Surf’s up! Are you ready for e-care?
Surf’s up! Are you ready for e-care?
Internet-based health care information sites, medical decision support companies, and disease management vendors are proliferating so rapidly that industry observers interviewed by Case Management Advisor call it the high-tech equivalent of the Wild West. Consumers are spearheading this e-care revolution, and if you haven’t already joined their swelling ranks, most analysts predict you will soon.
"The Internet is changing health care delivery in two very important ways," says Pieter Muntendam, MD, president of ProMedex, a disease management company with a rapidly growing e-care business in Raleigh, NC. "The Internet allows ongoing communication between the patient, the case manager, and the provider. Care delivered via the Internet for the first time becomes truly continuous. Traditionally, care has been limited in space and time. The patient sees the physician in the office, and care is suspended until the patient returns," he explains. "Now, patients can transmit vital signs, communicate symptoms, and receive reminders about taking medications or scheduling tests on an ongoing basis, and care is no longer fragmented."
Information about ProMedex’s Internet-based management programs is available on the company’s Web site at www.promedex.com.
Muntendam asks case managers to consider two scenarios that demonstrate how the Internet could improve quality of life for their patients:
1. A patient enrolled in a pain management program reports her pain scores to a case manager through the Internet daily. The program’s pain policy states that a pain score of more than four requires intervention. The patient reports an increase in her pain score overnight from a four to a seven. The case manager immediately contacts her for more information, then contacts the physician to suggest changes in the pain management plan.
2. A patient enrolled in an asthma management program downloads readings daily from a peak flow meter through the Internet to a case manager. The peak flow readings drop dramatically overnight, and the case manager contacts the patient for more information and to remind him about the need to start rescue medications immediately. By intervening quickly, the case manager is able to prevent a hospital admission.
"The Internet gives the case manager the ability to use yesterday’s clinical data to identify patient needs rather than last year’s claims data as is currently the case for many health care organizations," says Muntendam. "The case manager now has the ability to do something very meaningful in a limited number of interventions. Through an on-line patient survey, the case manager may discover a diabetic patient has a foot ulcer. She’s not guessing that he has a foot ulcer after reviewing old claims data. She knows the patient has a foot ulcer immediately after reviewing his on-line survey. She can zoom in on the problem and fix it. She can locate a wound care specialist in the patient’s area and call him to set up an appointment."
However, the promise of the Internet goes beyond improving individual patient care, says Muntendam. He sees the Internet’s greatest potential in more global terms. "I’m not sure that people understand how much medical knowledge is buried in medical charts. Medical studies are conducted outside the standard of normal medical care. A researcher may conduct a study on 100 patients, but the real-life experience is buried in paper charts that no one can access."
The Internet soon may change all that. "When we can safely move to electronic records, each time a patient is prescribed a particular drug, we can monitor what happens. It will be a continuous, ongoing experiment with thousands of participants. It will tremendously advance our knowledge, and we will no longer have to rely on small studies. On a monthly basis, we will be able to receive updates about which treatments work best in the real world."
Others outside health care are realizing the Internet’s potential and pushing health care organizations to move forward with Web-based programs. "We realized that we had to move forward quickly with Web-based products when our self-funded employers starting asking us for Internet capabilities," says Claire Rosse, RN, MBA, president and chief executive officer of FutureHealth, a population risk management company in Timonium, MD. "Our customers initiated our push to move to the Internet much faster than we had originally planned," she says. "The first thing employers seem to want is monthly health bulletins that they can send to their employees via company Intranet or the Internet. They’re also asking for Internet-based enrollment into management programs and nurse advice directories."
Anthem Blue Cross/Blue Shield in Manchester, NH, also has received inquiries from employers about Internet health management. "We have received requests from members who want to enroll for our diabetes program on-line rather than by mail. We’re just now beginning to track e-mail addresses in addition to street addresses and telephone numbers. It’s not the norm, but it’s beginning."
Instant feedback
FutureHealth found a partner to develop its Web-based programs. "The Internet is ideal for keeping health management programs in front of employees. We’re working with a partner to develop interactive capabilities to allow our nurses to work with their patients. For example, a diabetic patient could enter their meal plan for the day, the system could automatically make any necessary corrections in their diet, and the nurse could use that information as a teaching tool to discuss their diabetic dietary needs," says Rosse. "That instant feedback is very wonderful."
However, she predicts videoconferencing will be the cornerstone of FutureHealth’s Web-based health management programs. "Right now, most of our nurse-patient interactions are via telephone. I think videoconferencing will help bridge that gap between the case manager and the patient that you sometimes have with telephonic case management. I think that ability for the patient to actually see the case manager will result in better compliance," says Rosse, whose case management services recently received full accreditation by the American Accreditation Health Care Commission/URAC in Washington, DC.
Anthem decided the first step along the path to its Internet-based programs was to develop the internal processes necessary to move its programs out onto the Web as they develop. "Just because we make a program Web-enabled doesn’t mean our members will follow us out there," says Louise McCleary, MEd, director of health risk management at Anthem. "There are so many possibilities for improving patient care via Web-based activities that it’s almost overwhelming. We decided the first step should be to purchase a software system that could serve as a platform that would eventually enable us to link our existing technology with the Web."
Others agree that payers must understand that not all consumers are ready for e-care. "As exciting as e-care programs are, it’s unacceptable for payers to offer programs that are only available via the Internet. Not everyone has a computer. Not everyone who has a computer uses the Internet. Any program we offer, we also offer via Internet and more traditional channels such as mail, fax, and telephone," says Muntendam.
