THE FORUM ON TECHNOLOGY & INNOVATION

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E-HEALTH:

YOU, YOUR DOCTOR AND INFORMATION TECHNOLOGY

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FRIDAY,

JUNE 15, 2001

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This transcript was produced from a tape provided by the Forum on Technology & Innovation.

I-N-D-E-X

PRESENTERS . . . . . . . . . . . . . . . . . . .PAGE

Dr. Joseph Scherger . . . . . . . . . . . . . . .5

Dr. Mark Leavitt . . . . . . . . . . . . . . . . 8

Dr. Mark Smith . . . . . . . . . . . . . . . . .15

Dr. Gretchen Berland . . . . . . . . . . . . . .17

QUESTION & ANSWER . . . . . . . . . . . . . . . 23

P-R-O-C-E-E-D-I-N-G-S

SENATOR BILL FRIST: Let me welcome everybody this morning to what will be, or this afternoon now, to what will be I think a very fascinating, very useful hour and a half discussion, and I use that word discussion because that really ends up being the format of the forum that we have on a regular basis. Most of you have been here before, several of our guests have not been here, and some of you are new faces.

On behalf of the Alliance for Health Reform and the Forum on Technology and Innovation, I want to welcome all of you to this briefing, to this discussion, on E-Health and the impact that technology is having today, has had over the last few years, but what is most exciting, will have in a dramatic way, ways that we really can’t even envision over the next several years, and I probably should even say months, but years, an opportunity to really revolutionize our thinking, our approach to health care, to medicine and, when I say "our," I mean not physician, not senator, not policy maker, but individual people, citizens, children, adults, the population. That’s what’s so exciting because it is such an empowering approach. The implications are huge in terms of potential for quality of care, as well as cost savings.

Most all of you know that we’re bringing together two organizations today, the Alliance for Health Reform and the Forum on Technology. Senator Rockefeller and I, again, just to bring everybody up to speed of what we do with each of these groups, meeting separately about 90 percent of the time, but bringing them together on events like today, is to educate our colleagues, being the Senators, but most importantly doing that through people who, for the most part, work here on the Hill or in Washington or inside the beltway, though we’d love to have visitors from the outside. We find that this forum, where you can have a discussion, you ask the questions, we try to keep our talking to as little as possible, is the best way for you to take advantage of the expertise that it so generously donates the people, who so generously donate their time from coming in around the country.

We’ll probably be hosting more joint hearings because this intersection of health care and technology, as we all know, is becoming more and more prominent. Just a-before walking into the room, several of you saw me walk in with a hanging bag and a little suitcase and it’s because I’ve been traveling around today a little bit, but had a wonderful opportunity this morning to give the graduation address at the Walter Reed Army Medical Center for the graduates from what is called the National-or the National Capital Consortium, about 350 people who really go through various institutions here and who are in the military and in our armed forces and then go across the world. It was a real pleasure. But while we were there, I had the opportunity to take a walk through Walter Reed Army Medical Center and our discussion, totally separate from this, focused very much on the issue of E-Health, of medical records, of empowering patients, of empowering the consumers out there and so it’s really a continuation of what I’ve been doing the last three or four hours, that is, looking how we can best use technology to empower, to promote both quality as well as reduce costs.

Senator Rockefeller is-and I do this jointly and, as all of you know, we do our very best to be at each and every one of the meetings. Senator Rockefeller has a very good excuse today. He is chairing a hearing and I used to be able to say he is participating and somebody else is chairing, but since the flip in the Senate, he’s chairing the hearing and has no excuses for not being there, but a field hearing on aviation in Chicago.

He will have the opportunity to see this by Webcast. As most of you know, the Kaiser Family Foundation on kaisernetwork.org, that’s all one word, has a Webcast and, both the materials that are available in our handout-in the handouts here, most of them, as well as the Webcast itself, you can see by pulling up Web-by pulling up kaisernetwork.org. So Senator Rockefeller, as soon as he finishes his hearing, better go type in kaisernetwork.org and he’ll see exactly what’s happening. So, Jay, hello. I hope your hearing went well. I’m sorry you’re chairing it and not someone else, but that’s the way it goes.

Now with that, the Alliance’s participation in today’s meeting is supported by the California HealthCare Foundation and for that we are very, very appreciative. As I said, information technology does have the power to transform the way health care is delivered. Those of you who have attended some of our tech forum briefings this year have heard how American business has leveraged technology business broadly to lower their costs. At the same time, to boost productivity, to minimize errors and to improve the value of dollars that are invested, all to the benefit of consumers.

The wholesale of penetration information technology in health care, however, has not yet taken place. Health care is about one-seventh of our overall economy and so it’s surprising, when you look at the penetration in businesses broadly, which we do through the tech forum, to see how little actual penetration there is in health care today. Why, we’ll talk about that today. There’s some resistance in new technologies. Physicians have been slow to reach out and evolve. The briefing today will focus on this promise of E-Health, the perils of E-Health as well. We’ll talk about some of the medical privacy issues as well.

We’ll look at three aspects of E-Health: technology and the doctor-patient relationship, using technology to deliver the best clinical information to physicians and the quality of medical information available to consumers online.

We have a truly outstanding panel of experts with us today and, before introducing them, and I’ll turn right to the introductions here shortly, let me just say what our format will be. I’m going to ask each of the speakers to speak for about ten minutes and try to stay pretty much on that if you can. Again, we’re going to go up till 2:00 so we’ll have the opportunity to get other points out if you don’t have time to make those.

We’ve got microphones around on the floor and you-I always encourage that you go to the microphone and ask questions. We’ll have all three panelists present and then we’ll go straight-we’ll ask the questions pretty rapid-fire. If there are other experts in the room that want to comment, again, my job is to moderate and I want to be able to hear from you as well as we go forward.

Everybody has little cards. Are they green cards? Your typical green cards there. Feel free, as you listen to speakers, to write down questions. After each speaker, just hold it up in the air and, while the other speakers are walking up there, people can come through and grab those cards. Usually, I get so many cards, I can’t get through them all, so if you have a question, again, I encourage you to go to the microphone.

We will have evaluation forms in your packet as well. I do ask and I’ll remind you a little later to fill those out because that’s the way we keep this thing on time, moving along, improved. We got the format down pretty good, but we want to improve that throughout. So those evaluation forms are important.

With that, our speakers, in order. Joseph Scherger, a nationally recognized leader in family medical practice, will be our first speaker today. He’s currently Chair of the Family Medicine Department at the University of California, Irvine Medical School, and next month, or in three weeks, he’ll be the first Dean of the new Florida State University Medical School. He’s a passionate advocate of using information technology to deliver higher quality care to patients. He has a vision of how technology can transform medical practice and make going to the doctor a better experience for everyone. My patients already have a good experience. I don’t know. Let me-I want to introduce everybody, but welcome Joe.

Mark, who’s sitting to my right and your left, is a pioneer in the field of E-Health, having founded the premier company that manages electronic records for medical groups around the country and, through its Web portal, medscape.com, delivers up to date clinical information to physicians and other practitioners. He is unusual in another respect as well. In addition to his medical degree, he holds a Ph.D. in electrical engineering from Stanford. He worked as a professional engineer for several years before he began his study of medicine. And Mark, it’s glad to have you with us as well.

Third, Mark Smith, President and CEO of the California HealthCare Foundation. Mark is an expert on medical errors, the healthcare marketplace and the impact of technology on managed care. He is a Professor of Clinical Medicine at the University of California, San Francisco Medical School, and serves as an attending physician at San Francisco General Hospital. He sponsored the recent RAND Study of Online Healthcare Information. Joining him in presenting the results will be Dr. Gretchen Berland, Principal Investigator for the Study. And I want to welcome both Dr. Berland and, Mark, you as well.

So let’s start right in. I’ll ask each of the speakers to go to the microphone for the formal presentation. After that, we’ll be sitting here to answer questions and comments.

DR. JOSEPH SCHERGER: Hello. I’m delighted to be here. With that, Senator Frist, wonderful introduction and thank you. I’d like you, as the audience, to just think of me as your family doctor for a minute because it’s the main thing that I do for a living. And I’m terribly excited about how the new information technology can make being a family doctor really fun again; take it to a level that it used to be, but it’s different because of the new technology and to make health care as available and accessible to you as using your ATM or online banking.

