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A C A D E M I C H E A LT H G R O U P

The Blue RidgeThe Blue Ridge

Report 5

e-Health and the AcademicHealth Center in a Value-driven Health Care System

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Framing Health System Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Health e-Connectivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Findings, Recommendations, and Implementation Guidelines . . . . . . 12

Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13


Health e-Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18


Health Provider Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23


Public e-Health Knowledge and Empowerment . . . . . . . . . . . . . . . . . . . . . . . . 29


Universal Coverage and Value-driven Health Care . . . . . . . . . . . . . . . . . . . . . 34


Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . 40

About the Core Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

About the Invited Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Other Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Reproductions of this document may be made with the written permission of the University of Virginia HealthSystem by contacting: Elaine Steen, University of Virginia Health System, Box 800413, Charlottesville, VA 22908 Fax: (804) 243-6078, E-mail: [email protected].

e-Health and the Academic Health Center in a Value-driven Health Care System is fifth in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of the University of Virginia. This report is not intended to be relied upon as a substitute for specific legal and business advice.

Copies are available at a cost of $10.00 each. To order, see the enclosed form.

For questions about this report, contact: Don E. Detmer, M.D., University of Virginia, Phone: (804) 924-0198, E-mail: [email protected].

Copyright 2001 by the Rector and Visitors of the University of Virginia.

The Blue RidgeAcademic Health Group

Report 5

e-Health and the AcademicHealth Center in a Value-driven Health Care System

The Blue Ridge Academic Health Group

Mission

The Blue Ridge Academic Health

Group seeks to take a societal view

of health and health care needs

and to identify recommendations

for Academic Health Centers

(AHCs) to help create greater

value for society. The Blue Ridge

Group also recommends public

policies to enable AHCs to

accomplish these ends.

Members

David Blumenthal, M.D., Professor ofMedicine and Healthcare Policy, HarvardMedical School; Director, Institute forHealth Policy, The Massachusetts GeneralHospital

Enriqueta C. Bond, Ph.D., President,Burroughs Wellcome Fund

Robert W. Cantrell, M.D., Vice Presidentand Provost, University of Virginia HealthSystem

Don E. Detmer, M.D., Dennis GillingsProfessor of Health Management, JudgeInstitute of Management Studies,University of Cambridge*

Michael A. Geheb, M.D., Senior VicePresident for Clinical Programs, OregonHealth Sciences University

Jeff C. Goldsmith, Ph.D., President,Health Futures, Inc.

Michael M.E. Johns, M.D., Executive VicePresident for Health Affairs; Director, theRobert W. Woodruff Health SciencesCenter, Emory University

Peter O. Kohler, M.D., President, OregonHealth Sciences University

Edward D. Miller, Jr., M.D., Dean andChief Executive Officer, Johns HopkinsMedicine, The Johns Hopkins University

Jeff Otten, M.A., M.B.A., Chief ExecutiveOfficer, Brigham & Women’s Hospital

Mark Penkhus, M.H.A., M.B.A., Chief Executive Officer, VanderbiltUniversity Hospital

Paul L. Ruflin, M.B.A., Vice President,Cap Gemini Ernst & Young U.S., LLC

George F. Sheldon, M.D., Chairman andProfessor, Department of Surgery, Schoolof Medicine, University of North Carolinaat Chapel Hill

Katherine W. Vestal, Ph.D., VicePresident, Cap Gemini Ernst & YoungU.S., LLC

Invited Participants

Andrew Vaz, Vice President, Cap GeminiErnst & Young U.S., LLC

Dennis Gillings, Ph.D., Chairman andChief Executive Officer, QuintilesTransnational Corporation

John P. Glaser, Ph.D., Vice President andChief Information Officer, PartnersHealthcare System

Jordan J. Cohen, M.D., President,Association of American Medical Colleges

Staff

Cap Gemini Ernst & Young U.S., LLC

Danielle Federa, Senior Manager

Jacqueline Lutz, Associate Director

Sanjay Pathak, Senior Manager

University of Virginia

Charlotte Ott, Senior Executive Assistant

Jon Saxton, J.D., Policy Analyst**

Elaine Steen, M.A., Policy Analyst

*Chair**Editor

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Introduction

The advent of the Internet has beenalmost universally heralded. It has beencompared to most of the important techno-logical milestones in human history, fromthe capture of fire to the development ofelectricity, the steam engine, and the tele-phone. The Internet’s dynamic, even explo-sive, growth is often described usingbiological metaphors (e.g.,“a squirming,protoplasmic nexus of informational activi-ty” (Valovic, 2000, p. 24)) that suggest thedevelopment of a nascent hypertrophicorganism of uncertain but highly promis-ing ontogeny.

Indeed, the Internet, as a technology plat-form, is having a significant, even revolu-tionary, impact on communications, on theflow of and access to information, on thespeed and efficiency of many types oftransactions, and on connectivity betweenand among an ever-growing mass of elec-tronically networked individuals, organiza-tions, and systems. It is affectingeverything from the behavior of individualsto the conduct of commerce. “The Net”has spawned whole industries and trans-formed others. It has created new cate-gories of jobs and career paths, whilemaking others obsolete. It has affected

There is little doubt that within 20years the Internet will become asubiquitous and invisible as today’sphone or electrical networks.

– Don Tapscot, Blueprint to the Digital Economy, 1998

many aspects of our culture, from languageto customs to the meaning of symbols. Itsubiquity crosses national borders and polit-ical boundaries. It has created untold thou-sands of virtual or cyber communities andhas forever transformed many real commu-nities. It sparked “irrationally exuberant”activity in the nation’s stock market, cat-alyzing the creation (and more recentlysome destruction) of new wealth.

Novel applications of Internet-based tech-nologies are found or created almost daily.And several public and private initiatives,including the government sponsored NextGeneration Initiative (NGI) and the private-sector sponsored UniversityConsortium for Advanced InternetDevelopment (UCAID) are currentlyworking to develop vastly enhanced net-working technologies, applications, andnew Internet platforms for a variety ofcommercial, governmental, research, andcommunications applications (NationalResearch Council, 2000).

This nascent technology, perhaps some-what like a developing nervous system, isvectoring in multiple directions, creatingnew connections through multiple signal-ing pathways, and triggering adaptive(including protective and competitive)responses of many kinds. It is impossibleto predict at this early stage what thisevolving system will eventually look like,how it will function, or even whether itwill proliferate into an “Internetwork” ofInternet platforms. It is quite possible thatthe Internet’s proliferation will be suchthat it will never be completely compre-hensible; that what we now call theInternet will give way to simply ubiqui-tous connectivity among increasinglyintelligent agents endowed with one or

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another or a combination of continuous,at will, and/or contingent, “with permis-sion” data sharing. In any case, it is rela-tively certain that the Internet as atechnology platform will continue for theforeseeable future to grow and to spawnunprecedented and increasingly ubiqui-tous connectivity among networked usersand systems.

Relative to other industries, AHCs andother health care organizations are prov-ing to be slow adopters of Internet tech-nologies and capabilities. Few health carepolicy-makers or leaders would disputethat the Internet holds great promise forenhancing health care, health sciencesresearch and training, and drug anddevice development. Yet very few AHCsor other health care organizations haveprioritized the development of Internet-based resources or technologies. Mosthave not identified these as critical totheir core missions, competencies, orcompetitiveness, at least over the nextthree to five years.

The Blue Ridge Group reviewed a greatdeal of evidence and sought the input ofthought leaders concerning these andrelated observations. Convinced that theInternet has brought and will increasinglybring technology and resources of greatvalue to health research, training, andcare, the Blue Ridge Group provides thisreport as a resource to health sector lead-ers and policy-makers.

The report first provides a brief contextdescribing three essential trends in thehealth care system. It then surveys thestatus and trajectory of Internet technolo-gies, resources, and commerce in thehealth care sector. Finally, a series of

findings and corresponding recommenda-tions and implementation guidelines provide guidance for leaders and policy-makers seeking to understand and prioritize the evaluation, adoption, devel-opment, or enhancement of Internet-based health care, research, and trainingresources with a five to ten year horizon.

The Blue Ridge Academic Health Group(Blue Ridge Group)

The Blue Ridge Academic Health Group (Blue Ridge Group)studies and reports on issues of fundamental importance toimproving our health care system and to enhancing theability of academic health centers (AHCs) to sustain optimalprogress in basic and clinical research, health professionstraining, and patient care. Four previous reports describedopportunities to improve AHC performance in a changedhealth care environment and to leverage AHC resources inachieving significant improvements in health system access,quality, and cost. The Blue Ridge Group provides guidanceto AHCs that can improve financial performance, enhanceleadership and knowledge management capabilities. It encourage AHCs to contribute to the development of amore rational and comprehensive, but affordable and value-driven health care system (Blue Ridge Group 1998a,1998b, 2000a, 2001). In this, its fifth report, the Blue RidgeGroup considers the prospects for and barriers to theadoption, development, and deployment of Internet technolo-gies within the health care sector in general and, in particular,in support of the essential mission areas of the AHC.

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Exhibit 1: Recommendations

e-Connectivity• AHCs and other health care organizations should beengaged in ongoing, governing board and leadership-levelevaluation of operational and administrative capabilities andthe opportunities presented by new Web-based technolo-gies to enhance, revise, or redesign current service andbusiness processes and patient care capabilities.

• Evaluation, planning, and implementation capabilities forWeb-based operational and administrative systems shouldbe a core competency within all health care organizations. In the short or near term, health care, research, and trainingorganizations should prioritize development of Internet-based capabilities that strengthen local or regional marketposition, and services that are reliable, scalable, customer-friendly, and flexible.

• AHC leadership should explore opportunities across and among academic centers for shared investment in, or outsourcing of, Web-based operational and administrative systems.

Education• AHCs should actively investigate the opportunities andchallenges for the development of online curricular and ped-agogical resources for students and faculty.

• Medical and other health professions schools should priori-tize strategic evaluation and planning designed to maximizethe impact of online curricula and resources for health pro-fessions training.

e-Research• AHCs should aggressively pursue opportunities for thedevelopment or acquisition of online clinical trials design andmanagement.

• AHC faculty must become thought leaders and innovatorsin the new environment.

Provider Empowerment• AHCs should institutionalize and formalize the capacity tosupport the development and implementation of Internet-based technologies that can enhance and extend care.AHCs must conduct trials and demonstration projects andexpand their research agendas to facilitate exploration of thequestion: How is health care going to be transformedbecause of new Internet capabilities?

• As an important basis from which to expand and assertAHC leadership in Internet health care innovation, AHCs

should embrace health informatics as a full fledged profes-sional specialty in medicine, nursing, and public health.

• AHCs and other health organizations should vigorouslysupport the efforts of the National Committee on Vital andHealth Statistics (NCVHS), the National Committee onQuality Assurance (NCQA), the Data Council of the U.S.Department of Health and Human Services, the President’sInformation Technology Advisory Committee (PITAC), andrelated efforts to create and maintain a national health infor-mation infrastructure necessary to the burgeoning demandfor fast, secure, and reliable information transfer and pro-cessing.

• AHCs and other health organizations should vigorouslyadvocate for the Department of Health and Human Servicesto take leadership in overseeing and coordinating informa-tion technology initiatives aimed at optimal development of anational health information infrastructure for the twenty-firstcentury.

Public Knowledge and Empowerment• AHCs should take a leadership role in identifying, makingavailable, and assuring quality health care information fortheir patients and the public over the Internet.

Universal Coverage and Value-driven Health Care• AHCs and other provider organizations should exploreopportunities to vastly improve relationships with payorsthrough online transaction and information processing.AHCs should also explore opportunities to better manageand/or outsource in-house HR functions.

• AHCs should seek to work closely with payors andemployers as well as policy makers to ensure that the evolu-tion of consumer directed medical and benefits manage-ment strategies and payment systems track and reportinformation on quality, outcomes, and other metrics of carenecessary to informed consumer choice of plan andprovider.

• AHCs should continue to advocate for and seek opportu-nities to guide public policy that is more supportive of e-health care, including addressing limitations on reimburse-ment for telemedicine, state barriers to e-health, and univer-sal access to the Internet. Progress in these areas is vital toachieving universal coverage and the transition to a value-driven health care system.

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Over the last several decades, dynamicforces and trends in three areas have beenparticularly important in shaping ourhealth care system. The first is the historictransformation of the health care systemfrom a predominantly decentralized cot-tage industry of professionals and relatedlocal institutions, relatively insulated fromtraditional market forces, to a more cen-tralized, bureaucratic industry subject tothe forces of a highly competitive market-place. This transformation is still inprogress and its end point is not known. E-commerce and the trend towards stan-dardized market transactions may yetredirect health care away from bureaucra-tization towards organizations and prac-tices with more varied and permeableboundaries. Characteristics of the chang-ing environment are:

• The consolidation of large numbers of solo and small group practitioners into large provider and managed care organizations;

• The transformation of many solo and small group physicians into salaried workers;

• The closing and consolidation of many local and regional hospitals and medical centers;

• The loss by physicians of many of the perquisites and much of the autonomy of the traditional professional;

• The shifting of risk away from payors/insurers towards providers and consumers via capitation and other risk-shifting practices;

• Turbulence in sustaining managed care models, including the failure of major physician management organizations;

• Increased outsourcing of both clinical and administrative services; and

• Federal cost reduction policies, especially the Balanced Budget Act of 1997, mandating substantial reductions in payments to hospitals for care services through the year 2002.

These and many other forces are changingthe health care system and affecting thedelivery of care at every level.

The second trend is the evolution of theclinical relationship between physician andpatient from a hierarchical and paternalisticmodel to one that is more egalitarian andcooperative. This change corresponds aswell to the increasing role of self-care andthe fast-evolving possibilities for both betterpopulation health management and increas-ingly customized individual care enabled bynew knowledge and technologies.

