May 30, 2000

Physicians Now Face a Wealth of Clinical Information Online

After her 9-year-old daughter developed severe acne and an older daughter also had intractable skin problems, Seema Cicerone began to wonder whether her children had inherited their conditions. She told Dr. Larry Basso, her longtime physician and an internist at the Palo Alto Medical Foundation, and he dialed up a Web site for physicians created at Stanford University.

Dr. Basso quickly found information on the girls' disease -- congenital adrenal hyperplasia, a hormonal imbalance -- and printed out 20 pages of descriptions, recent research and treatment descriptions for Ms. Cicerone and her husband. They consulted pediatric specialists and eventually found a low-dose drug regimen that solved the problem.

"It was absolutely wonderful to have all the stuff there at your fingertips," Mrs. Cicerone said. "We could go to see the endocrinologist from a point of knowledge."

The Web site, which Stanford first made available to outside doctors earlier this month, is the latest entry in a race to transform visits to the doctor by providing a wealth of online clinical information for physicians. Several other top medical schools are preparing sites of their own, and there are several commercially operated sites in operation as well.

These Web sites reinforce a doctor's knowledge, suggest diagnoses, and provide on-the-spot answers to patients' questions about their symptoms.

In addition, the new Web sites may significantly improve medical care for patients who live far from leading medical centers. A doctor in rural Idaho using one of the new Web sites can learn about the latest treatments for any disease just as quickly as a doctor on staff at Stanford or Columbia-Presbyterian Medical Center in New York.

In the process, the new Web sites and all the other medical information becoming available online have the potential to alter the relationship between patient and doctor.

"There's a tremendous amount of information about my patients in the computer," said Thomas H. Lee, an internist and cardiologist who is the medical director for 1,000 doctors at the Partners Community Health Care network in Boston. "It's almost inevitable that as they ask me questions, my eyes glance over to the screen and I press a couple of keystrokes to get more insight into the answer.

Sometimes my eyes don't glance back so quickly."

Dr. Lee added: "I do think that something can be lost both in terms of learning what's going on with the patient and in communicating to patients."

But help from the computer to prescribe the right dosage of the right medication is also of huge value, he said. "The best doctors are going to figure out how to do both."

Amy Whitley, a second-grade teacher in Springfield, Mo., asked her doctor last winter about Relenza, an inhaler for flu symptoms that was advertised on TV. "He had never prescribed it before," she said. "He sat right there at the computer and worked it up on this Internet line." She got a prescription and a printout that she said was very helpful.

Experts on Internet health care developments say the ultimate goal, which is probably at least several years away, is to meld online patient records with information from textbooks and journals and guidelines suggesting treatment.

"The long-term big bang in health care will come when the data about the patient and the knowledge are completely interwoven," said Dr. Bill Detmer, who pioneered in making Medline, a huge Government database, available on the Internet in 1994.

Doctors can subscribe to e-Skolar, the Stanford service, for $240 a year, the cost of one or two print subscriptions to medical journals. E-Skolar is exploring the sale of sponsorships to drug companies, which might give subscriptions to the doctors that the manufacturers are already courting. Drugmakers spent $11.5 billion last year on marketing to doctors, the consulting firm McKinsey & Company estimates. Two services operated by medical publishers, MDConsult and Ovid, also charge fees.

Among the commercially operated sites, Medicalogic/Medscape, which is supported by advertising, is free. HealtheonWebMD has lined up sponsors, including DuPont and Microsoft, to pay for subscriptions for physicians.

Not coincidentally, these sites sometimes emphasize information on conditions that can be treated with the sponsors' drugs. Glaxo Wellcome, for example, sponsors a portion of the WebMD site devoted to irritable bowel syndrome, which raises awareness of a problem that may be treated with a Glaxo drug.

Nonetheless, primary care doctors say they appreciate the ability to get information online faster than they can by calling a colleague or opening a textbook that may be outdated. The latest medical Web sites, like Stanford's, are designed to find answers rapidly for doctors who may have little computer expertise.

"In the past, I might spend a couple of hours trying to find answers," Dr. Basso said. "Now, in two minutes I could have the answer."

"When you encounter a really weird illness, you can just flame the stuff up on your net," said Dr. Newman, a specialist in pulmonary problems.

Dr. Ted Shortliffe, who recently left Stanford to become chairman of the Department of Medical Informatics at Columbia University, said, "A good caring physician will often tell a patient, 'I have to look this up, talk to someone'," and respond in a subsequent appointment or refer the patient to another physician.

But if the answer is available when the question is asked, he said, "health care pays for one less visit, maybe unnecessary referrals to specialists don't have to occur, and the physician is more efficient."

For their part, managed care companies, which, on average, allot doctors in their networks 8.5 minutes for each patient visit, welcome any service that can help doctors shorten office visits even more to make time for other patients.

The companies are also interested in innovations that promote "evidence based medicine" -- procedures validated by rigorous clinical trials or by results from long usage -- as a route to cost effectiveness.

"Good medicine is less expensive," said James Hudak, an information technology executive at the UnitedHealth Group, a managed care company. "We will support both consumers and physicians getting access to evidence-based medicine."

Several big managed care companies, including United Healthcare and Humana are planning to join the race to provide online medical information for doctors.

Big medical groups and many managed care companies, including United, already try to persuade doctors to pay attention to costs by telling them how their choices of drugs and diagnostic tests and referrals to specialists compare with regional averages and other doctors in the same health plan. If these companies get involved with the new sites, they would have another avenue to communicate with physicians.

Stanford's Web site can answer a question raised by a patient 87 percent of the time, according to Dr. Kenneth Melmon, who developed e-Skolar for Stanford. He said speedy response was essential because doctors are desperate to become more efficient, partly due to pressures from managed care. Doctors demand responses from these online services within seconds, or they walk away, according to a survey conducted by McKinsey.

"Doctors are looking to increase their efficiency and the quality of care," said Steven P. Halper, a Wall Street health care analyst at Donaldson Lufkin & Jenrette. "It is a huge and underserved market. Over time, we think it will evolve into several leading companies," he added.

Indeed, Harcourt General, the training and publishing company, has just said that it would become sole owner of MDConsult by acquiring the rest of the online service from Wolters Kluwer, a Netherlands-based company that also owns Ovid and such medical publishers as Lippincott Williams & Wilkins.

Technology officials at a number of medical centers have reacted positively to the Stanford announcement. Johns Hopkins said it would soon introduce its own information Web sites for physicians. Meanwhile, Harvard's teaching hospitals are testing e-Skolar, which includes access to DXplain, an aid to diagnosing a disease that was developed at Massachusetts General Hospital, alongside the hospitals' system of electronic patient records.

"We're very excited" about the possibilities, said Dr. Robert C. Goldszer, chairman of the computer advisory group at Brigham & Women's Hospital in Boston, which has put information about drug orders and lab results on line.

"It's a really good idea, a real plus," said Dr. Brent C. James, a vice president of Intermountain Health Care, a technologically advanced medical system in Salt Lake City. "The technical problem would be to integrate it with what we already have."

The success of the online medical information services will hinge on how often doctors use them, said Jon Duane, the chief West Coast health-care consultant for McKinsey. To keep doctors clicking in, Medscape e-mails weekly newsletters telling specialists about the latest developments in their fields.

MDConsult even provides a synopsis of the latest episode of the popular television show "ER," to prepare physicians for questions from viewers among their patients.


By MILT FREUDENHEIM
Copyright 2000 The New York Times Company
http://www.nytimes.com/library/tech/00/05/biztech/articles/30visit.html

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