Let me ask you a few questions. How many of you, if you want to, can e-mail your personal physician? Let me see how many of you out there. Just a scattering. Just a few. Probably less than 10 percent. How many of you have your own health record online in a secure Web page or Web-based medical record right now? Just two hands I think. Okay. How many of you, let’s say, if you’re on birth control pills or if you’re a guy taking a pill to keep the hair growing on the top of your head or something like that and you’re on a medication and you visit your doctor and your doctor wants to give you an antibiotic, do you watch that doctor process that question through a machine to make sure that there’s no drug interaction and change of dose? Any of you see that happening? Couple of you.

Okay. How many of you, if you or a member of your family developed a serious illness, cancer or, you know, a serious illness, would you go online to find something out about that illness on the Internet probably? All of you. Okay. That’s the problem. You’re ahead of your doctors. You know, we need your help in Congress to get the health care system so doctors can keep up with their patients.

The Internet has enormous potential to improve care, yet care delivery is untouched by it. I’m a family doctor. I have an active practice. I now do two-thirds of all my patient communication over the Internet. It allows me to spend more time with patients when I see them and we don’t play telephone tag anymore.

The other thing that’s influenced me is I was a member of the Institute of Medicine Committee on Quality. I’ve given you the slide set of the IOM Report. We put out the Medical Error Report and now the more recent Crossing the Quality Chasm. Information technology is a key to making health care better. I’m going to touch on six areas very briefly.

Safety. You know, errors in health care is somewhere between the number four and the number eight leading cause of death. It kills more people than breast cancer or AIDS. We know that using a tool such as computerized order entry can reduce adverse drug events. This study by dates show that there was a greater than 50 percent reduction.

Some of you may have seen the coverage of the recent, just it was in May, JAMA. That was the study of three pediatric hospitals. And in that study, it showed that the medication error rate was 7 percent, the same as the earlier studies in the IOM Report. It validated that 7 percent of all children and adults by the previous studies, who go into hospitals, have a significant medication error occur. It’s inexcusable.

You know, most industries using new technologies and systems, have now achieved six sigma quality. That means six errors per million. We have seven errors per hundred. In that pediatric study, they showed that over 90 percent of those medication errors could have been prevented by a computerized correction of the spelling, the dosage, the timing and the interactions of those orders. Over 90 percent of the errors can be corrected. It is inexcusable that these technologies exist. There must be a mandate.

You know, government is paying for these mistakes. You know, our payment system with Medicare or Medicaid, you know, there’s no penalty when errors occur. You know, it’s a more expensive DRG when you have complications. There’s more reimbursement. There must be a mandate for this technology for safety. That’s really a major job of the government.

But it can also make care more effective. Reminder systems, computer assisted diagnosis will improve our care. You know, we live in an age where we know how to manage diabetes, we know how to manage asthma, but it’s not getting applied to the people out there at the point of service. We’re still delivering health care off the top of people’s heads and, as David Eddy says, the complexity of modern medicine exceeds the inherent limitations of an unaided human mind. An unaided human mind, I don’t care how smart a doctor, nurse or whatever you are, cannot remember it.

You know, there are now 50 commonly used drugs that prolong the QT interval of the heart. You don’t have to know what that is, but it’s serious. 50 commonly used drugs that prolong the QT interval of the heart. If you use two of those drugs at the same time in a patient, you increase their risk of a heart attack. Now tell me who out here, I ask this of doctors, who can remember the 50 drugs and who, at the point of service and looking at the patient’s medicines, is going to know that a patient might be on two of those drugs? You can’t. The complexity of modern medicine exceeds the inherent limitations of an unaided human mind. All practitioners of health care need peripheral brains. Just like in other industries, we wouldn’t think of doing things without decision support.

Patient centered. You should own your medical record. It should be a shared thing between you and your provider. It should be on the Internet. It should be continually updated. It should be readily available to you-to us and the Internet will do that.

It can make health care timely. You know, we receive reminders in our mail when our pets need their immunizations, but we don’t when our children need immunizations. I mean, we’ve not used the reminder systems. You know, when your mammogram is due, you should know about it. It’s your-your medical record should all of a sudden light up: Mammogram now due, and any other recommended test. Make care timely by putting the-putting information sharing asynchronous and available 24 hours a day, 7 days a week. Through electronic messaging, you can reduce the delays of care.

Much greater efficiency. You know, doctors are ordering tests, not because they’re needed, but because they don’t know the tests that were done because it’s not available to them. And 9 percent of redundant lab tests in the hospital could be eliminated with computerized systems. We have a wasteful system. How are we going to pay for this? Eliminate the waste.

You know, we just need to get this ball rolling because there’s so much waste in our system without these technologies. I mean, all the other industries bar-coding at the cash register, I mean you name it. They’re all doing it because it reduces waste. You know, if you do banking online, the cost to the bank is about 12 cents. If you call an 800 number and talk to a person, that bank is spending many dollars. It’s why the airlines are putting you on using the Web to do your reservations, because it saves them money. Health care can do the same. We just need to be moved in that direction.

And then finally for equity. A great public health issue today is to bring all Americans with access to the Internet. I know we have literacy issues, but you don’t have to be literate to be visual and be on the Internet. And the progressive community clinics around the country, like the one run by the University of Colorado, is using the Internet as the backbone of reminder systems and clinical guidelines and they will have workstations. If a person doesn’t have their own computer, the public library, the waiting room of the community clinic or the doctor’s office can be a workstation for them.

What I’m going to do here is, I told you that I now do two-thirds of my messaging over the Internet and I’m going to give you an example of a patient who, I just got her permission to use this e-mail. Beth is eight months pregnant. I had just seen her in the office for a prenatal visit, but it’s nice to do prenatal care with continuous e-mail access in between visits, because all those questions and things that come up.

What came up with Beth was, "Dr. Scherger, I have a question for you. I seem to have developed a wicked rash and was wondering what I can use to help with the itching. The rash looks like little hard pimples and they itch like crazy. I’ve attached a picture." This is the second time. Digital camera. I mean, Beth is an office worker. Her husband, you know, this is not a graduate education family. This is an average American family with a digital camera and this is the second time I’ve gotten a very nice picture and been allowed to care for it. "And I have tons of the bumps on my legs and hips and lower belly where my stretch marks are." I said she’s eight months pregnant. "Light sprinkling over my arms, wrists and hands. There doesn’t seem to be any on my face, neck, back, except right at the top of the arm." Very descriptive. I mean, these are people writing into their own medical record. No doctor would document it this well. "Any suggestions would be welcome." And then I can click into the picture.

Now, you won’t be able to see this very well, but a digital camera just sent to me by e-mail looks like the textbook. You know, she had, a couple years ago, sent me a classic patch of ringworm. You know, I was able to diagnose and treat, you know, the ringworm patch immediately before it spread, before she could get a visit, finally come in, etc., etc. This was a simple case of a foliculitis in pregnancy. That day I was able to respond to her. She got into a nice bath with Aveeno or the oatmeal type bath, reduced the itching greatly, was feeling much, much better. All turned around within 24 hours.

This is the way health care should be delivered. I can give you examples of preventive care, minor acute illnesses that you wonder whether you need a doctor visit or not, but it works best for monitoring chronic illness; helping people quit smoking, reduce weight, manage their diabetes, manage their asthma, develop a continuous online relationship with patients.

It reduces costs. It’s way more efficient. We need mechanisms to get paid for it, you know, capitation or user fees. You know, I have a couple ideas for that. I added up-I challenge you to go to your own monthly account of your own budget, as average Americans. How many user or service fees do you pay every month? You’ve got your Internet service provider, whether it be AOL or Earthlink, you might have a cable model or a DSL, you got your local phone service, your long distance phone service, you might have call waiting or caller ID, you probably have a storage facility, maybe you have a health club, you probably have cable television. All of these various amounts that can be in a service fee.

Physicians who-or medical groups who have actually done that kind of thing for continuous online care are finding it an excellent way to deliver service at very low cost to people in terms of access, but we need to enable this. We have a new way of delivering health care that just enriches the face to face visits and the other parts of care. We just need ways of putting that together so we can move into what 21st Century health care should look like. Thank you.

SENATOR FRIST: Good. Thank you very much, Joe. Mark? Go ahead.

DR. MARK LEAVITT: While we change the wires over so that I can use some slides, let me just thank you for inviting me, Senator and Ed Howard. I’ve had a vision of this for 20 years, of doctors using computers and the Internet and, I must say, even if I don’t see my vision come true in the next couple of years, sitting in this room with 300 congressional staffers and a Senator, is a pretty big chunk of that pie. Just having people think about it and talk about it is important so I’m really happy to be here.