Over the last five decades, the traditionalclinical model of the physician as the indis-putable expert in the provision of care andthe patient as a passive recipient of care hasbeen changing. Diverse forces have influ-enced this change. Starting in the 1950s,Dr. Spock’s books on managing child careand health led the popularization and pro-liferation of health and family-care guidesand programs. The Women’s HealthCollective first published the influentialbook, Our Bodies, Our Selves, in the 1960s,helping to empower women to betterunderstand and care for their bodies.

As the counter-cultural ‘60s and early ‘70sgave way to the increasingly market-focused ‘80s, public policy favored greaterindividual attention to, and responsibilityfor, healthy behaviors. Dr. C. Everett Koopset a new standard for healthy behavioradvocacy in the newly created post ofSurgeon General of the United States. Abroader patient advocacy movementemerged in the ‘90s in response to prob-lems encountered in the now competitivehealth care market place. Pharmaceuticaland other health care and insurance prod-uct and services companies have enhanced

Framing Health System Change

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the trend towards consumer and patientempowerment through new self-care andhome health care technologies and theaggressive deployment of direct-to-con-sumer marketing of drugs and devices. Theroles and responsibilities of providers, pay-ors, patients, and consumers continue toevolve as new knowledge and technologiesenable both broader and more customizeddissemination and utilization of healthdata, information, and technology.

A third major dynamic influencing healthsystem development is the continuingstruggle over universal access to quality,affordable health care. Universal health careinsurance and the costs to individuals andsociety of inadequate access to care areissues that have occupied American politicsand public policy throughout the twentiethand now into the twenty-first century.Periodic attempts to enact universal insur-ance coverage have failed, but importantsteps have been taken towards expandedaccess to quality, affordable care. Nationalprosperity in the post-World War II yearsestablished employer-sponsored coverage

as the norm for larger employers. Theenactment of the Medicaid and Medicaresystems in the 1960s served to providecoverage and access for many of the mostvulnerable in the population.

Despite these policies and programs, about15.5 percent of the population remainsuninsured even as the United States hassustained the highest per capita health carespending of any industrialized nation. As aresult, problems with health access andcosts have seldom been absent from localor national agendas. Following the ClintonAdministration’s failure to achieve univer-sal coverage, neither public policy nor themanaged care industry have addressed thecontinuing lack of affordable health cover-age for as many as 43 million Americans(U.S. Census Bureau, 2000).

The Blue Ridge Group is on record in sup-port of policies that can transition ournational health care system towards avalue-driven model of universal coverageand population health management,through a combination of public and pri-

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vate mechanisms (see Exhibit 2, BlueRidge Group, 1998b). With universal cov-erage for care scientifically proven to beeffective, health care organizations couldcompete to manage and improve the careof populations. This would catalyze thedevelopment of new population healthmanagement strategies, drive competitionto develop better ways to measure andreward quality and efficacy of care, andcreate more value for the health care dollar.

The Blue Ridge Group believes that thetrends described above suggest three fun-damental principles that support progresstowards a value-driven health system.These are:

• Standardization of health industry data, connectivity, and communications, attendant upon the industry-wide rationalization of provider and payor systems. Cost reduction and productivity enhancements have dominated early standardization efforts. Harder to define and establish, quality and value-driven care and delivery standards – including privacy standards – are steadily gaining prominence.

• Empowerment of providers and patients in the care process through access to new health and care-related information and technologies, and the growth of self-care, remote care, and customized care capabilities.

• Universalization of health insurance coveragefor scientifically proven effective treatments, with ongoing pressure to improve access, quality, and value of care for all.

Standardization, empowerment, and uni-versalization are principles that the BlueRidge Group believes can guide healthcare leaders and policy-makers in evaluat-ing and employing Internet technologiesand in leading the transition to a value-driven health system.

Exhibit 2: The Value-Driven Health System

A value-driven health system is grounded in the principlethat a healthy population is a paramount social good. It is ahealth system that promotes and improves the health of thepopulation by providing incentives to health care providers(both public and private), payors, communities, and statesto optimize population health status and rewarding cost-effective population health management. Such a health sys-tem would achieve better health outcomes and improve thehealth of citizens over the long-term while achieving costsavings for all stakeholders.

Two kinds of incentives exist within a value-driven healthsystem. First, there are incentives for individual citizens(patients), health care professionals, health delivery organi-zations, payors, and communities to seek and maintainhealth. Health insurance premiums, reimbursement rates,and grants to communities can all be structured to rewardbehaviors and strategies that advance health. Second,providers compete for populations to manage on the basisof quality and efficiency (where quality is defined in termsof health of the community or region as well as health ofindividuals). To do so, however, requires a fully insuredpopulation (universal coverage) so that population healthmanagement strategies can be implemented. It is antici-pated that in a mature value-driven evidence-based sys-tem, universal coverage will be less expensive than in thecurrent system.

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The development and adoption of com-mon standards is vital to the growth andmaturation of most modern industriesand services. Common standards enablemultiple actors on a shared platform toadd new value and forge competitiveadvantage. They enable the efficient andeffective utilization of data and informa-tion necessary to modern commerce andcommunication.

The Internet has emerged as a commonplatform upon which a vast array of newcommunications and connectivity tech-nologies can be developed and deployed.The Web has become the preferred con-nectivity technology because of the earlyand virtually universal acceptance and useof standard underlying software lan-guages. Hypertext Markup Language(HTML), and its latest incarnationsincluding Extensive Markup Language(XML), allow Web sites to be linked andtheir contents (digital data) to be trans-mitted to one another through a relativelysimple and easy to use Web browser.Browsers can be employed on everythingfrom dedicated terminals, to desktop andportable computers, to cell phones andother devices, thus enabling unprecedent-ed and relatively inexpensive communica-tion among users, systems, and sites.

Also important to the power of theInternet as a common platform is theincreasing use of sophisticated databasecoding. For instance, object-oriented,relational databases enable the discretelabeling and identification of every ele-ment in a database. This labeling enablesthe data to be utilized, analyzed, andmanipulated with almost unlimited flexi-bility and power.

Data sharing and processing is one of themost daunting issues in the changinghealth care industry. Many record keepingand clinical assessment and reporting sys-tems, including relatively sophisticatedcomputer and software systems, prolifer-ated over the course of the twentieth cen-tury. But most developed as proprietarysystems and were designed to addresslocal and/or payor specific recording andreporting needs but not to facilitate com-munication with other systems. With anestimated 30 billion eligibility, claim, lab-oratory, and referral transactions per yearalone, the health care industry is notori-ous for the difficulties encountered inderiving and sharing data among payors,providers, laboratories, and patients. Therapid transition to a competitive, cost-driven health care environment acceler-ates the need for standardized informationsystems that can connect and communi-cate ubiquitously and transmit data easily,efficiently, and securely. The AdministrativeSimplification sections of the HealthInsurance Portability and AccountabilityAct of 1996 (HIPAA, P.L. 104-191) repre-sent the government’s first attempt to settransmission standards for health datawhether for government purposes or not.

The volume of transactions is only thefirst hurdle. A second major hurdle in theimplementation of standardized health-related data systems is the diversity andcomplexity of the records that are createdand utilized in support of the careprocess. These include medical histories,diagnoses, examination notes, treatmentrecords, prescriptions, test and lab results,regulatory compliance reports, insuranceeligibility, billing and collection functions,scheduling, referral data, hospitalization

Health e-Connectivity

9

records, and so forth. Some of theserecords are generated at dedicated com-puter-aided patient intake stations, someon paper forms. Some records are jotteddown by hand by the health care profes-sional, and some are transmitted by fac-simile or dedicated electronic pipelinefrom provider to payor.

The average medical center or health caresystem uses at least six different clinicaland administrative systems. The complex-ity of the record creation and record keep-ing functions, and the multipleadministrative and delivery situations thatgive rise to them, have so far defied stan-dardization. One initiative devoted totackling this problem is the W3-EMRSProject. It is developing an Internet-basedsystem to access multiple heterogeneouselectronic medical record systems(Kohane et al., 1996).

Farthest along in electronic transmissionare insurance-related transactions. Two-thirds of health claims are processed elec-tronically; the majority of these arepharmaceutical claims. Eighty-seven per-cent of hospital claims are submitted elec-tronically. However, many of these aretransferred on tape media, and the vastmajority flow through dedicated, propri-etary lines and from legacy systems thatare extremely expensive to maintain andcumbersome to operate. Even with elec-tronic submission, relatively few claimscan be adjudicated electronically, creatingindustry-wide problems with the manage-ment of billions of denied and delayedclaims (Goldsmith, 2000).

A third daunting issue in the developmentof common standards in health data pro-

cessing is the need to ensure that newcomputer-based health records and sys-tems are secure and can provide optimalsafeguards to protect the privacy ofpatient data. Security and privacy of med-ical information is and must be a priorityof both industry and government. HIPAA-mandated action to establish proper stan-dards either by the Congress or by theDepartment of Health and HumanServices (HHS). HHS has released regula-tions that create and enforce standards forobtaining, holding, transmitting, authenti-cating, and utilizing sensitive health data.

The HIPAA-mandated rules now force allhealth care organizations, data handlers,and their business partners and affiliatesto adopt stringent policies and technologi-cal safeguards to protect sensitive healthdata. Standard transactions and other elec-tronic individually identifiable informationtransmitted between business partners willrequire encryption. A universal digital sig-natures security system, with tiered securi-ty access and clearance, likely will bemandated for use by all individuals with

The Web is also enabling new capabilitiesfor extending connectivity and care into thehome and other remote environments.

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access to covered or potentially sensitivedata, including providers, trainees, staff,patients and their families, as well asemployees of vendors, business partners,and affiliates. The new rules will likely beboth technically complex and expensive toimplement, requiring the employment ofsophisticated technologies and elaboratesecurity processes. For the present, theregulations will not affect those who con-tinue to use paper transmission.

A fourth daunting issue in the develop-ment of common standards for healthdata processing is that not all health sys-tem stakeholders have equal incentives toadopt common data processing standardsor efficient connectivity systems. Payorsoften derive financial benefit from delaysin making payments caused by the com-plexities and inefficiencies in claimsauthorization and processing. Providershave few incentives to establish electronicconnectivity to patients that can alterwork flows and increase workloads with-out commensurate remuneration, properstaffing, and new mechanisms for riskmanagement. Patients who desire direct

and easy connectivity to payors, employerbenefits plans, and providers also demandcomplex and failsafe privacy safeguards toprotect personal health information.While HIPAA is designed to help addresssuch payment system and other structuralimpediments to efficient and secure elec-tronic processing, unequal and often “per-verse” incentives are rife in the healthsystem and should not be underestimated(Kleinke, 2000).

The Web, in particular, is spawning a uni-verse of devices and capabilities designedfor use in the recording, processing, analy-sis, reporting, and transmission of data inalmost every conceivable environment forhealth care practice, administration,research, and teaching. Traditional ven-dors, such as IDX and McKesson/HBOC,as well as upstarts like Healtheon (createdby the billionaire Internet entrepreneur,Jim Clarke and then merged intoWebMD), MedicaLogic (which recentlyacquired Medscape), Athenahealth,ProxyMed, and MD Technologies, all areeither migrating existing systems online orare designing entirely new, Web-based sys-

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tems for use in all aspects of practice man-agement and administration. New softwareis increasingly enabling the conversion ofpre-existing or legacy content into thenewer standardized code, while more andmore original content is being entered andcreated online or in digital formats easilymigrated online.

This mass migration towards Web-basedinformation technologies and systems isdriven by the possibility of significantcost savings and productivity gains, withvastly more effective and efficient recordkeeping, including data mining, transmis-sion, and communication amongproviders, payors, and patients, and thestreamlining or improvement of manyother elements of the administration andmanagement of care. The Web is alsoenabling new capabilities for extendingconnectivity and care into the home andother remote environments. Already, thewired world of the Internet is rapidlybeing augmented, and in many areas vir-tually replaced, by wireless technologiesthat provide sophisticated mobile capabil-ities suitable to the full spectrum of care,teaching, and other non-static and remoteenvironments. Increasingly intelligent systems and devices are aiding all deci-sion-makers, from the patient to theprovider to the payor to the researcher, byenabling the conversion of complex datainto accessible information and knowledge.As sufficient connectivity bandwidth isinstalled, the goal of universal connectivityis moving closer to realization.

Both the proliferation of Web-based tech-nologies and the rapid rate of evolution,improvement, and invention of these newcapabilities create planning and deploy-ment challenges for the health care organ-ization. Web-based technologies are in theearly stages of development and will con-tinue to develop at a rapid pace for theforeseeable future. While the Web pro-vides a common standardization platform,there are many vendors and technologiesproviding a variety of pathways for systemmigration, from the incremental to theglobal. Appropriate decision-making con-cerning the adoption and deployment ofthese new technologies requires healthcare organizations to acquire the knowl-edge or expert assistance necessary toappropriate organizational planning andprioritizing. Most health care organiza-tions at this point have some experiencewith Internet technology. Most utilizeelectronic mail (e-mail) systems and oper-ate Web sites that serve both in-house andexternal connectivity functions.Information technology (IT) managersand support personnel are virtually indis-pensable to all significant health systemoperations.

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Findings

• The Internet, through the World WideWeb, provides health care organizationswith the ability to standardize data uti-lization and transmission, and to inte-grate disparate clinical and admin-istrative systems. This migration towardsa single, standard platform enablesunprecedented development of health e-connectivity, communication, andcommerce.

