want to find a urologist close to your office? Heard about a new drug for Alzheimer's and want to get your grandmother into the clinical trials? Not a problem. Check out the American Urological Association’s membership directory (www.auanet.org) or Centerwatch's clinical trial listing service (www.centerwatch.com). The Net is the answer to lots of consumers’ healthcare questions these days. Healthcare practitioners also are increasingly turning to the net for research, communication with peers and patients alike and, in some instances, for continuing education. Where will this all lead?
A forecast was prepared and published by the Institute for the Future (IFTF, www.iftf.org) has prepared a forecast for. the California HealthCare Foundation (www.chcf.org), published in January. The forecast seeks to provide a realistic assessment of the direction and pace of change in healthcare on the Internet. Driving forces, barriers and leading-edge applications described in the full forecast (free of charge from the foundation’s web site) are shown as Exhibit 1.
A growing share of healthcare consumers are, according to the IFTF, "new consumers,"-people who are actively involved in making choices about the healthcare they receive. New consumers have three characteristics that distinguish them from more traditional consumers: Cash, college and computers.
The Internet is particularly well-suited to meet the needs of new consumers and healthcare organizations. It is inexpensive, easy to use, democratic, spans long distances and is increasingly functional. The web platform is gaining in functionality and sophistication. In addition to its core browser functions, it now includes client- and server-side JAVA and will soon include XML (eXtensible Markup Language). These provide a much richer set of capabilities for deployment of interfaces and for integration across healthcare information systems.
For most of this century, American healthcare was isolated from the market forces that pushed other industries to become more efficient and to concentrate on excellent customer services. The last 10 years have seen the market come home to healthcare. Managed care, employer purchasing coalitions, assertive government payers and regulators and consumer organizations have force the system to adapt. Some of those adaptations favor the use of information technology and the Internet.
Bigger is better. Doctors, hospitals and health plans have all have seen strength in size correlate with market share and clout. As a result, a wave of consolidation has swept the industry in the last three years about 170 hospital mergers per year. According to IFTF, 18 large health plans merged to become six at the end of 1998. Vertically integrated enterprises have been created, spanning doctors’ offices, hospitals, home care, laboratories, imaging centers and health plans. Web technologies intranets, extranets and the Internet can serve as a low-cost, rapidly deployable platform for disseminating information across vertically and horizontally integrated healthcare organizations.
Full optimization of the net’s potential will be slowed by patients’ concerns for their privacy. Perhaps even more than their financial status, people don’t want open availability of their health history. The security challenges faced by healthcare providers seeking to use the net as a communications platform include:
• Protecting servers and databases from unauthorized intrusion or modification.
• Authenticating the identity of senders and recipients.
• Protecting the integrity of the message itself.
• Ensuring non-repudiation (that is, making sure that senders cannot falsely deny they sent a given message).
• Establishing audit trails.
• Ensuring the confidentiality of messages.
Some of the technologies becoming a routine part of healthcare network transmissions are data encryption such as DES and RSA (private key or public key encryption technologies); data signatures, hardware tokens and biometric authentication methods; firewalls, virus protection software, and smart cards (that store key information on a portable card that cannot be intercepted).
Breaching medical confidentiality calls for more than technical solutions, however. According to the Institute for the Future, laws, detection of violations, enforcement and punishment will be required. The European Union already is enforcing strict medical data security standards.
Another barrier to progress is the state of healthcare information systems in place today. The legacy information systems of most healthcare players insurers, hospitals and physicians aren't ready for prime time. Clinical information systems in labs, pharmacies and hospitals are fragmented and don’t play well with others.
Most transaction-intensive healthcare players especially health insurers have a mix of database and transaction systems, ranging from old flat-file, batch systems to real-time, relational databases. Some are experimenting with object-oriented databases. Eventually, all these will need to be real-time, to allow integrated access to information via the Internet.
Web orientation is not high on the "To Do" lists of hospital information services departments. They have resisted making investments needed to build a web presence. According to IFTF, many of these departments are underfunded. Healthcare as a whole spends much less on information technology than other information-intensive industries.
Available resources funds and personnel are being diverted this year. Resolution of the Year 2000 problem means many people will be invested in fixing the date fields in mission-critical applications.
In 1997, 43% of adult Internet users searched for health information online.
The most wired cities for users logging in from work are San Francisco, Austin, Texas, and Seattle. For home use, Austin (32.4% of adults) is far ahead. Besides seeking information, these people are eventually going to want their family records available online, too.
Healthcare providers are at the beginning of a slow transition a journey-toward electronic medical records (EMRs). Clinical functions of computers have typically been in departmental islands of automation, usually in the pharmacy, lab and specialty departments like the operating room and radiology.
A number of vendors and large institutions have developed and deployed full electronic medical records. Some, like Oceania (Redwood City, CA), rely on doctors to enter data. Others, such as the Scott and White Hospital and Clinics in Texas, transcribe physician dictation into an electronic document that is integrated into the computerized patient record. Many of these systems are proprietary. IFTF estimates that fewer than 55% of physicians are now using a comprehensive electronic patient record.
The islands of automation are the problem. The provider has two main choices: Go with a single vendor (will they have the best software module for every department?) or construct a front end that presents information from the disparate systems.
Standards work is always slow. But vendors will need to agree on how applications should link to the web. Health Level Seven (HL7), a standard for healthcare information, will likely incorporate XML (eXtensible Markup Language) as its browser mark-up language. XML documents have the same general look as conventional (HTML) web documents, but have more capability to represent structured records.
Institutions have developed their own web-based front ends for their EMRs. Most of these systems get information from legacy information systems and present it on a browser front-end. Data from across legacy systems is not integrated, simply presented in a consistent format. Web-based front ends to EMRs are expected to attract a lot of attention and development effort in the next five years.
The driving forces pushing the use of the Internet in healthcare are strong. Like the net itself, healthcare on the Internet will be advanced by the needs of consumers hungry for information about their health and demanding of control over the health services they receive.
The Institute for the Future is a nonprofit research and consulting firm founded in 1968 and dedicated to understanding technological, environmental and societal changes and their long-range consequences. The California HealthCare Foundation is a private independent philanthropy established in May 1996, as a result of the conversion of Blue Cross of California from a nonprofit health plan to a for-profit corporation.
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