I’d like to talk about getting doctors to use computers. Now, after Joe’s talk, you might think what’s the problem. Sounds like doctors just love the Internet. But I think if you go to your own doctor’s office, except for the two or three who held up their hand, you’re going to see stacks of paper charts, pink post-it notes stuck to charts, actually, they’ll be on the floor, too, if you walk through. You can cause medical errors walking through a medical office by having post-it notes stick to you.

Why? How come health care and, actually, this is an optimistic percentage, spends 3.9 percent of its budget on IT. Financial spends over 10 percent. Trucking spends more than health care. In fact, let me just give you a little anecdote, an epiphany. This happened to me.

I’d been in practice a year or two and, actually, I was already using computers but, of course, the rest of the world didn’t. I had a patient in front of me. I took a chest x-ray and it was abnormal. It had a spot and what I needed more than anything else was their previous chest x-ray from the radiology department of the hospital because, if the spot was then ten years ago, you’re fine, Sam. If the spot wasn’t, something serious. So I called the hospital and they were hunting for it. Meanwhile, of course, the patient’s wondering if they have cancer.

While we’re sitting there, the truck driver walks in from UPS, drops off a $9.95 package of tongue blades but insisted that I sign on an electronic clipboard that was wirelessly connected to the truck and-you could tear your hair out. The $10 package of tongue blades is tracked to the foot, to the inch, a decade ago. What about this chest x-ray? This patient’s life may depend on the x-ray and, if not their life, a month of anxiety. Sorry, they said, we can’t find it. That’s gone to the archives. We could get it in a few days. This is an everyday experience for doctors.

So why do we have this situation and why does it need to change? Actually, one of the nice things about being on a panel is you don’t know what’s going to happen before you. Dr. Scherger did this slide better than I ever could so I’m not going to elaborate on errors, on the quality, the fact that our preventive care compliance runs 20 to 40 percent and we’re ranked 37th in the world by the WHO in the efficiency of our health care system, in using its dollars to take better care of people.

And I want to point out one more because this may be a little different than the way you thought about it. Privacy. The paper chart is one of the biggest risks to privacy. It’s just that we seem to think computers are dangerous and people hack them. When you have a copy of your record sent, the entire chart is fed to the automated document feeder on your fax or your photocopier and the whole thing goes somewhere and, from then on, it can be copied, faxed, and you have no track of it. So, in fact, the lack of IT is a privacy risk as much or more than it is a privacy threat.

So what are the barriers? Why aren’t we there? Why am I here, happy to have 300 people thinking about it, rather than 300 doctors saying how can we upgrade our system one more tweak? Four barriers: cultural, technical, financial and systemic, and the cultural barriers are, for example, how do I feel as a doctor? Did I use computers and the Internet when I was training? Did I-do I model myself after my professors? Do my colleagues use computers and the Internet? And finally, how does it make me feel?

Well, the barriers are, if my colleagues don’t use it, I don’t want to be the first. I’ll seem like a nerd. And if typing on a keyboard seems to be associated with secretarial duties, as a physician, I couldn’t possibly do that. Other people do that for me. It’s just a cultural-a cultural melee and I’ll talk a moment about which of these are changing.

Technical issues. A few years ago, PCs were expensive and slow and buggy. Now they’re low cost, fast and buggy. Financial issues. Physicians don’t tend to accumulate capital. The main capital accumulation in health care is to build big buildings and hospitals, but they actually don’t accumulate capital for information technology and it does cost money.

For example, if you look at our systems for digital health records, the cost of the software is less than a third of the total cost of the investment. You need the workstations, you need the networks, you need training, you need implementation. In fact, if it costs $5,000 per doctor, and that’s roughly what it does for software, it costs about $25,000 by the time they’ve installed the hardware and the networks and done the training and that’s not capital that physician groups generally have.

And then I mentioned the systemic issues and these are the biggies. I would like to just say, in this area, no good deed goes unpunished. A physician who implements a system, like our digital health records, within a year, pops up on screens at the HMO saying "outlyer." Twice as many mammograms as everyone else. You know? Twice as many cholesterol screenings as everyone else. What is wrong with this doctor? In fact, one of our very valuable employees is a physician who was in a health system. He put in our system and his numbers went off the scale. Patient Satisfaction? Compliance with this, with preventive care guidelines and, in fact, he was almost ostracized by the other physicians and he found a happy home working for us. So the system does not reward quality. The system does not insist on safety. That’s one of the things that has to change.

So what has the Internet done? It’s helped a lot. Where has it helped the most? Cultural. I’ll guarantee you, you don’t graduate from med school today if you can’t use the Internet. In fact, 75 percent of residents graduating have a personal digital assistant. That’s one of the highest PDA usage percentages I know of, so they all have it. Basically, 98 percent of them use computers and the Internet.

And I have seen the transformation. Five years ago, when I went in front of doctors and said you should use this, someone would stand up and make fun of it and the others would sort of giggle and support him or her. Now if someone does it, the other ones will look away, ashamed of the doctors that says I’m never going to use computers, it’s not going to work for me. So, the Internet has really changed that. Every physician knows how to point and click. Never mind if they’re pointing and clicking to track their stocks instead of to take care of patients, they are pointing and clicking.

The Internet has helped with the technical issues. I give it two checks instead of three. It did give us a ubiquitous infrastructure that’s low cost, but we still don’t have the right workstations. The desktop PC still isn’t really right for a doctor. It doesn’t fit in the exam room and it isn’t easy to work with and the digital assistants we have aren’t powerful enough. So actually, I’m waiting for the Wireless Web Tablet, in between the PC and the hand held that’s powerful enough to hold the patient record and see the chart all on one screen, but not so clumsy and immobile as a PC.

On the financial side, I can really only give it one check mark. The Web does help drive down the cost of these systems but, unless we change the financial incentives, and this is the systemic topic that I talked about, it’s going to stall. In fact, I’m up here as the poster child for what’s happening with doctors and where it’s happening and where it’s stalling. I’m going to give you my experience.

I’ve basically dedicated myself to this for about 15 years. After I practiced medicine and this was starting to happen, I sold the practice and said I’ll do this full time. We had six people working for us, now we have a thousand. But to show you where the progress is and where it’s slow is, I think, a case study, an education in how this happens.

One thing I can tell you is it isn’t going to happen in one great leap. You can’t pass off or invent a product or have a TV show and suddenly every physician in America has a digital health record system and every patient can communicate by e-mail. It’s going to happen in a series of steps and the steps are pretty predictable because they’ve taken place in other industries.

The steps are first, content, then communication, then commerce and then complete embracing or complete solutions. Let me give you an analogy in the financial services field and this will be familiar to all of you, even if you’re not involved in health care.

The first thing people did with the Internet in financial services was read. That’s the content side. Oh, I think I’ll go online and read about this stock or read about this bit of news that might affect my stocks. I’m not putting anything in there, I’m not telling anyone my name or my credit card, but I’m reading it like a newspaper, but it’s more immediate and it’s got, you know, vastly greater amounts of information. Doesn’t take much commitment or trust to turn on the computer and read. That’s the first step.

The next step is communication. That means I’m willing to e-mail somebody. I will trust the Internet to be my post office, or perhaps I’ll go into a chat room and create a little forum and talk to other people about a stock or some issue, staying away from health care still.

Then finally, commerce. Okay. I’m going to put the credit card number in. My neighbor did, he didn’t get robbed and the credit card company is backing it up and saying you can’t lose more than $50 through fraud on the Internet and I’m going to take that step and buy something. That’s commerce.

Complete solutions. Actually, we’re not there yet in the financial world. The best example is there are financial software packages and, I try not to plug commercial products here, so I won’t mention the names, but there’s two. You know, you keep your checkbook on them. And they connect to the Internet, I can plug my own commercial product.

SENATOR FRIST: You can plug (inaudible).

DR. LEAVITT: Okay, well, you know about Quicken and Microsoft Money and all of that and you can keep your own checkbook on it, but they are seamlessly tied to the Internet. They will update your checkbook from your bank balance and reconcile. There’s a complete solution. And so we actually see that staircase in financial services. Okay?