• The Web is a technology platform thatwill become increasingly important to theefficient and effective administration andoperation of health care organizations.The Blue Ridge Group predicts thatwithin ten years, Web-based technologywill be indispensable to the ability ofhealth care organizations to operateeffectively and competitively in the healthcare industry.

Recommendations

• AHCs and other health care organiza-tions should be engaged in ongoing,governing board and leadership-levelevaluation of operational and administra-tive capabilities and the opportunitiespresented by new Web-based technolo-gies to enhance, revise, or redesign cur-rent service and business processes andpatient care capabilities.

• Evaluation, planning, and implementa-tion capabilities for Web-based opera-tional and administrative systems shouldbe a core competency within all healthcare organizations. In the short or nearterm, health care, research, and trainingorganizations should prioritize develop-ment of Internet-based capabilities thatstrengthen local or regional market posi-tion, and services that are reliable, scala-ble, customer-friendly, and flexible.

• AHC leadership should explore oppor-tunities across and among academiccenters for shared investment in, or out-sourcing of, Web-based operational andadministrative systems.

Implementation Guidelines

Web-based technologies are sufficiently advanced that health care organizationscan profitably focus on the followingdomains:

• Managing internal business and operational processes – there are significant opportunities for cost savings, operational improvement, and process reform in the areas of administration, human resources, claims processing, customer relations, and marketing.

• Managing internal patient care processes and improving patient/provider decision-making – there are significant opportunities for improving capabilities in evaluating the efficacy and efficiency of care, and in communicating and sharing data with patients and third-party payors.

• Managing health data privacy, confidentiality, and security – there will be significant requirements for implementation of HIPAA- mandated security standards, processes, technologies, and rules; both legacy health care information systems and newer vendors will be important partners in complying with these regulations.

e-Connectivity Findings, Recommendations,and Implementation Guidelines

13

Physician training standardized around ascientifically and evidence-based curricu-lum has been well established since earlyin the twentieth century, followingAbraham Flexner’s detailed report of theshortcomings of most training programs tothat point. Nearly 10,000 randomizedclinical trials results are now publishedannually, providing an ever-growing baseof evidence for clinical practice and pro-fessional education (Chassin, 1998).Communication of generally acceptedclinical and scientific content has beenstandardized through broad disseminationof a core curriculum and approved textsand reference works. Standard pedagogi-cal, clinical, and training protocols havebeen widely adopted and refined.

One of the most daunting ongoing chal-lenges in medical education is the amountof information, skills, and knowledge thatmust be assimilated by medical studentsand other health professions students. Thequantity of scientific and clinical knowl-edge has grown tremendously over the lastcentury. The rate of growth of biomedicalknowledge is increasing with advances intechnology, the growth of the researchenterprise, and the opening of whole newareas of inquiry, especially in genomics,structural biology, and many other emerg-ing fields. Some fields are advancing soquickly that it is difficult to keep pub-lished texts, and even journals, up to date.

Along with the increase in the amount andcomplexity of medical information thatmust be assimilated, is the pedagogicalchallenge of finding the best methods tofacilitate the learning process. Schools thattraditionally imparted basic science and

skills information to individuals throughlarge lecture classes increasingly havemoved to adopt group seminar formatsthat allow a focus on individual and groupproblem solving.

Pedagogical approaches also have changedin the clinical setting, which has beenmade more challenging because of man-aged care and changed reimbursementscales. With hospitalization rates andlengths of stay falling, medical educatorshave been hard-pressed to provide stu-dents with the patient exposure necessaryto ensure thorough clinical training. Manyschools have experimented with substitut-ing volunteer and paid actors for realpatients in order to present medical stu-dents with live subjects from whom theycan learn and practice the many skillsinvolved in taking histories and diagnos-ing health problems.

Increasingly, students are expected to uti-lize expert information, technology, anddecision support systems. There are exper-iments in training students to learn andshare skills and expertise in teams, includ-ing teams where more responsibility isallocated to skilled and advanced nurses,physician assistants, and other alliedhealth professionals. Biostatistics, epidemi-ology, behavioral modification, healthservices research, and bioinformatics allare gaining a more prominent role inhealth professions education.

The advent of the Internet and growth ofthe Web is transforming medical and healthprofessions education. A broad range ofmedical and public health information iswidely available online, increasing the

Health Professions Education

14

student’s access to new and existingknowledge. Among the resources readilyobtainable from public and commercialsources are professional journals, reports,and presentations (sometimes live) fromprofessional and scientific meetings, a fullrange of major medical reference works,and databases. In addition, health profes-sions students have access to searchengines that enable extensive and sophisti-cated information searches, to continuingmedical education courses and materials,as well as to supplies, devices, and equip-ment they might require.

Medical, dental, pharmacy, and nursingschool educational resources increasinglyare being moved online. Health scienceslibraries are migrating publications, cata-logues, and most other library resourcesand services online. Many schools havemoved significant elements of their cur-ricula online for ready access by studentsand faculty. An online private company,medschool.com (www.medschool.com),has staked out a significant Web presenceas a self-described “e-learning health carehub and virtual community offeringaccess to the highest quality medical edu-cation for students, educators, physicians,allied health professionals and sophisticat-ed consumers . . . that augments the cur-rent medical educational system andaddresses critical needs in health careeducation.” Additionally, thousands ofWeb sites are maintained by medical stu-dents, organizations and schools, pre-medpreparation companies, medical textbookpublishers, and many others with infor-mation on virtually any medical-schoolrelated subject or topic.

Similar advances are being made in con-tinuing medical education (CME). Many

medical schools now offer online courseswhere physicians can earn CME credits.The private sector is also playing stronglyin this field. CMEWeb.com, for instance,now provides more than 1100 hours ofonline accredited continuing medical edu-cation testing and processing.

Advances are also being made in schoolsof public health and nursing. The RollinsSchool of Public Health of EmoryUniversity, for instance, has developedeLearnTM, a suite of programs to deliverelectronic materials via the Web. Theschool offers a Career MPH degree, a 42credit-hour program in which studentsparticipate in both traditional face-to-faceclassroom sessions and on the Web. TheeLearn system enables students and facul-ty to interact via chat rooms, an electronicwhiteboard, and Internet video conferenc-ing. The program is designed to allowworking professionals to complete anMPH degree in approximately two and ahalf years.

Nursing schools long have been innova-tors in distance learning. Many are rapidlyadding innovative and extensive onlinelearning programs. At Duke UniversitySchool of Nursing (DUSON), for instance,nurse practitioner and clinical nurse spe-cialist students can participate in Web-based courses and programs, includingMSN degrees in Nursing Informatics,Health Systems and LeadershipOutcomes, and Clinical ResearchManagement. The DUSON is also one of agrowing number of schools with an infor-matics program, emphasizing clinicalinformatics tools for the improvement ofpatient health outcomes.

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Most expert observers see these develop-ments as only the very beginning of capa-bilities that will likely revolutionizeeducation and training in the health pro-fessions over the next two decades. [email protected] project of theAssociation of American Medical Colleges(AAMC) is the most sophisticated forward-looking assessment of medicaleducation resources and technologies thatare currently deployed, under develop-ment, and projected by experts. Thisvisioning project concludes that medicaleducation in the year 2010 will be suf-fused and enhanced by a host of newInternet-based technologies and capabili-ties. Among the projections for the future:

• A set of refereed multimedia cases that cover core medical concepts will be used for instruction at most medical schools.

• Lecture time will be replaced by small group sessions that build on independent study of Web-accessed information and resources.

• Intelligent information systems will provide learning materials that continuously adapt to learners’ needs and accomplishments.

• Procedural skills will be taught first on a digital simulator.

• Patient simulations (i.e., virtual patients) will be core experiences in widespread use for the evaluation of clinical skills and medical decision making.

• Continuing education will be personalized– delivered by online modules based on physician performance needs with his or her own patients.

A Tufts University Medical School projectthat anticipates many of these capabilities,is likely to significantly influence thedevelopment of online medical educationresources. Launched in 1995, the Tuftsonline Health Sciences Database is aunique and powerful online curriculum

resource that combines the capability of adigital library with a course delivery sys-tem and a curriculum management sys-tem. The Database contains an imagedatabase (e.g., micro slides), course syllabi(including some textbooks), video clips,lecture slides with audio, and self-assess-ment quizzes to monitor progress. Morethan 60 percent of the first and secondyear curriculum is online. An object-oriented database provides flexible,expandable, and integrated content thatcan be utilized, searched, updated, andcustomized.

The Database provides students with inte-grated course materials that can beaccessed and utilized in a variety of for-mats. Faculty and students can build onand refine course materials. All users canshare materials with one another and withusers outside the institution. As the Tuftscurriculum and others migrate online, theopportunities for sharing and cross-fertilization in the elaboration of pedagogi-cal tools and biomedical knowledge andskills will increase exponentially. TheAAMC hopes to form a consortium toconnect such resources and facilitate theirfullest development.

Medical, dental, pharmacy, and nursingschool educational resources increasinglyare being moved online.

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Internet-enabled enhancements to healthprofessions education will drive educatorsto rethink and even re-conceptualize tradi-tional pedagogical methods. Internet-based curricula will soon be capable ofproviding customized elements of thebasic curriculum that are directed andupdated by intelligent online teaching sys-tems; in fact, most non-experiential learn-ing is likely to be accomplished over theInternet. What will be the implications forfaculties and students? Will the education-al model move from memory-based toprocess-based learning? Will faculties bereduced in size? Will faculty size remainstable with curricula leveraging onlinelearning to enable faculties to spend moretime providing individualized clinicalmentoring and counseling, criticallyassessing and guiding the development ofprofessional values and ethics? Will thecriteria by which students are selectedchange to focus differently on certaincharacter traits, intelligence, adaptability,communication skills, leadership attrib-utes, ability to interface both with tech-nologies and between digital andbiological systems?

What will constitute a school under thesecircumstances? What would it mean tomatriculate? If much of the basic curricu-lum can be conducted interactively online, will hospitals or health plans or otherorganizations stake a claim to the neces-sary hands-on health professions training?If curricular material can be packaged intointelligent learning systems, will commer-cial companies, like the Kaplan test prepa-ration organization or privately ownedfor-profit professional schools, becomeleaders in the development of such sys-tems, with a legitimate claim of being ableto provide or host the training? Could anyor all of this apply to residency and otheradvanced training?

The Blue Ridge Group believes that thebest scenario is that new Internet-basedcapabilities will serve to strengthen theexisting system of health professions edu-cation, enriching the curriculum andenabling more individually, culturally, andtechnically nuanced training of a diversecohort of students. Faculty can be freed ofmore mundane and repetitive tasks andhave more time for trainee contact andmentoring, and to pursue unprecedentedopportunities for curricular and pedagogi-cal innovation.

The Internet’s influence is overestimated forthe next two years – but underestimated forthe next 10.

– Bill Gates, 1999

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Findings

• The Internet is a platform that will become integral to medical and healthprofessions education over the next tenyears. Universities and an array oforganizations and commercial enterpris-es will develop online educationalresources and programs. Most medicaland other health professions schools willmove substantial elements of their cur-riculum online. There will be new compe-tition from the private sector to provideeducational materials and services to thestudents, universities, the health profes-sions, health care organizations, and thegeneral public.

• Increasingly, health professionals will need to know both their clinical special-ties as well as how to utilize informationtechnology in their research and prac-tice. This has implications for howschools must train health professionalsand researchers.

Recommendations

• AHCs should actively investigate the opportunities and challenges for thedevelopment of online curricular and peda-gogical resources for students and faculty.

• Medical and other health professionsschools should prioritize strategic evalua-tion and planning designed to maximizethe impact of online curricula andresources for health professions training.


Medical schools should work closelywith the AAMC, the Liaison Committeeon Medical Education (LCME), theLiaison Committee on Graduate MedicalEducation (LCGME), specialty boards,specialty societies, and other relevanthealth professional education associa-tions to maximize the utility of curricularinnovation and to ensure the integrityand quality of online educationalresources and programs.

Education Findings, Recommendations, andImplementation Guidelines

18

Through the first seven decades of thetwentieth century, basic biomedical(including behavioral) and clinicalresearch were almost exclusively theprovince of AHCs and their affiliated hos-pitals, a few private hospitals and treat-ment centers, and philanthropicallysupported care and research centers. Thepharmaceutical industry also conductedand sponsored basic and clinical research,but focused primarily on applying discov-eries to the drug development and mar-keting process. Over the century,standards for the conduct and reporting ofresearch were developed through the aus-pices of the National Institutes of Health(NIH), the National Science Foundation(NSF), and other federal agencies, profes-sional societies and associations, and pri-vate foundations, all of whom havecooperated to ensure the quality andintegrity of the research enterprise. Aspopular trust in and support for biomed-ical research grew, so did federal dollarsallocated to the NIH, NSF, the Departmentof Defense, and other agencies to supportsponsored research.

Beginning in the late 1970s, the explosiveemergence and growth of the biotechnolo-gy industry signaled the maturation ofbiomedical science to the point where itcould generate and support a national andinternational marketplace with a constantand widening spectrum of new products.As the biotechnology and pharmaceuticalindustries captured unprecedented financ-ing and found or created huge new mar-kets, competitors increasingly looked forways to accelerate, lower the costs, andimprove the efficiency of the drug anddevice development process. The tradi-tional university-centered biomedical andclinical research enterprise came under

intense pressure to provide better admin-istrative support and vastly improved effi-ciency and industrial responsiveness fortheir clinical trials and technology trans-fer capabilities. Most AHCs have not beenable to achieve the levels of operationaleffectiveness and productivity in clinicalresearch desired by industry.