"I really think employers are the missing link in developing the full potential of Web-based health care," says McCleary. "The majority of Americans have access to the Web at work. I think health care organizations have to focus the selling of these programs on employers. The self-insured have a particularly strong reason for embracing this new opportunity, which has the potential to effectively manage chronic illness to prevent complications for very low cost."
McCleary says that rather than jump blindly onto the Internet bandwagon, Anthem answered these questions:
• What are we really trying to accomplish?
• What is our ultimate end goal?
• Are our administrative functions ready for this move?
"The more I research the Web, the less I feel I understand all the potential it holds," she notes. "We purchased a system from Confer Software in Redwood City, CA, to act as our platform to move the programs we’ve worked so hard to develop ourselves out to the Web when the time was right."
Of course, patient privacy remains one of the biggest concerns about any Web-based health care application. "We are making sure that the Internet-based applications we’re developing meet all HIPAA [Health Insurance Portability and Accountability Act of 1996] requirements for transferring identifiable health data. I don’t think we know all the potential ways in which people can misuse the Internet," says Rosse. "That’s where you have to be alert and protect against abuse. It just makes sense."
Although strictly informational health sites probably aren’t providing services that fall under HIPAA requirements, the line between activities that do and those that don’t is often very fine, says one attorney. "There’s a lot of misunderstanding about Web-based health care activities and the types of relationships covered under HIPAA," says Alexander J. Britten, a partner with McKenna & Cuneo in Washington, DC, who recently spoke about legal issues related to e-care activities at the recent Commission/URAC 10th annual quality summit.
"E-commerce privacy is a completely different animal than e-care privacy. If a site allows me to keep a diary of health information — for example, my blood pressure — and keeps a folder on me and it’s never disclosed to anyone else, only stored, that’s not an activity that falls under HIPAA requirements," he notes. "However, if a case manager monitors my blood pressure and calls to tell me my blood pressure falls outside acceptable parameters and I should contact my provider, I think that would be defined as a provider-patient relationship under HIPAA. In that case, I would err on the side of being cautious and comply with HIPAA regs," adds Britten who is completing a book for the Commission/ URAC on HIPAA security and privacy that should be released shortly after the HIPAA regulations are finalized later this year.
"In the early 1990s when this bill was first introduced, legislators weren’t even adding the Internet into the equation. They were only thinking about authorizations, etc. The Internet took off before the Department of Health and Human Services [DHHS] could even react. Before there was an opportunity to expand the statutory authority of HIPAA, all kinds of new situations arose due to the Internet explosion."
Many health care organizations have decided to take no chances that e-care activities will run afoul of HIPAA. (For more on HIPAA, visit the DHHS Web site at waisgate.hhs.gov.)
Any Web-based health care application should protect the privacy of its users, but most studies show that many health Web sites fail in that regard. A recent survey of 1,000 Internet health site users by LaurusHealth.com, an e-care company in Irving, TX, found that 70% of Internet users were unaware that personal health information provided to some health Web sites is shared or sold to third parties. That same survey revealed that 57% would be more likely to use a Web site that guarantees personal information will not be sold or shared. (For results of other studies on health Internet usage and Web site privacy practices, see pp. 77-78.)
"The truth is, your health records weren’t safe under the traditional system either," says Michael Samuelson, chairman of the consumer advisory council of cancerfacts.com in Seattle. "When medical records were stored in the back room of physicians’ offices and hospitals, anyone could gain access to your paper records. What consumers and health care organizations must understand is that if those records are electronic and transferred via an Intranet or the Internet, there is at this point absolutely no foolproof way to prevent others from accessing it. If you ask me if it is safe enough for the average person to be comfortable, I’d say yes.’ If you ask me if it’s foolproof, I must say no.’"
How much concern consumers and case managers should have about the misuse of health data shared on the Internet depends greatly on the sensitivity of the information, notes Samuelson. "If I was newly diagnosed with HIV, I wouldn’t want that information out there on the Web for a variety of reasons. I might not be ready to inform my family, friends, or more important, my employer about my condition. Unfortunately, a study of Internet users conducted by cancerfacts.com indicates that the more severe a person’s condition is, the more likely they are to waive their rights in order to gather as much information as possible. They want information at any cost. There’s a real potential for abuse there." (For more on who uses the Internet to find health information, see p. 80.)
Several consumer advocacy groups have formed to develop e-care codes of ethics and generally improve the quality of health care activities on the Internet. Organizations such as Health On The Net Foundation in Geneva, Switzerland, and the Internet HealthCare Coalition in Washington, DC, have drafted codes of ethics for e-care companies and are asking for health care organizations to voluntarily comply in an effort to safeguard the public. (The ethics codes can be accessed on the organizations’ Web sites at www.HON.ch and www.ihealthcoalition.org.)
"There are very few marshals out there protecting the public against the unregulated Wild West of e-care," says Samuelson, an active member of the Internet HealthCare Coalition. "We’re working to conduct regular site checks of Internet-based health sites, but there are too many out there. We’d really like consumers to start reporting abuses. We’d like to be the Better Business Bureau of the Internet."
HON and www.quackwatch.com also allow Internet users to report misuse of personal information by health care Web sites.
At the very least, Samuelson recommends that any health Web site should provide any site visitors with the following:
• Information on how data shared will be used.
• Assurance that no personal profiles will be created without the user’s knowledge and consent.
• An option to check a box that says either "yes, you can use my information," or "no, you can’t use my information."
"Unless you inform others that your data belongs to you and cannot be shared without your consent, it will be open to abuse," cautions Samuelson. (For more tips on safe Internet use, see p. 79.)
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