In health care, in physician adoption, I believe we will be following the same staircase and you’ll see evidence as I show you what we do. As a first step in this staircase, we provide a physician Web portal. This is the equivalent of your medical journal, except it doesn’t come six months after the research and it doesn’t take three weeks to get it in the mail. And once you put it on your shelf, it doesn’t lie there, a one-quarter inch slice of unusable information. It’s instantly searchable. It’s retrievable from one day ago or three years ago with the same search. So it is powerful and it has been adopted and I’ll give you some numbers later.

So, this provides not just the journal articles, but news, a summary of the conference that you couldn’t attend. You couldn’t go to Baltimore for this conference because you were busy. The next day you have a summary of the important papers presented. It provides editorial opinion. It provides continuing medical education and, in fact, the fastest growing part of this is continuing education. Last year, we delivered more than 100,000 hours of doctor education online. We’re the biggest provider of that. So, we’re seeing this adoption.

The next step up is this-in the normal world, not the health care world, is communication, physician-patient e-mail. We created a product back in Christmas of ’98. We put it out there in ’99. Had it pilot tested at four major systems. Twisted the arms, convinced the doctors who said this is gonna take more time and patients are going to barrage me and, in fact, they don’t. But has this been widely adopted? No. You’ve seen the percentages, although I saw a more recent number from Harris Interactive that suggested that more like 19 to 20 percent say they will communicate with their patients online, but I don’t know if they’re telling the truth. It does not jive with the three people who raised their hands here, so I don’t know about that.

But this not only lets patients communicate with their doctor, but see their record online. Something that is now going to be mandatory through the HIPAA regulation. You have the right to see your record, you have the right to amend it. This lets you do it digitally. So that could be a very great driver. But up to now, no more than a few thousand physicians have adopted this, even though we put the technology out there.

The next step up is commerce. You start to do some business and the analogy in health care is particular transactions and of course a big one is writing a prescription. So instead of scribbling it, you could click it into a hand held device, or you could put it into a personal computer if you’re using a computer.

The interesting thing that’s happened in this is it’s not actually the doctors that are driving the adoption, but the people who either get the prescriptions or pay for the prescriptions and, interesting case study here, you know, we started to build it and we were scratching our head. Will doctors pay for it? You can go ask them and they’ll say no. Would you pay 20 a month, 50 a month? It costs money to do these things.

Well, we actually ended up at the table with General Motors and, at breakfast with-you can tell it’s important when you get to go have breakfast with the CEO of General Motors. Health care must matter to them and, in fact, I learned they spend more on health care than they do on steel and yet they make cars, they don’t do bypasses. So there’s something wrong with the picture and, in fact, the fastest growing component of their health care expense is pharmaceuticals and we said we have this product. It can guide the doctor. Tell him this is on formulary, this isn’t, this is an equivalent and here’s an interaction, watch out. And basically they said, we want to partner with you and roll that out and that’s happening actually right now. It was launched this-just this last week. Hand held prescriber and we’re going to the cities where GM has plants and they are subsidizing it so the doctor doesn’t have to pay for it and we’re going to measure the savings, the decrease in errors, the decrease in costs and, if it justifies itself, roll it out more broadly.

The final step at the top is the complete solution and that’s where, basically, the computer is your whole record and we actually have a product there that does everything. It does reminders, alerts, drug interaction, checking, handouts in English, handouts in Spanish, but it’s a pretty big step to get there.

Here’s the numbers and then I’ll sum up. That first step, the Physician Web Portal, it’s been operating five years. There are more than half a million physicians worldwide registered and, actually, another 1.65 million allied professionals, the nurses, the pharmacists, the physician assistants. So, I’d say that’s happened. That’s happened. Physicians are using it and valuing it.

What about hand held digital prescribing? Well, we put one out there for free which didn’t write the prescription but let you look up the drugs, the warnings, the interactions and in-actually, 10,000 downloaded it in the first week and we’ve had more than 70,000 download that in just six months. So you can see a simple application that’s free, you can get an incredible speed of adoption. That does not jive with doctors not liking technology or computers so I think that tells the story.

What about getting all the way to the digital health record so that you’ve got all you interaction checking and you can find the record, you don’t lose it, reduce the lab duplication? 12,000 in what I would have to say is about 10 bloody years of combat and I’m glad to take off my jacket and show you the scars. But that’s still a lot and, in fact, we have about 19 million patients now have digital records as a result of the products that we have and that’s, you know, 6 percent of the population so we’re getting there. But what will it take?

Let’s talk about it. We know that health care’s lagged badly in adopting the technology. I believe it will dramatically improve efficiency, safety and quality when adopted and the Internet has reduced many of the barriers, the cultural barrier, which was a tough one, and the technical barrier, but the financial and systemic barriers remain. And, if we’re going to make our way up the staircase and not get stuck on the first step or the second step, we’re going to have to rewire the motivations and the reimbursement systems so that the doctors get wired. It doesn’t take a lot, but it may take some small amount of the reimbursement that’s tied to furnishing digital evidence of quality care, furnishing digital evidence of good preventive care, furnishing evidence that you’re using digital technology to prevent errors and eventually making people accountable for those errors once they’ve had time to adopt the technology.

Thanks very much and I look forward to the question and answers.

SENATOR FRIST: Thank you very much. Let me remind everybody to be filling out their cards as questions arise. Again, I want to encourage the microphones and you can raise them up in the air after the next speaker and we’ll start right in with questions. Go ahead.

DR. MARK SMITH: I’m going to be very brief. I’m mainly going to just set a little context for the Foundation’s funding of the recent study that Dr. Gretchen Berland’s going to present, but I thought I’d really do three things: First is to say why the Foundation funded this study and why we think it’s important. Second is to say a little bit about the potential role of people in the public and private sectors about this issue, and third is to illustrate a little of this from my own experience.

I, too, am a family doctor but only if your family has AIDS. So I’m kind of used to this resetting of the balance between patient and doctor that is a new thing for family docs and internists because, for the last 15 years, I’ve had patients come to me with-asking me about the article that’s going to be in next week’s JAMA, wanting to know where can I get this, what’s the dose.

The Foundation is mainly focused on questions of health care in California and much of what we do, most of what we do, is really quite specific to California, but there are a couple of things, including E-Health, that are certainly important in California, but not exclusive to it and we therefore are glad to try to play a role more generally. That’s why we supported this forum. That’s why we supported this issue of Health Affairs and I’ll do a commercial for John Iglehart.

If you haven’t read this, you should. They’re outside and it is a great compendium of what some of the principal challenges and problems are facing this potential revolution. The potential revolution is the important part because there clearly has been dramatic change in a number of areas. You’ve heard about some of them today. Like all revolutions, this one has some potentially dark sides to it and, among them, are the issue of security and confidentiality and the issue of quality, which are two of the issues that we’ve tried to focus on.

You will see throughout this issue and throughout much of the discussion about the role of the Internet the issue of it’s great that people are using this information. I note that when Joe Scherger asked how many people have gone online to find out information about a serious illness or would do so, everybody raised their hand. Of course we all have. The question, of course, is what do you get when you get there? And that really was the question that the RAND Study that Gretchen will present was designed to begin answering.

Second question has to do with the role of philanthropy and the public sector in this process. It’s interesting because the last five years have had a tidal wave, a tsunami of innovation and development of things like Medscape. Technologies, business to consumer, education, a whole variety of innovations in health care as in other sectors and, as this tsunami and the venture capital that formed it have started to recede, we’re beginning to see some beached organisms. We’re beginning to see some things that were great ideas and are still great ideas, but it turns out were not perhaps profitable ideas or at least not yet. And so it seems to us, and it’s a subject of intense thinking on our part, and I would commend to those of you who are congressional staff who are watching, and policy makers, there are some areas where two years ago we considered investing, for instance, in lots of information to consumers about their health care and we looked and we said, gee, there are 10, 12, 2 dozen companies doing this. We can never potentially match them and we thought, silly us, because they were advertising on the Super Bowl, they must have been profitable.

Well it turns out that’s not right and it turns out that, in health care, as in other areas, that some of the innovations of the last couple of years may be orphaned by the collapse of some aspects of the venture capital market and, for lack of an economically viable business model. You heard about these issues of approval, these issues of investment. I always laugh when I hear people talk about what doctors will pay for something. I know the answer to that. The answer is nothing! They won’t pay anything for it. I have no idea how you run a business where you’re trying to market to a population for whom free is not cheap enough.