Into this competitive fissure grew a newindustry of contract research organiza-tions (CROs) competing to provide thebiotechnology and pharmaceutical indus-tries with efficient and effective drug anddevice development services. Many in thebiotech and pharmaceutical industriesalso added new research and developmentcapabilities, and all hired leading scien-tists and some of the most promisingyounger scientists away from traditionalacademic careers. As universities havestruggled to improve industry-sponsoreddevelopment and clinical research services,the new CRO and biotechnology indus-tries have proven effective competitors.While universities conduct the vastmajority of sponsored basic research, it isestimated that universities now conductonly about 30 percent of industry-spon-sored clinical research, down from 70 per-cent two decades ago (Rich, 2000). Therapid development and consolidation ofthe highly competitive and well capital-ized biotechnology, pharmaceutical, andCRO industries continues to put a premi-um on improving the efficiency and effi-cacy of drug and device development.

The Internet is proving to be a very com-pelling and promising medium throughwhich to expand and further enhance bio-medical research and the drug and devicedevelopment process. In basic research,the Internet has been widely employed by

Health e-Research

19

researchers to increase the speed and effi-ciency of the transfer and sharing of infor-mation. Collaborators can more easily andquickly share data, feedback, and results.Peer review panels now save weeks ormore in the manuscript review process bybeing able to post reviews and otherwisestreamline study section administrativeprocesses online. Bioinformatics appearspoised to assume a larger role in academicmedicine, nursing, and public health.Significant programs now exist at BostonUniversity, Northeastern University,Stanford University School of Medicine,University of California at Santa Cruz,and Washington University in St. Louis,among others.

The Internet is also serving as an excellentplatform for databases that allowresearchers virtually unlimited access.Major online databases include theNational Library of Medicine’s MEDLINE,an index of the entire biomedical serial lit-erature since 1966; PubMed, a searchengine hosted by the National Center forBiotechnology Information; GENBANK,the major database of DNA sequences,hosted by the National Institutes of Health;and OMIM, Online Mendelian Inheritancein Man, hosted by Johns HopkinsUniversity. Many other important databas-es are available online, both free and bysubscription. These online resources havebecome basic tool sets and forums for col-laboration in biomedical research and forrapid growth in the field of bioinformatics,where AHC leadership is central.

Yet, the research community struggleswith the implications of this efficient newmedium. For instance, in 1999 HaroldVarmus and colleagues at NIH proposedthe creation of an Internet repository,

E-Biomed, for the posting and disclosureof both peer and non-peer reviewedresearch results and papers (Varmus, etal., 1999). The proposal envisioned aninternational repository where researchersworldwide could share results and discov-eries with unprecedented speed, receivefeedback, respond to queries and criti-cisms, and in many other ways open-up,accelerate, and improve the research pub-lication, review, and disseminationprocess. While well received by manyresearchers, the proposal was met with atorrent of criticism from many others andfrom journal publishers, professional soci-eties, and other quarters. Much of thecriticism stemmed from the fear of thedamage such speedy dissemination coulddo to the integrity of the research reviewprocess and to public trust in the researchenterprise. A scaled-down version of theoriginal proposal is now being imple-mented. Researchers and policy expertsare monitoring the program carefully tolearn if and how the research review anddissemination process can be enhancedthrough such a repository.

The Internet provides a robust platformfor addressing and managing virtually allaspects of clinical trials.

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While academic researchers and physi-cians continue in their vital role at theleading edge of discovery research andclinical innovation, the pharmaceuticalindustry is assuming unprecedented lead-ership in defining and driving the futureof treatments for disease and disability.Research and development spending bythe pharmaceutical industry, whichreached $26.4 billion in the year 2000, isnow 50 percent higher than the $17.8 bil-lion sponsored research budget of the NIH(Drews, 1996). Pharmaceutical industryspending will accelerate clinical researchand drug and device development over thenext ten years. The industry has approxi-mately 500 biological targets for drugdevelopment. With advances in molecularbiology and the successful mapping of thehuman genome, within a few years therewill be up to 10,000 such targets, vastlyexpanding the universe of treatable condi-tions and the efficacy of treatments. Theindustry is targeting currently untreatableconditions, especially cancer, and lifestyledrugs, such as Viagra.

The roles that AHCs will play and theextent of their participation in the surge

of pharmaceuticals development are amatter of some uncertainty. AHCs havelost significant ground in their traditionalrole of conducting clinical trials to testthe efficacy of therapeutics. As suggestedabove, AHCs have been only partially andinconsistently successful in improvingtheir capacities to reliably conduct effi-cient and effective clinical studies. Mostcenters are plagued by administrative dif-ficulties, especially in recruiting andretaining sufficient trials participants, inrecords management, and in timely man-agement of human subjects and other reg-ulatory requirements. Nevertheless, AHCsremain a compelling locus for such stud-ies, if they can solve the critical adminis-trative and process issues. AHC facultiesare well suited to the complex challengesof arbitrating and translating informationto and from clinical practice.

Perhaps most compelling is the gradualbut unmistakable shift from in-hospitaltreatments as the dominant site for dra-matic improvements in life expectancy tooutpatient management where medica-tions taken chronically help the greatestnumbers. Indeed, with joint replacements

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and similar treatments the hospital is nowincreasingly the site for quality of lifeimprovement and palliative treatmentsrather than life-saving care. The newmedicine will increasingly be “high-tech,low-touch.”

The Internet provides a robust platformfor addressing and managing virtually allaspects of clinical trials. A partnershipbetween Quintiles TransnationalCorporation and WebMD to develop clini-cal trials capability in a Web environmentillustrates the ability of the Internet tosupport new levels of connectivity, collab-oration, and commerce in medicalresearch and pharmaceuticals develop-ment. The Quintiles/WebMD partnershipis creating an integrated set of Web por-tals that will enable online design andmanagement of clinical trials. Web portalsdedicated to patients, investigators, andresearch sponsors enable customizableconnectivity and collaboration among anyand all participants. These portals willmanage:

• Recruitment of physicians and patients;

• Feasibility assessments;

• Study design and protocols;

• Data collection, processing, and management;

• Labs and clinical supplies ordering and tracking;

• Real time information on status of trial andaccess to educational materials, news, and study documents;

• Clinical monitoring and audits;

• Ethics, human subjects, and regulatory requirements;

• Adverse event reporting; and

• Online training, including Web casts.

Project management modules, extensivedata mining capabilities, automated newsand reporting functions, comprehensivesecurity and privacy safeguards, all con-nected to data warehouses, will accommo-date the needs of investigators, patients,payors, and sponsors. This system willalso be able to support and integrate withother functions up and down the produc-tion chain, from research, to development,to sales, to quality control and assess-ment. The implementation and refine-ment of this system is expected to have asignificant impact on the costs, manage-ment and success of clinical trials.

The development of this level of onlinecapability is beyond the reach of mostAHCs and other health care organizations.But AHCs can partner with organizationsbuilding such capabilities if AHCs acquireor create appropriate electronic orInternet-based administrative and datamanagement capabilities.

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Findings

AHCs have been unable to achieve lev-els of operational effectiveness expectedby industry and have lost significantground to contract research organiza-tions in their traditional role of conduct-ing clinical trials in support of drug anddevice development. New models showthat the future of clinical trials design andmanagement is online. AHCs can remainstrong research and development part-ners if they aggressively acquire relevantInternet-based administrative and opera-tional capabilities.

Recommendations

• AHCs should aggressively pursueopportunities for the development oracquisition of online clinical trials designand management.

• AHC faculty must become thoughtleaders and innovators in the new envi-ronment.


AHC leadership should seek strategicpartnerships for online connectivity andcollaboration with contract research andpharmaceutical organizations.

e-Research Findings, Recommendations,and Implementation Guidelines

23

Health Provider Empowerment

As reviewed above, the Internet isspawning Web-based technologies withunprecedented capabilities for connectivi-ty and data exchange between providers,payors, patients, and other parties.Integrated Web-based practice manage-ment programs, in use by some physi-cians and organizations, are expected tomigrate to a majority of providers by theyear 2010. Online practice managementshould enable the realization of signifi-cant efficiencies and cost savings in theutilization and transmission of care-related data. Providers and payors willachieve new levels of accuracy and timeli-ness in the processing of eligibility andinsurance claims. Providers and providerorganizations will realize new levels ofadministrative effectiveness in the man-agement of medical records and patientflow. Patients should reach new levels ofcustomer satisfaction with easier andmore reliable scheduling, billing, andmedical record keeping, and withenhanced connectivity for the purposes ofcommunicating with or accessingresources and information from providersand payors.

The complexity and diversity of healthcare practices hinders the developmentand adoption of a broadly accepted orindispensable model for care delivery andmanagement. Instead, the Internet is serv-ing as a common platform for the devel-opment of a wide spectrum of newproprietary clinical care and process relat-ed capabilities. Since they are being devel-oped on a common platform, they will beable to share data and connectivity in thedelivery and management of care amongproviders, payors, pharmacies, patients,and other parties.

As a group, physicians have been slow toadopt Internet-based technologies in theirclinical practice – or to adapt clinicalpractice to new Internet-based orenhanced technologies. Surveys of physi-cian Internet usage vary, but on the wholeindicate that anywhere from 50 to 85 per-cent of physicians now have access tocomputers at home or in the office. Thevast majority utilize the Internet, but notto support of clinical care. Typically,physicians use the Internet the way othersdo –for e-mail, news, entertainment, andfor information searches on both profes-sional and personal topics. Measures ofphysician utilization of the Internet forclinical or patient-related topics showusage to be relatively low.

A recent online survey conducted byWebSurveyMD.com sampled a cohort ofphysicians with online access. Only 27 per-cent believed that the Internet would helpreduce health system costs over the nextfive years. Fewer than 50 percent believedthat the Internet would help improvephysician-patient communication. Twentypercent use the Internet to communicatewith patients, 19 percent to consult withcolleagues. Of most interest to those sur-veyed, was the potential of Internet-relatedtechnologies to extend care to patients atremote sites (WebSurveyMD, 2000).

Many analysts attribute low physicianInternet utilization to practitioners’ indi-vidual and collective reticence to changelong-standing practices, resistance to newtechnology, or even professional arro-gance. These explanations miss the point.Limited utilization of the Internet forcare-related activities is primarily a func-tion of the lack of demonstrated utility

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and value of Internet technologies to thecare process. To date, only a few Internetor Web technologies have been developedthat seem capable of providing the physi-cian with new capabilities, efficiencies,practical benefits, margins on productivi-ty, or cost savings in the actual provisionof care that would justify their adoption.Among these, Allscripts (allscripts.com),ephysician (ephysician.com), and severalother vendors have pioneered the devel-opment of portable or hand-held wirelesselectronic prescription capabilities thatenable physicians to create electronic pre-scriptions in the exam room.Prescriptions can then be sent electroni-cally to the local retail, mail order, orInternet pharmacies, printed in the office,or for the most commonly prescribedmedications, dispensed in the physician’soffice. On a separate track into the physi-cian’s workflow, MDeverywhere (mdeverywhere.com) and Pocketcode(pocketcode.com) have developed wire-less charge capture devices for use byphysicians at the point of care.

Many other technologies promising in-office and care-extending benefits are beingdeveloped. Providers are likely to get prod-ucts that enhance care delivery, but onlyincrementally, because of operational, tech-nical, legal, and professional hurdles.Technologies that enhance clinical care willgain momentum among providers and pay-ors, and are likely to become integratedwithin clinical practice environments overthe next decade. Examples include clinicaldecision support and care monitoring,especially to remote environments.

Clinical decision support will becometechnically feasible as both search engines

and clinical practice guidelines becomeincreasingly sophisticated. Decision sup-port in medicine requires an extremelycomplex set of capabilities, includingcomputer terminals or appliances that areeasy to use, portable, and can access anddisplay data and patient records in realtime. Also required are extensive andsophisticated databases that include up-to-date research and clinical findings andprotocols. Rendering all of this informa-tion available and useful to diagnosis andtreatment requires search engines andsoftware that can process and analyze thedata in ways that are useful to the clini-cian in the clinical setting.

Several organizations and companies tar-get specific diseases and conditions forclinical decision support and guidance.The diagnosis, treatment, and manage-ment of conditions such as asthma, heartdisease, and diabetes are supported byincreasingly sophisticated products andapplications. I-Trax (Itrax.com) has hadsome early success with pediatric provideradoption of its Asthma Watch System.Health plans are increasingly looking tosuch solutions for monitoring and guid-ing the care of their members. The man-aged care company, Humana, Inc., hasbegun utilizing an online coronary arterydisease (CAD) management productdeveloped by CorSolutions, Inc. (ecorso-lutions.com).

Taking a more general approach, StanfordUniversity created and spun-off as a pri-vate company, e-SKOLAR.com, a Web-based clinical care support site that itdescribes as a “knowledge serviceprovider.” The site is designed for use byphysicians and other providers to conduct

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rapid searches across multiple medical references. Users can access the most up-to-date medical information and clinicaldecision support at the point of care.e-Skolar.com also promotes the concept of physician-initiated in-context learning,providing the opportunity to earn contin-uing medical education credits in a“learning while doing” model. e-SKOLAR.com grew out of Stanford SKOLAR, M.D., a powerful search enginedeveloped by an interdisciplinary team offaculty members and students from theschools of computer science and medicine.

Another start-up, EBM Solutions (ebmsolutions.com), in a partnership withVanderbilt University’s medical center andfive other AHCs, developed a package ofWeb-enabled evidence-based disease-specific practice guidelinesdesigned for use by both the professionaland the patient. Guidelines allow bothprovider and patient to view care optionsbest supported by reported research andevidence compiled and reviewed by thesix AHC partners. Connectivity tools arebeing designed to facilitate communica-tion and information exchange, includingcompliance reporting between patient andprovider.

A number of companies provide and aredeveloping diagnostic and testing devicesfor use at the point of care and remotely.I-Stat (I-Stat.com) provides blood analysistools built into a portable device for use atthe point of care. IGEN International(IGEN.com) is a well-established diagnos-tic and life sciences company developinga product capable of performing a widerange of diagnostic tests both at the pointof care and remotely.

Internet-based or enhanced telemedicinecapabilities are poised to move from thestatus of esoteric technologies of marginalutility, to mainstream care managementtools. Already, many pathology and radiol-ogy practices routinely employ theInternet to transmit images and data.Various telemedicine systems areemployed to connect providers to patientsin homes, assisted living and skilled nurs-ing facilities, and correctional institutions.

Home health care is beginning to emergeas a market with increasingly sophisticatedand practical technologies of interest topayors, providers, and patients. Remotemonitoring and other connectivity prod-ucts have the potential to reach millionsof patients, especially those with chronicdiseases and conditions who represent thehighest cost cohort in the health care system. Cyber-Care (cyber-care.com),American TeleCare (americantelecare.com),Medtronic (medtronic.com), and severalother companies have developed and arerefining systems that connect the homeand other remote locations to the

Limited utilization of the Internet for care-related activities is primarily a function of the lack of demonstrated utility and value of Internet technologies to the care process.

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provider. Terminals enable audio, visual,and digital communication, as well as thereading, monitoring, and transmission ofhealth metrics such as blood pressure,blood oxygen levels, weight, heart rate,glucose levels. Regularized, ongoing mon-itoring of these and other metrics, alongwith visual and voice communications,should allow providers to better managepatients’ health, increase patient compli-ance, and help prevent both over andunder-utilization of care.

While these and other initiatives are pio-neering new ground in health e-care,there are significant technical, opera-tional, legal, privacy and security, reim-bursement, and quality assurance issueswith which both vendors and e-care uti-lizers must contend. Migration of clinicaldecision support and other clinical func-tions online can be accomplished onlywith operational accommodations in allclinical settings. Hospitals, physicians,other providers, administrators, and staffmust be open to incorporating new capa-bilities, learning new skills, adjustingpatient flow, and helping to test and refinenew technologies.

Electronically enhanced or extended carecreates legal issues and responsibilities inthe areas of professional licensing,provider, vendor, and payor liabilities, pri-vacy, reimbursement, ethics, and otherareas (Silverman, 2000). HIPAA rules nowregulate all health-related electronic data.All health sector participants must devel-op capabilities for compliance. Remoteconsultation, technologies enabling newdiagnostic and treatment options, andpractice innovations of many kinds will

all require payment adjustments andaccommodations by both public and pri-vate payors. New technologies will requireand enable unprecedented quality assess-ment and assurance measures for use byproviders, payors, employers, regulators,and patients alike.

Growing employment of the Internet forclinical care will require ongoing researchand investment in a national health infor-mation infrastructure that includes tech-nologies and standards that provide forvastly increased capacity, speed, reliability,and security for data analysis, processing,utilization, and transmission (NationalResearch Council, 2000). At the nationallevel, several entities have begun to ana-lyze and project these needs and to makerecommendations for meeting them.These include: the National Committeeon Vital and Health Statistics (NCVHS),the National Research Council (NRC), theNational Committee on QualityAssurance (NCQA), the Data Council ofthe U.S. Department of Health andHuman Services (HHS) the President’sInformation Technology AdvisoryCommittee (PITAC). Lacking, however, isan official body, office, or individual thatcan provide overall leadership or coordi-nation of national policy and resources fora national health information infrastruc-ture (National Committee on Vital andHealth Statistics, 1998). HHS is widelyseen as the appropriate locus for strategicleadership of health IT issues, particularly“aggressive involvement in the area ofnational networking” (Shortliffe, 2000).

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Findings

• Internet and Web-based technologiesthat can enhance or extend clinical careare still in early stages of developmentand adoption. Internet-based technolo-gies as yet do not provide practical solu-tions that address the needs of the vastmajority of providers overburdened byadministrative tasks and with too littletime to spend with patients – thoughmany technologies are gaining incre-mental acceptance. Over the nextdecade, such technologies are likely tobecome increasingly sophisticated,enabling AHCs and other providerorganizations to improve care-relatedoperational processes, clinical decision-making, patient, provider, and payorconnectivity, and the efficiency andeffectiveness of care.

• Significant technical, operational, legal,privacy and security, reimbursement,and quality assurance issues remain tobe addressed by federal and stateauthorities, vendors, and those whowould employ e-care solutions.

• AHCs have much to contribute ascenters for innovation, collaboration, andnationwide advocacy in the developmentof Internet-based capabilities that canenhance or extend care.

Recommendations

• AHCs should institutionalize and for-malize the capacity to support the devel-opment and implementation of Internet-based technologies that can enhanceand extend care. AHCs must conducttrials and demonstration projects andexpand their research agendas to facili-tate exploration of the question: How ishealth care going to be transformedbecause of new Internet capabilities?

• As an important basis from which toexpand and assert AHC leadership inInternet health care innovation, AHCsshould embrace health informatics as afull fledged professional specialty inmedicine, nursing, and public health.

• AHCs and other health organizationsshould vigorously support the efforts ofthe National Committee on Vital andHealth Statistics (NCVHS), the NationalCommittee on Quality Assurance(NCQA), the Data Council of the U.S.Department of Health and HumanServices, the President’s InformationTechnology Advisory Committee (PITAC),and related efforts to create and main-tain a national health information infra-structure necessary to the burgeoningdemand for fast, secure, and reliableinformation transfer and processing.

• AHCs and other health organizationsshould vigorously advocate for theDepartment of Health and HumanServices to take leadership in overseeingand coordinating information technologyinitiatives aimed at optimal developmentof a national health information infra-structure for the twenty-first century.

Provider Empowerment Findings, Recommendations,and Implementation Guidelines

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• AHCs should create high-level workinggroups to identify and support on anongoing basis, the evaluation, develop-ment and testing of Internet-based clinicalcapabilities within and between their cen-ters. Clinicians, departments, and/or clini-cal delivery services that are willing andpositioned to participate should be identi-fied and enlisted in these efforts.Appropriate IT, legal, and administrativeresources must be committed to theseefforts.

• AHCs should begin by identifyingprocesses that need to be fixed orstrengthened within the overall clinicaland business strategy. AHC leadersshould not allow strategy to be con-trolled or driven by technology. AHCs are most likely to make progress in thisarena by focusing on basic and incre-mental steps while working with newtechnologies to improve quality, cost, and delivery of care.

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From the point of view of the patientand the public, there has been remarkabledevelopment of Internet-based health careresources. The Internet is providing accessto health information in unprecedentedvolume, depth, and breadth. But beyondsimply providing information, hundredsof online commercial and non-commercialinitiatives are deploying new capabilitiesfor health care services that enable indi-viduals to engage more effectively in man-aging their health, insurance coverage,and care. As these capabilities becomemore broadly and equally accessible,patients and health consumers areincreasingly empowered to participate inmanaging their care. The Blue RidgeGroup also predicts that over the next tenyears, there will be dramatic increases inthe growth of patient competence in self-care and remote care.

The first stage of patient and public accessto health information came with theexplosive growth of consumer-focusedhealth information portals. Among theearly leaders with a strong academic pedi-gree were Intelihealth (originally a jointventure of Johns Hopkins Medical Schooland Aetna U.S. Health Care),DrKoop.com (with health care contentprovided in part by the DartmouthCollege Medical School), and the MayoClinic’s own Health Oasis site. Among theprivate concerns that emerged stronglywere HealthCentral, HealthGate, andOnHealth, each of which has developed asignificant portal that provides a broadrange of easily navigable resources andinformation. Another leading portal,Medscape.com, began as a physician-focused site providing professional news,articles, and research resources along with

connectivity to other professionals. As market trends and consumer interestescalated, Medscape partnered with thetelevision network, CBS, to create CBSHealthwatch.com, a portal for customersand patients.

It is WebMD, however, that has come toepitomize the commercial health care portal.Through a series of major strategicalliances and acquisitions, WebMD hasachieved an unparalleled size, scope, andmarket presence across almost the entirespectrum of e-health services and capabil-ities. But WebMD’s ambitions to becomethe major portal through which all formsof health care information, data, andtransactions will flow have also become asignificant management problem thatrecently caused the company’s share priceto plummet and its leadership team toexperience significant turnover. It remainsto be seen whether this model of health por-tal and transactional gateway can flourish.

Also sponsoring major Web-based healthinformation portals are many governmen-tal agencies (e.g., the National Institutesof Health; nih.gov/health/ and clinicaltrials.gov), professional associa-tions (e.g., the American MedicalAssociation; ama-assn.org), pharmaceuti-cal companies (e.g., drugstore.com),health maintenance and other providerand payor organizations (e.g., KaiserPermanente; KPOnline.org), philanthrop-ic and policy organizations (e.g., theKaiser Family Foundation; kff.org), anduniversity medical centers. HealthWise, anon-profit health-promotion organizationand publisher of popular self-care guides,has become a leading vendor of onlineconsumer oriented, evidence-based self-

Public e-Health Knowledge and Empowerment

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care guidelines and information, whichcan be licensed by managed care organizations, health plans, hospitals, andemployers for use with their members andemployees.

A different model, and equally importantto the diffusion of better health knowl-edge and the empowerment of patientsand the public, has been the developmentof online communities of interest centeredaround diseases and conditions orcohorts. Online communities have a widevariety of sponsors, from individuals todedicated, disease-specific advocacyorganizations, to the major health portals.These online communities have playedvery important roles in the evolution ofexpectations for health knowledge acqui-sition and interactivity both betweenproviders and patients and amongpatients and others with shared disease orother health-related experiences andinterests.

Yet research shows that consumers wanteven more. In most other service and con-sumer industries, the level of information-al access that has been achieved in healthcare has been supplemented with impor-tant follow-on transactional capabilitiesthat enable levels of service and commercethat have so far not developed in healthcare. As a result, health portals continue tomove towards consumer customizationand the integration of health-related prod-ucts, services, interactivity, and informa-tion. Consumers increasingly can goonline with any of the major portals notjust to find information, but to purchasehealth products and pharmaceuticals,maintain personal and family health data,track and assess personal health status,join discussion forums, and identify and

communicate with health care profession-als, insurance companies, health plans, oremployee benefits managers.

For example, DiabetesWell.com andDiabetesManager.com provide integratedpackages of information and services todiabetes patients. Both provide: e-mailaccess to medical professionals; daily e-mail updates and news; local lab referralsor online help for testing and complica-tions; online glucose monitoring withdata displays and graphs; a secure Webpage to track treatment; medication;access to a personal food plan developedby a registered dietitian; a personal fitnessplan created by an exercise physiologist;and online education. Both sites encour-age the patient to pull their physiciansinto online care management throughthese dedicated online services.

Women’s Health Interactive (womens-health.com) is typical of Web sites provid-ing health information for specific cohorts(other widely targeted cohorts include theelderly, children, and teens). This site pro-vides information, research, chat roomsand a variety of related resources on therange of women’s health issues. Resourcesinclude guidance and links to clinical,insurance, and other services.

Beansprout.com is an example of thetrend towards integrating both health andrelated services to particular cohorts ofconsumers. Beansprout is targeting par-ents of young children with an onlineservice that connects parents, pediatri-cians, child care professionals, and dedi-cated childcare resources. The AmericanAssociation of Retired Persons sponsors aWeb site providing comprehensive cover-age of issues of importance to senior

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citizens, including a health site,aarp.org/healthguide. Seniors can find awide range of articles, books, research,and legislative advocacy materials onhealth care, fitness, nutrition and well-ness, care giving, health insurance,Medicare, Medicaid, managed care, long-term care, and other issues.

One of the greatest challenges for patientsand the health-interested public is evalu-ating the quality of health informationand care they receive. An increasing num-ber of health care portals are providinginformation and guidance in evaluatingproviders and the quality of care.

DoctorQuality.com and Quackwatch.comare two examples of initiatives to provideguidance on health information and care.DoctorQuality.com is a growing onlineservice that provides information andresources of use to providers, payors, andthe public in understanding and improv-ing quality of care. For consumers, thissite gathers and provides data on doctorratings and hospital errors, and providespatients with best practice guidelines tohelp in understanding and managing dis-ease. DoctorQuality.com has collectedpublic data for all U.S. hospitals, includingvolume of cases, regulatory and accredita-tion status, and services available. For U.S.physicians, DoctorQuality.com collectsdata including physician’s background andtraining (such as board certification),years in practice, and any sanctionsagainst their license (such as convictions,substance abuse, or fraud). Reported per-formance data is collected from physi-cians, hospitals, third-party sources (suchas managed care plans), or publicly avail-able state or federal data.

Quackwatch.com is a nonprofit organiza-tion with a Web site run by a physicianwhose purpose is to identify and debunkhealth-related frauds, myths, fads, and fal-lacies. This site works with volunteers toinvestigate questionable claims for med-ical procedures, cures, products and out-comes as well as misleading or illegalhealth products marketing. Patients andthose interested in health can receive reg-ular e-mail updates on various issues andconcerns, submit questions, or reportquestionable claims and practices.

Sites such as these are now augmentingthe thousands of informal networks ofindividuals who share experiences, anec-dotes, gossip, rumors, facts and informa-tion of all kinds in Web site chat roomsand forums. Many health care organiza-tions and providers are well aware of theimportance and power of such informalnetworks in affecting patient and publicperceptions and steering patients towardsparticular therapies, practitioners, orinstitutions.

An increasing number of health care portalsare providing information and guidance in eval-uating providers and the quality of care.