So people have learned-people have learned the hard way that, just because it’s a good idea, good idea for doctors, a good idea for hospitals, a good idea for consumers, doesn’t necessarily mean that you can find somebody to pay for it what you would need them to pay for it to be profitable under the current circumstances. And it will be left to some of us in the public and philanthropic sector, ironically, to walk down the beach and look through some of the beached organisms and see which of them we may want to salvage as they come up high and dry as this Tsunami continues to recede.

The last point I want to make has to do with my own experience as a physician, talking about what Drs. Scherger and Leavitt have said. There’s no question that more and more patients are coming to us with information they’ve gotten from the Internet. Sometimes it’s right, sometimes it’s not. There’s more and more-there’s no question that more and more, we are having to acknowledge that we don’t have all the answers to questions.

I had an experience at an AIDS clinic a couple of weeks ago of having a patient who is co-infected with HIV and Hepatitis C and he asked a question, well, gee, what’s the actual chance that my Hepatitis C will lead to liver failure? That’s one of those millions of facts that I’m not smart enough to keep in my head and I turned to my big, clumpy, not very ergonomic desktop PC. We went to the CDC Website and in about 20 seconds I actually had a definitive answer for him, as opposed to kind of blowing him off and say I’ll have to look into that or giving him some number that I remember from residency 20 years ago.

But more and more, there is this question for patients and doctors alike, how good is the stuff you get when you get there, and that’s what we asked some of the best scientists in the world at RAND to answer and that’s what Gretchen Berland will tell us. Gretchen?

DR. GRETCHEN BERLAND: Thank you, Mark. I’d like to, before I start my talk today, to really thank the California Healthcare Foundation, particularly Mark Smith and Sam Karp for supporting this study. We’ve been talking about this for about-started talking about this about a year ago and just want to thank you for your support.

So, I know that Dr. Scherger asked many of you earlier that you would go to the Web to look for health information, but how many of you have actually gone online to look for health information on the Web? Can I see a show of hands? Well, you’re one of the estimated 97 million Americans who report going online to look for health information on the Internet, according to a Harris Interactive Survey just conducted in March of 2001 and, as you can see, that since July of 1998 up until March of 2000, that number has nearly doubled. So we know that the Internet is a very popular place. We also know that the Internet is a very big place. There is an estimated 17,000 health related Websites offering over an estimated billion pages of health information. So, for those of you who have gone online, you know that there’s a virtual sea of information on the Web.

The Internet has attracted a lot of attention because of its size and popularity. Optimists predict that consumers will have ready access to health information and that this access to information will motivate consumers to participate more actively in their care. Others worry that information may be complete, inaccurate and misleading but, to date, there has been a lot of opinion that’s been written about what the Internet should be; however, really little is known about the accessibility, quality and the reading level of some of the information that you might find when you’re going to the Web.

So, with some of those questions in mind, in July of 2000, with support from the California Healthcare Foundation, RAND designed and conducted a large three-part study to evaluate health information on the Internet on Spanish language and English language materials and we really set out to answer three questions.

Our first question asked what are consumers likely to find when they search for a specific health information online? How easy is it to find information that’s related to your search? I’m sure many of you know when you go in and you type a word into the search engine, where do you get taken to? Our next question asks, well, if I land on a place, how comprehensive, accurate and current is the information on some of these more popular E-Health Websites? And finally, our third part of the study asks, well, if we can find the information and if the information is there, what is the level of literacy required to understand the information? Can I actually use it? Can I read what I find? So this right here is really a roadmap for-you’ll see it a couple other times in my presentation, for what we at RAND were thinking about when we designed this study.

Now I’d like to walk you through the first part of our study, which really studied search engines and search engines are computer programs that take people to health information on the Internet. An example of a search engine would be Yahoo! or Google for those of you who are-who don’t use the Web.

We-first, we picked four conditions and this applied to each part of our study. We studied breast cancer, childhood asthma, depression and obesity and we chose these conditions for a variety of reasons. We know that reasons that related to cancer is a very popular reason that people go online to the Internet, hence our reason for choosing breast cancer.

Mental health is another reason that many people go to the Web, hence our reason for depression. Childhood asthma is increasing in prevalence. It represents a condition that parents may go to the Web to study and, finally, obesity-actually, according to Cyber Dialogue in a survey conducted six months ago, is the most popular health condition that people go to the Web.

We then selected search engines; ten English language search engines and four Spanish language search engines and we chose them for two reasons. Some we chose the most popular search engines, according to industry reports that people use. For instance, Yahoo! We then chose a subset of search engines that basically ranked programs a little differently than others. Not every search engine is alike, so we picked a variety of search engines to see whether or not the different type of ranking algorithms affect where you get taken.

Then on each search engine, we conducted a series of standardized searches using simple search terms and then categorized the results of these searches. So, what took us several months to do was probably what you do in one second. It took us about ten months to do that. When you go to your computer, you type in the word obesity, you click. We basically categorized those steps and now what I’d like to do is walk you through a little bit about what each of those steps was.

So, for instance, you take a search engine. You enter the search term, let’s say breast cancer, if you will. You hit click and that produced long lists of links. We then classified those links into two categories. Was the link relevant to my search or was it not relevant to my search? And we defined relevant very broadly, meaning that, let’s say you see a link. If it contained the word breast cancer in the link itself, then it was counted as relevant. But if it contained another term related to breast cancer, for instance Tamoxafin or lump or mammogram or ultrasound, we developed 40 terms for each condition, then that would count it as relevant, too.

If it contained the term in text surrounding the link, and I think you’ve seen that on a link-you’ll often see text written beside a link describing where you might get taken to. That also meant it was relevant. Overall, when you enter a search term, on your first page of results, about a third of the links are relevant to the topic that you’re searching about.

We then conducted a search experiment. We picked a-we randomly picked a sample of those relevant links and followed them to say, okay, if a link contains the term breast cancer, am I going to get taken to information that is about providing information about breast cancer? And we found that, overall, from start to finish, once you enter the term breast cancer and you end up on a page that’s providing information about content, your chances are one in five of finding health information that’s relevant to your search on Spanish language materials. If you’re using a Spanish language search engine, your chances are one in eight of finding information that’s relevant to your search. So, as you can see, the Web is a big place and our first part of the study showed that finding information on the Internet is somewhat of an obstacle course.

We also wanted to know, does it matter which search engine you use? The two lists here on this slide represent the first ten Websites if you were to go into search engine A and search engine B and type in the term breast cancer. This is an example of lists of Websites produced from each search. On average, the number of sites that are common between two search engines was only 10 percent. So it meant that if you start using search engine A versus search engine B, you end up at very different places.

We said okay, if you land on information that contains-that is related to your search at hand, since most of the E-Health world is sponsored by advertising, our next question was, well, how much commercialized material was present on these pages? And on English language materials, information that was explicitly presented as an ad, meaning a banner ad that is on the top of the Web page or a side bar ad, was found about a little more than half the time. As you can see on Spanish language materials, it was present a little more than one-third of the time.

We also looked on these pages to say, okay, if-we also found that a little less than half the time, information was also promotional in nature that was less subtle than an ad. For instance, it was in the text itself, information that was promoting a provider or promoting a service that a provider was offering. And we found this was on a little less than half of the pages on English language materials and a little more than 20 percent on Spanish language materials. So our first part of the study really found that, at this point in time, using a search engine, finding health information is often an arduous task.

Our next part of the study asked, well, if the information is present, how comprehensive, accurate and current is information on selected E-Health Websites? We used-I’d like to now walk you through the approach we used to evaluate Websites. We first convened panels of patient advocates and clinical experts for each condition. They were given a task. They were assigned a task. We went to each panel and said we would like for you to develop about five to seven really need to know and consumer oriented questions. These were supposed to reflect questions or topics that they felt should be present on a Website, if you will.

After these topics and questions were developed, we then developed standardized answers to each of these questions, based on literature of use and I’ll provide some examples of those later. So let me give you an example of what a consumer- oriented question was. For breast cancer: I have a lump in my breast. What should be done to check this? For childhood asthma: What causes asthma? Is it curable? For depression: If my doctor recommends an antidepressant medication for the treatment of my depression, how long should I take it for? What should I expect and when will I feel better? And for obesity: Who should consider weight loss surgery? What are the risks and how well does it work? And I point these out because these are really sort of low bar questions. Basic questions that the expert panels felt should be, if someone were to go a general health related Website, they should be able to find an answer to these questions.