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The World Health Organization (WHO) is pursuing a novel course to enhance thecredibility of health information offeredworldwide. The WHO applied to theInternet Corporation for Assigned Namesand Numbers (ICANN) to become the registrar of a new top level domain(TLD)– health. Within the ICANN frame-work, new top level domains may berestricted or unrestricted. A restricted TLD,empowers the sponsoring organization toset policy on how the TLD is allocatedand used, including who may apply for aregistration within the domain, and whatuses may be made of those registrations.As registrar of the .health domain, theWHO would have the ability to requiredomain name holders to adhere to a common set of standards for online healthcontent and services. Though not yet suc-cessful, this effort illuminates the importanceof establishing worldwide standards of care.

Efforts such as these to promote standardi-zation and evaluation of care are contro-versial and complex, but inevitable. Thereare many unresolved difficulties in defin-

ing, tracking, measuring, and assessinghealth claims and information, profession-al competence, patient compliance, andclinical outcomes. Nevertheless, the objec-tive of defining, measuring, and enforcingstandards in all of these areas has longbeen embraced. Professional societies,national and state regulatory and accredit-ing bodies, and not uncommonly, thecourts, all have had a role in developing,promulgating, evaluating, and enforcingprofessional ethics, truth in advertising,product safety, and practice standards.Individuals and communities too havealways formed opinions and points of viewabout practitioners, institutions, products,and information. That the Internet is nowserving as a platform for the migration andfurther development of this process onlineshould not be surprising. The vast data-generation and -handling technologiescoming online guarantee that there willbe unprecedented, ongoing developmentof resources to assess quality, safety, per-formance, outcomes, and other healthcare metrics.

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Findings

The proliferation of Internet health careinformation provides patients and ahealth-interested public with extraordi-nary new access to health-related infor-mation that can be used to betterunderstand health and improve patients’participation in the management of theirhealth and care. However, few patientsor consumers have the knowledge orexperience to assess the quality and util-ity of much of this information. Researchsuggests that patients and the publicneed and prefer local, hospital orprovider recommended sources of reli-able health information.

Recommendations

AHCs should take a leadership role inidentifying, making available, and assur-ing quality health care information fortheir patients and the public over theInternet.


AHCs should create or seek partner-ships in a Web site or sites that providetheir patients and public with relevant,reliable, timely and trustworthy healthinformation and educational materials.AHCs not yet ready or able to createtheir own sites can often partner in theeditorial and quality control of e-healthcontent for Web sites otherwise availableto patients and the public.

Public e-Health Knowledge and Empowerment Findings,Recommendations, and Implementation Guidelines

The vast data-generation and -handlingtechnologies coming online guarantee thatthere will be unprecedented, ongoingdevelopment of resources to assess quality,safety, performance, outcomes, and otherhealth care metrics.

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The Internet enables significant advancesin standardization and empowerment inhealth care. Standardization allows data tobe shared across systems, users, and sites,contributing to the de-balkanization ofhealth care. This, in turn, enables thedevelopment of unprecedented improve-ments in the speed, accuracy, and cost ofhealth care, information utilization, andcare management. The empowerment ofpatients and providers through the cre-ation of new technologies and the diffu-sion of new knowledge providesopportunities for gains in professional-directed and self-managed health andcare. Both are necessary to progresstowards a more cost effective and effica-cious health care system.

By themselves, standardization and empow-erment are not sufficient to the develop-ment of a health care system that providesquality, affordable health care services forthe entire population. The actuarial,resource utilization, and other metricsrequired to provide the best value and out-comes in managing health services for agroup or population depends upon the abil-ity to define, measure, and then work withthe group. Both nationally and locally, aprogressive, value-driven health systemremains unworkable absent an inclusivesystem of universal coverage for healthservices. Although the Internet as a plat-form may or may not help catalyze move-ment towards universal access to affordablehealth insurance coverage, it is proving tobe a platform upon which both public andprivate payors are learning a great dealabout value-driven health services.

Since the early 1960s, the Medicare andMedicaid programs provide coverage for health care services for many of the most

vulnerable in the population. Employer-based health insurance systems providecoverage for most of the non-poor andnon-elderly employed and their families.Yet, consistently since the 1960s, about 15percent of the population has not beencovered by any of these programs. In itsmost recent report, published September28, 2000, the U.S. Census Bureau reported42.6 million uninsured at the end of 1999,down from 44.3 million in 1998 – a dropof 3.8 percent. This was the first droprecorded by the agency since it begancounting the uninsured in 1987, loweringthe percentage of uninsured Americansfrom 16.3 to 15.5 percent. The bulk of thedecline was attributed to the expansion ofemployment-related health insurance.Nevertheless, projections suggest that thenumber of uninsured could grow signifi-cantly during a substantial downturn inthe economy (U.S. Census Bureau, 2000).

The rapid transition over the last decadefrom the traditional fee-for-service insur-ance system to a managed care model hasserved, if nothing else, to provide unprece-dented public and professional exposureto the choices and trade offs necessitatedby a more cost-sensitive health care mar-ket place. Managed care organizations andself-insured employers have developedincreasingly sophisticated systems formanaging utilization, population health,patient education, and actuarial risk (oftenshifting it to providers). Providers arelearning more efficient utilization, patienteducation and care, and risk (includingpopulation health) management. Patientsand consumers are becoming more awareof the costs and consequences ofunhealthy behaviors and environmentalconditions; they are becoming moreinformed buyers of health care products

Universal Coverage and Value-driven Health Care

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and services; and they are becoming moreactive participants and advocates in man-aging their health and care.

Despite these gains, it is fair to say thatfew providers, payors, or patients are veryhappy with the state of the health care sys-tem. Providers have had to cope with newproductivity and efficiency demands andsometimes drastically reduced paymentsfor services. Health care workers and pro-fessionals universally report less satisfac-tion and more stress in their workenvironments. Both payor and providerorganizations have been forced to engineersignificant changes in benefit plans, prod-uct lines, payments systems, regulatoryand compliance rules. Many payors andproviders have had to reorganize, reduce,or eliminate services, infrastructure, andstaff. Patients and the public have beendissatisfied with many cost reduction poli-cies that sacrifice provider choice and per-haps service quality. All have been affectedby rising drug and device prices. Makingall of these challenges and changes moredifficult is the absence of clear policies orsystem goals, except perhaps the goal ofcost containment, to guide planning anddecision-making at the national or evenregional or local levels.

The Blue Ridge Group believes that thewidespread dissatisfaction from all quar-ters with the existing system indicates thatthe health care system must and will con-tinue to change. Absent significant nation-al policy initiatives, the market place andconsumer pressure are likely to be the twostrongest drivers of system change.HMOs, insurers, self-insured employers,and other payors face challenging andconflicting cost control and consumerpressures that are increasingly difficult to

manage. Many payors are working tomanage this conflict by leveraging theInternet to develop health coverage thatprovides new levels of information andchoice to consumers and patients. About20 percent of payors currently enablemembers, employers and/or providers toconduct online transactions (FirstConsulting Group, 2000). Along withgreater information and choice, it is likelythat payors are also going to introducenew coverage models that require andenable consumers to assume increasedresponsibility for managing the costs andadministration of their care (Goldsmith,2000).

Blue Cross/Blue Shield of California(blueshieldca.com) subscribers can accesshealth benefits information, researchproviders’ backgrounds, choose careproviders and provide quality assuranceand customer satisfaction feedback. TheirMyLifePath.com site also offers the fullrange of consumer health news and infor-mation. Blue Cross/Blue Shield of SouthCarolina provides online access to a vari-ety of information and functions formembers, employers, providers, and bro-kers. Members can use the online MyInsurance Manager to check claims status,inpatient and outpatient eligibility and

The Blue Ridge Group believes that the wide-spread dissatisfaction from all quarters withthe existing system indicates that the healthcare system must and will continue to change.

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authorization status, the status of bills,and how much they have paid towardstheir deductible. Payors like HighmarkBlue Cross/Blue Shield of Pennsylvania(highmark.com), are also starting to sellhealth insurance directly to consumersonline, thereby removing the middleman/insurance brokers (many of whom arescrambling to Web-enable their businesses).Employer-payors are increasingly takingadvantage of the Internet to manage or out-source human resource functions.

By moving these capabilities online, payorscan use the Internet platform to furthercustomize information, services, andfunctions while collecting, tracking, andanalyzing extraordinary new dataresources by which they can reduce costsand manage care. They can customize anddeliver interactive disease managementresources to high-risk subscribers, trackvariability in patient risk and cost indelivery systems, and promote informedchoice concerning invasive versus non-invasive or alternative therapies. By link-ing patients with their physicians, eitherwith automatic alerts or manual querying,they can head off emergency room visitsand other costly inefficiencies or mis-takes. And of course in connecting direct-ly with providers and employers, payorscan accelerate claims and eligibilityreview, instantaneously make payments,and automatically bill patients’ creditcards for co-pays.

By employing an Internet platform, payorshave an opportunity to introduce improvedefficiencies and new levels of customer sat-isfaction. Based on estimates from otherindustries, e-enabling administrative andtransaction processes could yield cost sav-ings in the billions of dollars. For instance,

the retail banking industry put the costsfor manual teller transactions at $1.07 pertransaction. Moving transactions to theInternet reduced these costs to $.10 or less.Traditional paper systems for claims pro-cessing cost an average of $7 per claim tosubmit. The same claims submitted overthe Internet cost $.30. Potential savingsfrom electronic management and transac-tions for the payor industry have been esti-mated to be $18 billion (Darlington,1998).

As payors and employers Web-enable sub-scriber information and functions, theyare looking for opportunities to meet con-sumer demand for choice while bolsteringtheir own risk management strategies.The traditional model for employee healthbenefits is built around employers provid-ing a finite set of benefits options (some-times only one) from which theiremployees can choose. Employees oftenare not satisfied with the limited choice ofcoverage and providers. A new modelwould have employers simply providing adefined contribution to the costs of cover-age (plus perhaps catastrophic coverage),empowering the employee to pick andchoose from a broad menu of benefits andoptions offered by an employer retained e-broker, or to go out into the market placeand choose their own plans. Health planswould compete for employees’ dollars asemployees build custom-designed virtualhealth plans or choose among health net-works on the Web.

The theoretical appeal of defined contri-bution systems is hard to argue with,since it appears to fit both consumerdesire for empowerment and payors’ andemployers’ desires to control costs andshare or shift risks to those who incur

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the costs. Nevertheless, this will not be aneasy system to implement. Among thecomplex issues to be addressed are:

• The implications of risk pool fragmentation, and whether new concepts of risk and newgroup-identity structures must or can be developed;

• Affordability and cost stability for consumers;

• The future of medical management and ability to track utilization, claims, and other data;

• Customer service and consumer protection;

• Identifying incentives to improve care coordination;

• The cost of catastrophic umbrella/out of network coverage; and

• Information and data management challenges in supporting an open benefits market.

So while there is a significant opportunityfor payors to recast their businesses, foremployers to reduce their benefits costs,and for employees to achieve new levelsof health market choice, there are alsodaunting implementation challenges.These challenges ensure that there will bean incremental transition towards definedcontribution, employee and consumerchoice coverage models, likely extendingthrough the next decade.

Nevertheless, change in this directioncould have significant implications for thehealth care system. Progressively empow-ering consumers with increasingly sophis-ticated information systems by which toparticipate in a competitive market placefor health care coverage could have a sig-nificant impact on consumers’ andpatients’ knowledge, experiences, and

expectations. It is possible to foresee avariety of future developments.

For instance, the example set by employ-er contributions could be extended bypopular demand to federal and state pay-ors. There are already many advocates forthe creation of Medicare and Medicaiddefined contribution programs, for theexpansion of the Federal EmployeesHealth Benefits Program (FEHB), and fortax credits for individual and familyhealth coverage purchases. Unexpectedcomplications and problems with estab-lishing fair and open markets in coverageoptions could create a consumer backlashagainst the market-based approach.Would the generalization of the definedcontribution model result in increasedcooperation or competition between pub-lic and private sector payors and pro-grams? How much of a regulatoryframework would be required and howtruly “free” could or would such a marketbe? These and many other critical publicpolicy issues would have to be addressedbefore a defined contribution modelcould be implemented.

The movement towards a defined contri-bution model is also likely to refocus andperhaps intensify the continuing debateon universal coverage. It could well leadalso to the development of new knowl-edge and new information systems thatwill provide the online technical and datafoundations for revolutionizing under-writing and creating new mechanisms forextending coverage universally.

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Findings

• Payors and employers, along with spe-cialized vendors and other health careorganizations, are using the Internet toprovide new levels of information, service,and functionality to consumers, patients,providers, and others in the manage-ment of health care and insurance cov-erage. There will be gradually increasingopportunities for AHCs and otherprovider organizations to adopt or out-source HR and benefits managementcapabilities for their employees.

• In order to better manage risk andcost, payors and employers are explor-ing “defined contribution” strategies thatleverage advancing information technol-ogy and consumer/employee desire formaximum choice of benefits andproviders.

• While it is impossible to predict withcertainty, the trajectory of payor andemployer online technologies, capabili-ties, and strategies suggests that manynew and important tools could be creat-ed for use by both public and privatepayors to enhance the technical anddata foundations necessary for progressin extending coverage universally.

Recommendations

• AHCs and other provider organizationsshould explore opportunities to vastlyimprove relationships with payorsthrough online transaction and informa-tion processing. AHCs should alsoexplore opportunities to better manageand/or outsource in-house HR functions.

• AHCs should seek to work closely with

payors and employers as well as policy-makers to ensure that the evolution ofconsumer directed medical and benefits

management strategies and paymentsystems track and report information onquality, outcomes, and other metrics ofcare necessary to informed consumerchoice of plan and provider.

• AHCs should continue to advocate forpublic policy that is more supportive ofe-health care, including addressing limi-tations on reimbursement for telemedi-cine, state barriers to e-health, andInternet access issues. Progress in theseareas is vital to achieving universal cov-erage and the transition to a value-drivenhealth care system.

Universal Coverage and Value-driven Health CareFindings and Recommendations

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The Internet is rapidly becoming amajor force in the transformation ofhealth care. It enables the standardizationof health industry data and allows con-nectivity for transactions and communica-tions. It empowers providers and patientsin the care process and is likely to con-tribute significantly to the development ofinsurance coverage that provides univer-sal access to quality healthcare.

For AHCs, the Internet and Internet-based technologies serve many functionsand can be employed to support core mis-sions in research, education, and patientcare. In turn, AHCs and their faculties arewell positioned to play critical roles inshaping and enhancing online healthresources and capabilities. The Internet isspawning many of the tools and technolo-gies necessary to the establishment of avalue-driven health care system. AHCsand other health care organizations arewell advised to take full advantage of thisextraordinary opportunity.

Conclusion

It is not the strongest of the species thatsurvives, not the most intelligent, but the one most responsive to change.

– Charles Darwin

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The Blue Ridge Academic Health Groupseeks to take a societal view of health andhealth care needs and to make recommen-dations to academic health centers to helpthem create greater value for society. TheBlue Ridge Group also recommends pub-lic policies to enable AHCs to accomplishthese ends.

Three basic premises underlie this mis-sion. First, health care in the UnitedStates is experiencing a series of transfor-mations that ultimately will require newapproaches in health care delivery sys-tems, education, and research. Second,the recent upheavals in health care havebeen largely driven by financial objec-tives. Yet the potential exists for funda-mental changes in health care to improvehealth and manage costs. Analysis andevaluation of the ongoing evolution inhealth care delivery must address thisimpact on the health of individuals andthe population, as well as on cost. Third,AHCs play a unique role in the U.S.health care system as they develop, apply,and disseminate knowledge to improvehealth. In so doing, they assume responsi-bilities and encounter challenges otherhealth care provider institutions do notbear. As a result, AHCs face greater risksand opportunities as the U.S. health caresystem continues to evolve.

The Blue Ridge Group was founded inMarch 1997 by the Virgina Health PolicyCenter (VHPC) at the University ofVirginia and the Health Market Unit lead-ership at Ernst & Young, LLP (now CapGemini Ernst & Young, CGE&Y). Groupmembers were selected to bring together

seasoned, active leaders with a broadrange of experience in and knowledge ofacademic health centers in the UnitedStates. Other participants are invited toBlue Ridge Group meetings to bring addi-tional expertise or perspectives on a specifictopic.

Blue Ridge Group members collectivelyselect the topics to be addressed at annualmeetings. Criteria for selection of reporttopics include relevance to AHCs’ opera-tions, consistency with AHCs providingvalue to society, the likelihood of beingable to make specific recommendationsthat will lead to productive action byAHCs or other organizations, and theability to frame useful recommendationsduring two-day meetings.

Before each meeting, an extensive litera-ture review is conducted. During themeeting, participants reflect on emergingtrends, share experiences from AHCs, andhear presentations on specific issues. Mostof the working session is dedicated to adiscussion of what AHCs can and shouldbe doing in a particular area to achievevisible progress, or a discussion of whatpublic and private policy and philanthrop-ic organizations can do to facilitate theefforts of AHCs to fulfill their societal mis-sion. The results of the group’s delibera-tions are presented in brief reports that aredisseminated to targeted audiences.

About the Blue Ridge Academic Health Group

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David Blumenthal, M.D., M.P.P.DirectorInstitute for Health Policy The Massachusetts General HospitalProfessor of Medicine and Professor ofHealth Care Policy Harvard Medical School

Dr. Blumenthal is director, Institute forHealth Policy and physician at TheMassachusetts General Hospital/PartnersHealth Care System in Boston,Massachusetts. He is also professor ofmedicine and professor of health care pol-icy at Harvard Medical School. Dr.Blumenthal previously served as seniorvice president at Boston’s Brigham andWomen’s Hospital, as well as executivedirector of the Center for Health Policyand Management and lecturer on publicpolicy at the John F. Kennedy School ofGovernment at Harvard. Dr. Blumenthalis a member of the Institute of Medicineof the National Academy of Sciences andserves on several editorial boards, includ-ing The New England Journal of Medicine,American Journal of Medicine, Journal ofHealth Politics, Policy and Law, and theBulletin of the New York Academy ofMedicine. He serves on advisory commit-tees to the National Academy of Sciences,the Institute of Medicine, the NationalAcademy of Social Insurance, and severalfoundations. He is currently executivedirector for The Commonwealth FundTask Force on the Future of AcademicHealth Centers and Chairman of theboard of the Massachusetts Peer ReviewOrganization. Dr. Blumenthal is also thefounding chairman of the Academy forHealth Services Research and HealthPolicy, the national organization of health

services researchers.

Enriqueta C. Bond, Ph.D. President Burroughs Wellcome Fund

Dr. Bond is the president of the BurroughsWellcome Fund. She formerly held anumber of research and administrativepositions at the Institute of Medicine,National Academy of Sciences;Department of Medical Sciences, SouthernIllinois University School of Medicine;and the Biology Department at ChathamCollege. Dr. Bond also serves on severaladvisory committees and boards, some ofwhich include the Council of the Instituteof Medicine and the National Center forInfectious Diseases, Centers for DiseaseControl and Prevention. She has authoredand co-authored more than 50 publica-tions and reports in science policy.

Robert W. Cantrell, M.D.Vice President and Provost University of Virginia Health System

Dr. Cantrell is vice president and provostfor the Health System at the University ofVirginia. He is the former president of theAmerican Academy of Otolaryngology-Head and Neck Surgery. As a captain inthe U.S. Navy, he served as chair ofOtolaryngology-Head and Neck Surgery atthe Naval Regional Medical Center in SanDiego, California. Dr. Cantrell was alsothe Fitz Hugh Professor and chair of theDepartment of Otolaryngology-Head andNeck Surgery at the University of VirginiaSchool of Medicine. He also has been aconsultant to the Surgeon General of theU.S. Navy and to the National Institutesof Health (NIH). Dr. Cantrell is a memberor fellow of 33 otolaryngological societies

About the Core Members

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and has taken an active leadership role inmany, including the American College ofSurgeons, the American Society for Headand Neck Surgery, and the AmericanBroncho-Esophagological Association. Dr.Cantrell received the Mosher Award forclinical research, has published numerousarticles, and lectured nationally and inter-nationally.

Don E. Detmer, M.D.Dennis Gillings Professor of Health ManagementDirectorCambridge University HealthUniversity of Cambridge

Dr. Detmer heads the health policy andmanagement center within the JudgeInstitute of Management at CambridgeUniversity’s business school. He chairs theBoard on Health Care Services of theInstitute of Medicine and is a board mem-ber of several organizations, including theChina Medical Board of New York, theNuffield Trust in London, and theAmerican Journal of Surgery. He hasauthored numerous scientific publica-tions. Dr. Detmer earned his medicaldegree at the University of Kansas afterundergraduate studies there and atDurham University of England. He con-ducts his work with the Blue Ridge Groupthrough a professorship at the Universityof Virginia where in the past he served asvice president and provost for HealthSciences and University Professor.

Michael A. Geheb, M.D.Professor of Medicine and Senior VicePresident for Clinical ProgramsOregon Health Sciences University

Dr. Geheb is professor of medicine andsenior vice president for ClinicalPrograms at Oregon Health SciencesUniversity. Dr. Geheb has also served asprofessor of medicine, and was the firstdirector and chief executive officer of theUniversity of Alabama at BirminghamHealth System. Prior to that, Dr. Gehebwas associate dean for Clinical Affairs,and director of Clinical Services at theState University of New York at StonyBrook University Medical Center. Dr.Geheb’s professional associations includethe American Federation for ClinicalResearch; the Board of Directors of theUniversity Hospital Consortium; and theAmerican Board of Internal Medicine’sBoard of Directors. Dr. Geheb is co-editorof the textbook Principles and Practice ofMedical Intensive Care and co-editor for the Critical Care Clinicsseries. He also speaks frequently tonational audiences on health care policyissues related to academic productivityand financial models for academic clinicalenterprises.

Jeff C. Goldsmith, Ph.D. PresidentHealth Futures, Inc.

Dr. Goldsmith’s consulting firm assists awide range of health care organizationswith environmental analysis and strategydevelopment. He is a director of CernerCorporation, a health care informatics

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firm, and of Essent Healthcare, a hospitalmanagement firm, as well as a member ofthe Board of Advisors of Burrill andCompany, a private merchant bank inbiotechnology and health sciences. He iscurrently an associate professor of med-ical education at the University ofVirginia. He is a former lecturer in theGraduate School of Business at theUniversity of Chicago. He has also lec-tured on health services management andpolicy at the Harvard Business School, theWharton School of Finance, JohnsHopkins, Washington University, and theUniversity of California at Berkeley. Dr.Goldsmith has served as national advisorfor health care for Ernst & Young LLP,was director of Planning and GovernmentAffairs at the University of ChicagoMedical Center, and special assistant tothe dean of the Pritzker School ofMedicine. Dr. Goldsmith has written forthe Harvard Business Review and has beena source for articles on medical technolo-gy and health services for The Wall StreetJournal, The New York Times, BusinessWeek, Time and other publications. He is amember of the editorial board of HealthAffairs. He earned his doctorate inSociology from the University of Chicagoin 1973.

Michael M.E. Johns, M.D.Executive Vice President for Health AffairsEmory UniversityDirectorThe Robert W. Woodruff Health SciencesCenterChairman of the Board and Chief ExecutiveOfficerEmory Health Care

Dr. Johns heads Emory’s academic and

clinical institutions and programs in thehealth sciences and is a professor in theDepartment of Surgery. A former dean ofthe Johns Hopkins School of Medicine, hewas professor and chair of theDepartment of Otolaryngology-Head andNeck Surgery at Johns Hopkins. Beforethat he was assistant chief of theOtolaryngology Service at Walter ReedArmy Medical Center. Dr. Johns is amember of the Institute of Medicine, andthe Executive Council of the Associationof American Medical Colleges and a fel-low of the American Association for theAdvancement of Science. He serves on theGoverning Boards of the NationalResearch Council and the Clinical Centerof the National Institutes of Health, andon the advisory committee of the directorof the Centers for Disease Control andPrevention. He is the president of theAmerican Board of Otolaryngology, editorof the Archives of Otolaryngology-Head andNeck Surgery, and a member of the Boardof Trustees of Genuine Parts Company.Dr. Johns received his Bachelor’s degreeand continued with graduate studies inbiology at Wayne State University. Heearned his M.D. at the University ofMichigan School of Medicine.

Peter O. Kohler, M.D. PresidentOregon Health Sciences University

Dr. Kohler is president of Oregon HealthSciences University. After holding posi-tions at the National Institutes of Health(NIH), he became professor of medicineand chief of the Endocrinology Divisionat Baylor College of Medicine. Later, heserved as chairman of the Department ofMedicine at the University of Arkansas

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and then as dean of the Medical School atthe University of Texas Health ScienceCenter in San Antonio. Dr. Kohler hasserved on several boards. He has beenchairman of the NIH EndocrinologyStudy Section and chairman of the Boardof Scientific Counselors for the NationalInstitute of Child Health and HumanDevelopment. Currently, he is chairmanof the Institute of Medicine Task Force onQuality in Long-term Care and past-chairof the Board of Directors of theAssociation of Academic Health Centers.Dr. Kohler received his B.A. from theUniversity of Virginia and earned his M.D.at Duke Medical School.

Edward D. Miller, Jr., M.D.Dean and Chief Executive OfficerJohns Hopkins Medicine

Dr. Miller is chief executive officer ofJohns Hopkins Medicine. His formerposts include chairman of the Departmentof Anesthesiology and Critical CareMedicine; Interim dean of the School ofMedicine; professor of anesthesiology andsurgery and medical director of theSurgical Intensive Care Unit at theUniversity of Virginia; E.M. PapperProfessor at Columbia University; andchairman of the Department ofAnesthesiology in the College ofPhysicians and Surgeons. Dr. Miller hasauthored and co-authored more than 150scientific abstracts and book chapters. Hereceived his A.B. from Ohio WesleyanUniversity and his M.D. from theUniversity of Rochester School ofMedicine and Dentistry.

Jeffrey Otten, M.A., M.B.A.PresidentBrigham and Women’s Hospital

Mr. Otten is president of Brigham andWomen’s Hospital where he previouslyserved as executive vice president andchief operating officer. Before joiningBrigham and Women’s, Mr. Otten waschief operating officer for the Hospital ofthe University of Pennsylvania inPhiladelphia and associate director andchief financial officer at UCLA MedicalCenter in Los Angeles. He has also servedin senior management positions at LosAngeles County – USC Medical Centerand Harbor – UCLA Medical Center. Inaddition, he has been a consultant inhealth care strategy and financial manage-ment. He has held teaching positions atCalifornia State University Los Angeles,UCLA, Wharton, and the Harvard Schoolof Public Health. Mr. Otten is the immedi-ate past chairman of the MassachusettsHospital Association (MHA). He is direc-tor of corporate development of theMassachusetts Heart Association, chair-elect of the Board of Trustees of theGreater Boston Food Bank, a member ofthe Boston 2000 Consortium, and vicechair and executive committee member ofUniversity Healthsystems Consortium.Mr. Otten also serves on the Board of theCouncil of Teaching Hospitals at theAssociation of American MedicalColleges. He received a Master of Artsdegree in 1975 and a Master of BusinessAdministration degree in 1983 from theUniversity of California at Los Angeles.