We then developed answers for each of these questions and, as you can see, these are four answers for the evaluation of a palpable breast mass that the expert panelists felt should be there. So for I have a lump in my breast, what should be done to check this, they felt that the information new breast lumps should be brought to the attention of a physician, mammography and ultrasound are useful in evaluating lumps. A negative mammogram does not eliminate the need for further evaluation, and a persistent non-filled breast mass, felt by a physician, should be biopsied. Again, sort of very basic, low bar types of information that they felt should be present on a Website.

After these questions and answers were developed, two searchers went to each of the Websites that we were studying to look for information related to the questions. So they took the question, I have a lump in my breast, and went to the Website and spent a specified amount of time looking for information related to those materials. They were not given the answers.

The results from each search were saved and assembled into notebooks and, just to give you a sense of the amount of information that we accumulated during this study overall, a total of 19,530 printed pages were pulled from Spanish-from English language sites. On average, one search-if you were to go to a site on an English language site, a searcher found about 250 pages of material.

As you can see from Spanish language materials, we studied fewer sites, but still, the amount of information that was retrieved from a Website was far less; on average, about 70 pages of material was produced from a search.

After the material was pulled from the Websites, we then developed standardized rating forms for each of the four medical conditions. We recruited 34 physician experts to rate the information that the searchers had retrieved on two dimensions: coverage and accuracy.

Let me give you an example, for the topic breast cancer screening, how we asked experts to evaluate coverage. So, within the material from a Website that a searcher pulled, if no mention of mammography was anywhere in the material whatsoever, it received a score of no coverage. If, in the material, it mentioned that mammography was a way to identify early breast cancers, but didn’t mention when screening, who should receive screening, what the different types, when screening should be started, it received a score of minimal coverage. And if it mentioned, for instance, that women over 50 should receive an annual mammogram and discussed some of the pros and cons of mammography in high risk populations, any of those things allowed it to receive a score of more than minimal coverage.

Let me give you an example of how the experts were asked to rate coverage for the question related to antidepressant medications. If a Website did not mention antidepressant medications at all, it received a score of no coverage. If it mentions antidepressants but didn’t discuss any of the side affects, it received a score of minimal coverage. And finally, if it discussed side affects, as well as other therapies, then it was-received a score of more than minimal coverage.

Now I’d like to tell you what we found. On English language sites, on average, as you can see, breast cancer was a condition that was handled fairly well. Two-thirds of the topics that the expert panelists felt should be covered by a Website were handled well. Childhood asthma did not do as well. Barely one-third of the topics were handled well.

Now, the-that may look somewhat discouraging, but when you look at the Spanish slide here, as you can see that, on average, on breast cancer, which did the best, only one-third of the topics were handled well by Spanish language Websites. On depression, two-thirds of the topics were not covered at all in any of the Spanish language materials.

Now, our final part of the study really asked the question, if the information is present, what is the level of literacy required to understand the information provided by these sites? We used widely accepted readability formulas and measured-which measure grade levels of the function, the sentence and word complexity in a sample of text and we then applied these formulas to randomly selected passages.

Now, why does this matter? We know that, in the United States, the average education level of most Americans is grade 12. However, the average reading level of most Americans is grade 9. As you can see from this slide that the average reading grade level on the English language Websites that we studied was grade 13. That means that, for many people, health information, even if it is present, is not accessible because it’s too difficult for them to read. Spanish language materials faired a little bit better. The average reading level was grade 10.

So what did we find from this study? Where you start matters and even where you start, using English language search engines and Spanish language search engines, overall, you have a one in five chance of finding health information using English language search engines and a one in eight chance of finding health information using Spanish language search engines. Overall coverage varies by language and condition. English language materials significantly performs better then Spanish language materials and, even if the information is covered, it’s clear that, given the current reading levels presented on the current Web, that many people may not have access-may not find this information accessible.

And I’d just like to point out here that what we did was, as you can see this slide, the first computers, we really described and took a slice of what we found-of what someone might find on the Internet. There clearly needs to be more work for how health information influences patients, how health information influences physicians, how it influences the doctor-patient relationship and, finally, how it influences health care outcome. Thank you.

SENATOR FRIST: Ms. Berland, thank you very much. All four panelists, thank you for what was excellent both in terms of content and also each talk complemented the other.

Let’s go straight to the microphones. I’m gonna always give preference to the microphones. I’ve got a number of cards. Do put your hands up in the air if you have cards. We’ll have somebody come by and pick up those cards and do we have anybody at a microphone? Yes. Let’s go back-we’ll just go-we’ll alternate back and forth between the two microphones. We’ll start over on the right of the room.

MS. CINDY TRUTANIC: (Audience Member) Hi. My name is Cindy Trutanic and I’m here wearing several hats, but I’ve been involved in the health informatics and telemedicine systems world for the last nine years, both in the government and in the private sector. Most recently slugging it out in the trenches, running a personal health record company. There are a lot of reasons why we don’t have a uniform clinical patient record today and the reasons are not necessarily just of content, they’re very complex and, after eight years of trying, we still don’t have a uniform record. So there are issues of nomenclature, inner operability and-in an industry where we have the most information intensive work and the least computerized.

To address this, I just wanted to make the forum and the people here aware of something that’s going to go on in late January by the National Quality Forum, which is headed by Dr. Ken Kaiser. I’m helping him with an IT summit, which will be an invitation only summit, but it’s going to include representatives from both the IT industry, the purchasers, the providers and the users of health care to try to come up with a program for implementing a plan to accelerate use of information technology in clinical service delivery, which is something that I think needs to be done and we all might agree and, to that end, I am hoping that the discussions of funding IT in health care would be cognizant that this forum is going on. There will be a report coming out after the forum to which we would be happy to deliver and include representatives from various committees on the Hill. Senator Frist and any other committees that may be interested. So--.

SENATOR FRIST: Cindy, thank you. Let’s just hear a comment and then we’ll go on with this. I want to have plenty of questions. But it is true. I go to hospitals all the time as I travel around the country and from the time when I was last practicing medicine every day, seven years ago, every hospital is doing something different about medical records. Everybody’s trying to develop a good electronic medical record. Cindy mentioned a number of the reasons. Let’s hear comments among our panelists on both the inadequacies, why it’s been so slow and what the outlook will be. Joe, you want to comment?

DR. SCHERGER: Yeah. One thing that our IOM Committee wanted to point out is the medical record is not the place to start with IT in health care. It’s actually a later development, with all due respect to my colleague on the left, and it is important. But if we wait for an electronic medical record, we’re slowed down. The Internet shows us that communication information sources done better, you know, the obligation of any health care provider. I think that Gretchen’s study shows that we need to provide good information because it isn’t going to happen automatically out there, and then give the doctors or other providers decision support. Give patients some decision support. And that the fully mature medical record kind of becomes the complete system and is a much later development. So, if people want to help be catalysts for IT in health care, the medical record isn’t the place to start.

SENATOR FRIST: Mark, you want to comment and then we’ll go to the microphone.

DR. LEAVITT: Sure. I would actually-I commend the efforts to create standards and they will help, but I would again argue that it’s business drivers that are limiting things. For example, the standard that we use on the Internet, with PCIP and all that, that was invented 20 or 30 years ago. What made the Internet take off was people thought you could make money on it and there have been efforts to try to standardize medical records for 20 or 30 years and what’s holding us back is that it’s not profitable to make your records electronic and measure your quality more carefully and monitor your errors. So we need the standards, but just fixing that won’t solve the problem.

SENATOR FRIST: Mark, any other thing to add?

DR. SMITH: No.

SENATOR FRIST: Okay, let’s go to the microphone and, again, we’ll keep the discussion going fairly quickly. We can come back to medical records because it is such a fundamental issue in everybody’s mind.

MALE SPEAKER: (Audience Member) Yeah, question about the California RAND Study. In doing like a bazillion searches for health information on the Internet, using predominantly Google, what I have found is that they virtually never turn up any government sources of information, NIH, CDC or FDA. Have to search those separately. My question to you is A) can you confirm that, that government sources for some reason rarely come up with commercial search engines and, B) how accurate would the information be if, rather than doing a Google search or something like that, if you went directly to the NIH Website or the CDC or the FDA Website? Is their information highly accurate compared to these others?

SENATOR FRIST: Great question. Gretchen, what’s been your experience?

DR. BERLAND: Thank you. Well, I recommend someone contact Google and some of the other search engines because I think that that is one of the users which we know for the most part consumers spend 30 minutes on average looking for health information on the Web. They don’t go beyond the first 25 Websites, even though other search engines promise you billions and billions of pages. Have you ever clicked to the end? So, I think that portals, as the Internet gets bigger, health portals are going to-people will become more reliant on search engines because, unless they know that they’re going to go to a government site, it’s harder for them to-that’s their way of navigating the Web. So, we didn’t-.

SENATOR FRIST: Is it-is it-does everybody agree? It’s hard to get on the government sites unless you go through a government portal?

DR. BERLAND: We did not specifically study, for instance, in the top ten Websites, where the government sites were present. We didn’t do that. That’s not in our data. But I can tell you anecdotally that there often not listed in the top ten Websites and-and the criteria that search engines use to explicitly rank sites is not something that’s easy to find right now. That is a problem.

SENATOR FRIST: Let’s go-Mark?

DR. LEAVITT: A brief comment and maybe one of the reasons is that commercial search engines sell their links. For example, AOL, which is probably one of the biggest ways that people get on the Web, you have to buy a key word. If we want them to send them to Medscape-if they say Medscape, in fact, we have to pay for the privilege so I’m not surprised that the government sites aren’t showing up.

DR. BERLAND: But I would like to add just one more point. It’s that actually the government sites-there were two statistically better performing sites in our study, which I didn’t mention in my talk. For breast cancer, it was oncolink.com, and for depression it was nimh.nih.gov. So they are-the government sites, the one site that we said it clearly did perform better on average, but the reading levels are still high. Thank you.

SENATOR FRIST: If anybody in the audience has-wants to comment on that or can sort of contribute to that, that would be helpful or send Ed or myself or Jay, because that is pretty critical-pretty fundamental of what we can do by encouraging people for those sites. Question at the microphone? From the cards. Does e-mailing between doctor/patient increase malpractice liability? Will this increase malpractice rates? How about it, Joe?

DR. SCHERGER: Short answer is no, but I don’t have data to back it up. One of the real causes of malpractice problems in cases is gaps in communication. Anything that’s going to increase communication and close the gaps in care, the dropped information, the lost information, if you’re going to fill that in, you’re likely to reduce risk. On the other hand, e-mails create a certain liability also. I mean, it is part of the medical record, it’s part of care, it needs to be read seriously. Patient sends an e-mail to the doctor, the doctor doesn’t really read it carefully and see what indeed is there, there could be liability for a gap in communication. So you got to sort of look at the scale and decide where it tips, but if-I’ve been teaching risk management for a long time and commonly serve as an expert witness in this arena and my own sense is, is I think it’s going to significantly reduce liability risk.

SENATOR FRIST: Any other comments on liability? Again, I would love to hear-microphone.

MS. BERNADETTE FERNANDEZ: (Audience Member) Yes, Bernadette Fernandez from Health and Human Services. My question is in response to Dr. Scherger’s remarks, but I invite the entire panel to respond and it’s this. While I appreciate the call to arms for government to support these technologies, in particular with respect to developing payment systems, we know that this is not a single payer system and one of the perspectives I think that’s really important that wasn’t-that’s absent from that panel, are health insurers and what I’d like to know is what are your thoughts on what role they would play in encouraging consumers and physicians to use these kinds of technologies?.

SENATOR FRIST: And that is a number of the questions that we’ve received is about health plans, how they might either incentivize the system, what their role will be, the reimbursement issue surrounding that.

DR. SCHERGER: But just to give a couple of early examples, Blue Shield of California has strongly endorsed e-mailing and has partnered with a company called Healings to provide a secure portal for e-mailing and has led the way. First Health in Illinois is now paying doctors $25 per e-visit for 6 chronic conditions that they believe will be improved. These are early examples.

Other insurances will allow the doctor to bill a co-payment, like $5 or $10 to provide E-Health advice, but if you bump up against Medicaid and Medicare, you know, co-payments are illegal, or doing anything that is in addition to that and government pays for over 40 percent of health care, over 40 percent of health care is paid for by health insurance through people’s employers. You know, and government should try to keep up with those employers insurance companies that seem to be taking the lead in supporting electronic communication between doctor and patient.

SENATOR FRIST: Mark, why don’t you elaborate a little bit further on the health plans role in accelerating the use of technology.

DR. LEAVITT: I think the challenge for health plans in accelerating it is, unless they can see the return on the investment within the average enrollment period of a member, it’s hard for them to make the investment. If they’re seeing people change health plans every year or two, some of these technologies pay back some of the chronic disease prevention technologies take longer. However, I would talk about the self-insured employer, which is in essence a payer. Sometime they use an HMO to administer the payment, but in effect, they assume the risks and they have the employees for much longer and they’ve actually formed a group called the Leap Frog Group, which has, I think, more than 100 of the largest employers and are driving some of these adoptions of technology and they’re starting to demand it. So I think that’s one of the most helpful signs and I think it will take government coming along, maybe demonstration projects, maybe not a massive change in the Medicare payment system, to not be left behind and to also support that.

SENATOR FRIST: Mark?

DR. SMITH: Couple of comments. First, there’s a whole series of policy issues around the acceleration and adoption of E-Health, which the Foundation has commissioned papers on, so maybe four months, but e-visits and reimbursement in there. A number of these issues that will require some thinking about how you coordinate the private and public payment systems.

Second is I think the role of the health plan depends a lot on how the delivery system is structured. If, as we have in California, a significant amount of health care is delivered in a capitated way, that is to say, if the plan pays the medical group $85 per member per month, and the medical group is really responsible for care, the question will then go back, does the medical group have the wherewithal, the investment philosophy, the capital, the margins to make the investment because some of the infrastructure invested may not be a plan issue. It may be a medical group issue so, to some extent, the role of the plan depends on the role of the plan in the financing system generally. It’s a question of-that may look very different in Maryland than in California.

SENATOR FRIST: I might just add in this whole reimbursement end, I think you will see, as people follow under the current Administration, as we look out over the next several years and in response to legislation, there are things that can be done in terms of incentivizing the system and the obvious one we talked about is medical errors. The way that information in terms of reporting medical errors for hospitals or facilities could affect reimbursement. Right now, there is not very much of an incentive but, whether it’s adjustments year to year or whether it’s market basket adjustments, the way that information is asked for, there could be a reward system built in in terms of those people who are responding in an appropriate way or what we regard as appropriate. It could be the way they report it, the success and response to reporting medical errors.

So it’s a very exciting time because all of a sudden, the tools are out there that we can marry with the money that’s going in, marry with the response. We have to have a system that’s flexible enough. If you take market basket and say everybody’s going to get the same amount of percentage adjustment year after year, it’s not going to work. If you have a system which is facile, flexible, responsive, you can start building in these incentives as we go. Yes.

DR. SCHERGER: One additional comment I think is really important. I often say that capitation came out a decade too early. E-Care is a dream for capitation and I think that as this-to implement it, one way you can jump start it is really do it as a capitated payment. You know, capitated help drive telephone care, but telephone is not an efficient way to deliver health care. It’s got usefulness. But E-Care, then being more selective in the need for face to face visits still important and critical, but, you know, capitation really runs itself very well.

SENATOR FRIST: Dr. Berland, I found it fascinating, your presentation, in terms of Spanish versus English and also the grade level at which the population is both inquiring and in which the information is provided. There’s several questions in here that were related to that, but one, which is in part related is that, what issues are involved with the elderly’s access to the Internet and e-mail? Everybody can answer it. Obviously access has to do with digital divides and access to computers and the like, but in anything that you studied in terms of the seniors, in terms of their use, was there anything in your study about age? Age related?

DR. BERLAND: Thank you for pointing that out, Senator Frist. I think it’s important to point out we did not-this study was in some ways not naturalistic. It was the first attempt to kind of slice this massive organism which you might call the Internet so we didn’t use consumers, but I know that the Spry Foundation has actually done a lot of work with looking at senior citizens using the Internet and a recent Pugh and Harris Interactive Survey showed that actually the population that’s going online more frequent than other groups are the elderly. So I think that that’s an issue, in terms of how they access information will-and the use for chronic conditions will hopefully really-.

SENATOR FRIST: We’ll come back to the seniors, but again, the question was-is there somebody at the microphone? Yes, go ahead. I’m sorry.

MS. RACHEL CHRISTIANSON: (Audience Member) Thank you, Senator Frist. My name is Rachel Christianson. I’m with the Employee Benefit Research Institute here in Washington and this is specifically for Dr. Leavitt. I was very interested by your comment on information technology and privacy. I’ve been writing on the connection between quality and privacy, especially quality improvements that involve computers and the Internet and I was wondering if you could talk a little bit more about how Internet and online records might be safer than paper records. You did make that comment.

DR. LEAVITT: Good. Thank you for asking the question. I think the first distinction that has to be made is between the Web and the Internet because, when people think of the Web, they think of something you put a word in a search engine and you find it on the Web. And when you say, oh, we’re going to have your records available using the Internet they think my records are going to be on the Web.

The Internet is just an electronic connection between computers. It was built to create a secure communication system so that, if there was warfare and you knocked out a key link, it wouldn’t go down. So it’s important to get that out of the way. So when we talk about digital records, you may use the Internet as a transmission mechanism, but you can encrypt them, just like you encrypt credit card numbers and financial transactions and, basically, you have something that’s way more secure than mailing or faxing a record.

The other issue though is, once you have a lot of records in a database, does that not create an attractive target for a hacker and the answer is, yes, it does. But-so does everything else we do in America that’s done on computers and databases and so we have to adopt policies, procedures and technology. But the key point is, if you give a patient access to their record and give them an audit trail of who has seen it, you create greater privacy because the biggest threats are not technologic, they are human and, giving the patient access to their record and a list of who’s seen it basically puts all the humans on notice that patients can ask questions about that and I think, ultimately, we’ll find that will be something that people expect and demand is to not only have a record that they control, but they can see who’s looked at it.

SENATOR FRIST: I think it’s fascinating. That whole area of privacy. Your comments, Mark, really helped me to understand a lot better. Let’s go to the microphone.

MS. SUSANNAH FOX: (Audience Member) Hi. My name’s Susannah Fox. I’m the Director of Research for the Pew Internet and American Life Project and thank you so much for mentioning us in your-.

DR. BERLAND: Thank you for providing the survey for us.

MS. FOX: (Audience Member) And we’re actually going to be coming out in July with a special report about senior citizens online so I can give you a sneak preview, as long as press don’t release any of the data that I talk about.

SENATOR FRIST: Yeah, they won’t. In Washington, DC, it never happens.

MS. FOX: (Audience Member) I’ll just talk generally about some of the findings, especially particular to health care and that is that 15 percent of senior citizens are online. What’s interesting there is that once they get online, they’re incredibly enthusiastic. They’re actually more likely to be online on a typical day than a teenager or someone who is middle aged and that may be because they have more free time than a lot of us, but also they’re finding a lot of utility, especially with e-mail and with health care information.

It’s one of the top five activities for senior citizens online. They are just as excited about health care information as a middle aged user. And one thing that might be interesting is that senior citizens are more likely to log on in the early morning so those who are running health Websites might want to push the senior content early in the morning and then take it down in the afternoon when the middle aged are online from the office. So those findings will be coming out in mid-July and it’s all available on our Website at pewinternet.org.

SENATOR FRIST: Yeah, that’s fantastic. Thank you. That’s the great thing about having these conferences the way we do. Is there a mic-yes, go ahead.

MR. JIM DAVIDSON: (Audience Member) Yes. My name is Jim Davidson. I’m an attorney involved in health care issues here in Washington. I’m curious because I also serve on the board of a company in Houston called IPQM (?) that is now providing public Websites in conjunction or paired with radio stations around the country. We’ve got over 2,000 radio stations across the country that we do the health care Website with. And the goal there is to make quality health care information available to the general public and I’m curious as to whether or not Ms. Berland or the rest of the panel has seen evidence with the high numbers of interest in and access to health care information on the part of consumers, if that’s having a pull effect on the health care community, on physicians or other health care institutions, to catch up with that. Is there-have we seen that evidence of a pull?

SENATOR FRIST: We’ll turn to whoever-yes, anybody want to comment?

DR. LEAVITT: I can comment. I think he addressed it to Dr. Berland, but-.

SENATOR FRIST: Go right ahead.

DR. BERLAND: No, please. Feel free.

DR. LEAVITT: Okay. I think there is a pull effect and it’s actually patients pulling doctors to the Internet and I’ll come back to the radio in a moment, because every doctor who practices is now familiar with the experience of the patient that comes with a stack of Internet printouts. It used to be the patient that comes with a small laundry list of complaints, but now it’s a stack of Internet printouts and so that actually-that was one of the things that forced doctors to go online to catch up with their patients.

The problem with what you’re talking about, broadband media, radio and video is we just don’t have as much broadband connection as we hoped we would and, in fact, Dr. Berland and Dr. Smith’s comments about lower education, I actually think, being involved with a Website, I’m struggling to improve it by saying lets write it to a lower level. I think that video and audio is a more effective education medium for people of lower literacy. So, again, it’s those connections and then you can actually deliver that more appropriate content and that’s-I know Congress-that’s an issue that they’re looking at is getting the Internet across the digital divide and getting the broadband out there.

MR. DAVIDSON: (Audience Member) That’s already proved to be a challenge for us. We have designed holograms for various parts of the body to illustrate body parts and to educate consumers as to how to identify problems that they might have. But, obviously, when you’re delivering that, it takes a pretty wide pipe to send it.

Similarly with other kinds-we use other kinds of video illustrations to show that but, again, that limits the number of people that can get that in a real time format.

SENATOR FRIST: Thank you. One of the things that Jay Rockefeller and I try to do is start this close to on time and end on time. On days like today, where the discussion is so powerful because we all know it’s going to change each of our lives. There’s no question what we’re talking about now is going to change our lives, all of our lives, over the next year and so it is always hard to bring things to a close. Let me-I’m going to close with one more statement, but if everybody could fill out that little evaluation form that’s in your packet. Again, it helps us improve each of these conferences as we go-as we go forward.

Just-let me just close with sort of the contrarian view and, with that, and read from an article that’s actually in all of your packets. It says, "Vaporware.com: The Failed Promise of the Healthcare Internet," and I was going to ask the panelists to respond to this contrarian view, but basically, in abstract, it closes with that, "The Internet will exacerbate the cost and utilization problems of a health care system in which patients demand more, physicians are legally and economically motivated to supply more, and public and private purchasers are expected to pay the bills." Would anyone like to comment on that?

DR. SMITH: Well, I think like-with most resolutions, there’s always a dark side. I think the promise really does come in what Joe Scherger said. There are clearly lots of patients who will continue to need high intensity, high touch, face to face interactions. The biggest promise I think that E-Care has is in driving out error, in driving out waste and in being able to do those routine things for patients who are often relatively well in a way that’s cheap enough that you may actually be able to afford to focus those resources where they are needed most.

When I think about when I was in training and think about how many times we had patients coming to see us for things that now can be done quite easily remotely, but we’re all just kind of in the mindset of the visit, the unit of production for the health care system is still "the visit to the doctor." And if we get out of that mindset, my sense is, this really can find us ways to concentrate resources where they’re necessary, but it won’t happen automatically.

DR. SCHERGER: It’s often commented that people have an insatiable appetite for health care and they want someone else to pay for it. I think people have an insatiable appetite for health information and we can make health information free.

But by and large, people don’t like to get health care they don’t need. Now, of course there’s exceptions to that, but give you one example.

In my area of Orange County, California, I’m sure it’s going on in other places, there’s an epidemic of people who can afford it to go get total body scans and they’re putting down their $500 or $600 and they’re getting their total body scan and then they’re showing up in my office saying, you know, why do I have this little lump on my liver and a little cyst in my kidney and they found a little cyst on my ovary and what does all this mean? And I, you know, then talk to them about, you know, why they probably shouldn’t have got this total body scan, because the body’s full of lumps and bumps and they get very angry. And I think there’s gonna be a backlash against this kind of excessive stuff because it’s medicalizing people and it’s medicalizing people’s lives. I mean, ultimately, you know, we got better things to do than become a continual professional patient. So, you know, there is this kind of effect and phenomenon but the fact that Internet makes all health information free, it puts it in our laps, then lets us process information with a health care system. I think we can come out better rather than the scenario that this cynical philosopher expressed.

SENATOR FRIST: Okay. Listen, we’re gonna close down because it’s 2:00 and Joe Scherger, Mark Leavitt, Mark Smith, Gretchen Berland, I thank you for coming so far, being with us. It’s a real inspiration for me. I learned a lot over the last hour and a half. Why don’t we all give them a round of applause.

(Applause)

(Whereupon, the proceedings were concluded.)