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Mark L. Penkhus, M.H.A., M.B.A.Chief Executive Officer and Executive DirectorVanderbilt University Hospital

Mr. Penkhus is chief executive officer andexecutive director of Vanderbilt UniversityHospital. Prior to joining Vanderbilt, Mr.Penkhus was a partner and business unitleader for Healthcare Consulting (Mid-Atlantic area) in Washington D.C. forErnst and Young LLP, and served as anational leader for academic health cen-ters. During his career, he has workedwith a variety of organizations as an inno-vator, and change agent with a specialemphasis on strategic, operational, andfinancial performance improvement. Mr.Penkhus received a B.S. degree from IowaState University, a master’s degree inHospital and Health Care Administrationfrom the University of Iowa, and anM.B.A. from Rensselaer PolytechnicInstitute in New York. He is also a gradu-ate of the Advanced ManagementProgram, Wharton School of Business, atthe University of Pennsylvania. He is afellow of the American College ofHealthcare Executives (ACHE), a fellowin Project HOPE, Washington D.C., and amember of the Johns Hopkins UniversitySchool of Hygiene and Public Health,Department of Health Policy andManagement. Mr. Penkhus serves on sev-eral non-profit and for-profit boards inTennessee and nationally.

Paul L. Ruflin, M.B.A. Vice PresidentHealth/Managed Care Consulting PracticeCap Gemini Ernst & Young U.S., LLC

Mr. Ruflin leads the health/managed careconsulting practice for Cap Gemini Ernst& Young U.S., LLC (CGE&Y) and isresponsible for all business developmentand service delivery to CGE&Y’s provider,managed care, and health/technologyclients. He has over twenty years of healthcare consulting experience with a focuson developing and implementing strate-gies to transform health organizationsincluding major providers and academicmedical centers. He previously served asdirector for business transformation serv-ices for the health consulting practicewhere he had national responsibilities foroperations improvement, merger integra-tion, turnaround, medical management,physician practice management, supplychain, clinical improvement, and benefitsrealization services. Mr. Ruflin is a CPA,and holds a M.B.A. from Bowling GreenState University and a B.A. in Accountingfrom Walsh College. He is a member ofAICPA, Ohio Society of CPAs, HospitalInformation Management Systems Society,and Healthcare Financial ManagementAssociation.

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George F. Sheldon, M.D.Chairman and Professor Department of SurgeryUniversity of North Carolina at Chapel Hill

Dr. Sheldon’s background in graduatemedical education spans four institutions:Kansas University, Mayo Clinic, Universityof California at San Francisco, andHarvard University. He is currently chair-man and professor, Department of Surgeryat the University of North Carolina atChapel Hill and was formerly professor ofsurgery in the Department of Surgery atthe University of California, SanFrancisco. He has held several nationalappointments, including: president of theAmerican Surgical Association and chair-man of both the American Board ofSurgery and Council on Graduate MedicalEducation. He is currently chair of theAssociation of American Medical Colleges.He was past president of the AmericanCollege of Surgeons, and past chair of theCouncil of Academic Societies of theAssociation of American Medical Colleges.He has published 195 articles and bookchapters and co-authored eight books.

Katherine W. Vestal, Ph.D.Vice PresidentHealth Consulting Practice Cap Gemini Ernst & Young U.S., LLC

Dr. Vestal leads the academic health cen-ter sector for Cap Gemini Ernst & Young’s(CGE&Y) health consulting practicewhere she focuses on large-scale organiza-tional change for a wide range of healthcare delivery organizations. Prior to join-ing CGE&Y, Dr. Vestal held several exec-utive positions in academic health centersand taught at the graduate level at theUniversity of Texas. Her backgroundincludes over 25 years of operations man-agement and consulting in the areas ofbusiness transformation, post merger inte-gration, and clinical management. Shespeaks nationally on issues of organiza-tional improvement and is a MalcolmBaldrige National Quality AwardExaminer. Dr. Vestal received a B.S.N.from Texas Christian University, an M.S.from Texas Women’s University, and aPh.D. from Texas A & M University. Sheis a Fellow of the Johnson and JohnsonWharton School of Finance, AmericanCollege of Healthcare Executives, and theAmerican Academy of Nursing.

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Jordan J. Cohen, M.D.President and Chief Executive OfficerAssociation of American Medical Colleges

Dr. Cohen’s career in academic medicinespans almost 40 years. Most recently, heserved as dean of the medical school andprofessor of medicine at the StateUniversity of New York at Stony Brook,and president of the medical staff atUniversity Hospital. Prior to serving asdean at SUNY-Stony Brook, Dr. Cohenserved as professor and associate chair-man of Medicine at the University ofChicago-Pritzker School of Medicine, andphysician-in-chief and chairman of theDepartment of Medicine at the MichaelReese Hospital and Medical Center. Hehas held medical faculty positions atHarvard, Brown, and Tufts universities.Dr. Cohen is also a former president ofthe medical staff at the New EnglandMedical Center Hospital in Boston. Hehas held a wide variety of leadership posi-tions in almost all aspects of academicmedicine, including chair of the AmericanBoard of Internal Medicine and theAccreditation Council for GraduateMedical Education, as well as president ofthe Association of Program Directors ofInternal Medicine. A member of theAmerican College of Physicians since1978, he has served as vice chair of itsBoard of Regents and Chair of itsEducation Policy Committee; he wasawarded a mastership from the college in1993. Concurrent with his leadership ofthe AAMC, Dr. Cohen also serves on theBoard of Directors of the Foundation forBiomedical Research andResearch!America, and is a Trustee of theEducational Commission for ForeignMedical Graduates. He is a member of the

Special Medical Advisory Group of theDepartment of Veterans Affairs. In 1994,Dr. Cohen was named a member of theNational Academy of Sciences Institute ofMedicine. He is a graduate of YaleUniversity and Harvard Medical Schooland completed his postgraduate trainingin internal medicine in Harvard service atthe Boston City Hospital. He completed afellowship in nephrology at the Tufts-NewEngland Medical Center. He is the authorof more than 100 publications and is edi-tor of Kidney International’s NephrologyForum.

Dennis Gillings, Ph.D.Chairman and Chief Executive OfficerQuintiles Transnational Corporation

Dr. Gillings began providing statisticalconsulting and data management servicesto pharmaceutical clients in 1974 duringhis tenure as professor of biostatistics atthe University of North Carolina inChapel Hill. Quintiles grew from his con-sulting activities and was incorporated in1982. Today, Quintiles has 19,000employees in 38 countries around theworld. It is the global market leader inhelping pharmaceutical, biotechnologyand medical device companies develop,market and sell their products. Dr.Gillings devotes much of his time tostrategic planning for continued interna-tional expansion of Quintiles. In addition,he oversees day-to-day operations of thecompany. Dr. Gillings has consulted forthe pharmaceutical and biotechnologyindustries and has worked with a numberof agencies, including the NationalCancer Institute, the National Institute forDental Research, and the Institute ofMedicine. He has published widely in

About the Invited Participants

48

scientific and medical journals. Dr. Gillings’research interests include statistical meth-ods in the analysis of clinical trials andmathematical models to improve thedelivery of health services in fields such ascancer, perinatal care, cardiovascular dis-ease and rheumatology. Dr. Gillings serveson several boards and councils, includingthe University of North Carolina School ofPublic Health Dean’s Advisory Council;the Graduate Education AdvancementBoard of the Graduate School of theUniversity of North Carolina at ChapelHill; North Carolina Institute of Medicine;ICAgen, Inc., Triangle Pharmaceuticals,Inc., and Healtheon/WebMD. Dr. Gillingsreceived a diploma in MathematicalStatistics from Cambridge University in1967 and a Ph.D. in Mathematics from theUniversity of Exeter, England, in 1972. Heserved for more than 15 years as professorat the University of North Carolina atChapel Hill.

John P. Glaser, Ph.D.Vice President and Chief Information OfficerPartners HealthCare System, Inc.

Dr. Glaser is vice president and chiefinformation officer, Partners HealthcareSystem, Inc. Previously, he was vice presi-dent, Information Systems at Brigham andWomen’s Hospital. Prior to Brigham andWomen’s Hospital, Dr. Glaser managedthe Healthcare Information Systems con-sulting practice at Arthur D. Little. Dr.Glaser was the founding chairman of theCollege of Healthcare InformationManagement Executives (CHIME) and ispast president of the HealthcareInformation and Management SystemsSociety (HIMSS). He was the founding co-chair of the Affiliated Health InformationNetworks of New England, is a member

of the advisory board of CounterpartCapital, and a fellow of HIMSS andCHIME and a member of the AmericanCollege of Medical Informatics. Dr. Glaserhas been awarded the John Gall award forhealth care CIO of the year. PartnersHealthcare has received several industryawards for its effective and innovative useof information technology. Dr. Glaser hasbeen a member of National Academy ofSciences studies on the role of theInternet in health care and health careconfidentiality and security. He is on theeditorial boards of CIO Magazine,Healthcare Informatics and Topics in HealthInformation Management. He has pub-lished over fifty articles and a book on thestrategic application of information tech-nology in health care. He holds a Ph.D. inHealthcare Information Systems from theUniversity of Minnesota.

Andrew VazVice PresidentNational Health e-Commerce PracticeCap Gemini Ernst & Young U.S., LLC

Mr. Vaz is vice president managing theNational Health eCommerce practice forCap Gemini Ernst & Young U.S., LLC. Heleads the development of the firm’smethodology and intellectual capital inthe areas of e-Commerce and businessstrategy for both the provider and payorsectors. Mr. Vaz also holds responsibilityfor the firm’s health care “dot com” prac-tice and health new ventures initiatives.Prior to his current role, he was the man-aging partner of Ernst & Young’sNortheast U.S. health practice and thenational director of the Canadian healthcare practice. Mr. Vaz’s consulting careerhas spanned strategy and business plan-ning, business transformation and the

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management of change. His client basehas included academic medical centers,large integrated delivery systems, managedcare companies and most recently, “dotcoms” in the health care space. He hassuccessfully led the development of e-Commerce strategies for world class healthorganizations, enterprise wide businesstransformation and re-engineering of aca-demic medical centers in Canada and theU.S., facilitated numerous mergers andjoint ventures, and developed leading edgestrategies for organizations in the provider,payor and life sciences sectors.

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Blue Ridge Academic Health Group.1998a. Academic Health Centers: GettingDown to Business. Washington, D.C.: CapGemini Ernst & Young.

Blue Ridge Academic Health Group.1998b. Promoting Value and ExpandedCoverage: Good Health is Good Business.Washington, D.C.: Cap Gemini Ernst &Young.

Blue Ridge Academic Health Group.2000a. Into the 21st Century: AcademicHealth Centers as Knowledge Leaders.Washington, D.C.: Cap Gemini Ernst &Young.

Blue Ridge Academic Health Group.2001. In Pursuit of Greater Value: StrongerLeadership in and by Academic HealthCenters. Washington, D.C.: Cap GeminiErnst & Young.

Chassin, M.R. 1998. Is health care readyfor six sigma quality? Milbank Quarterly76 (4): 565 – 591.

Darlington, L. 1998. Banking withoutboundaries: how the banking industry istransforming itself for the digital age. InBlueprint to the Digital Economy: CreatingWealth in the Era of E-Business. Tapscott,D., Lowy, A., and Ticoll, D., eds. NewYork: McGraw Hill.

Drews, J. 1996. Genomic sciences and themedicine of tomorrow: commentary ondrug development. Nature Biotechnology14 (11): 1516-8.

First Consulting Group. 2000. Survey:Health Plans on the Road to e-Health.

Goldsmith, J. 2000. The Internet andmanaged care: a new wave of innovation.Health Affairs 19 (6): 42-56.

Kleinke, J.D. 2000. Vaporware.com: thefailed promise of the health care Internet.Health Affairs 19 (6): 57-71.

Kohane, I.S., Greenspun, P., Fackler, J.,Cimino C., Szolovits, P. 1996. Buildingnational electronic medical record systemsvia the World Wide Web. Journal of theAmerican Medical Informatics Association 3(3) 191-207.

National Committee on Vital and HealthStatistics. 1998. Assuring a HealthDimension for the National InformationInfrastructure. A Concept Paper presentedto the U.S. Department of Health andHuman Services Data Council, October14, 1998.

National Research Council. 2000.Networking Health: Prescriptions for theInternet. Washington, D.C.: NationalAcademy Press.

Rich, R. 2000. Personal communication.

Shortliffe, E.H. 2000. Networking health:learning from others, taking the lead.Health Affairs 19 (6): 9-22.

Silverman, R.D. 2000. Regulating medicalpractice in the cyber age: issues and chal-lenges for state medical boards. AmericanJournal of Law and Medicine 26 (2000):255-276.

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Tapscott, D., Lowy, A., and Ticoll, D., eds.1998. Blueprint to the Digital Economy:Creating Wealth in the Era of E-Business.New York: McGraw Hill.

U.S. Census Bureau. 2000. HealthInsurance Coverage: 1999. (P60-211).http://www.census.gov/hhes/www/hlth-in99.html.

Valovic, T.S. 2000. Digital Mythologies:The Hidden Complexities of the Internet.New Brunswick, New Jersey: RutgersUniversity Press.

Varmus, H., et. al. 1999. E-BIOMED:a proposal for electronic publications in thebiomedical sciences.http://www.nih.gov/about/director/pub-medcentral/ebiomedarch.htm.

WebSurveyMD. 2000. Update onPhysicians and the Internet. July 12, 2000.http://Websurveymd.mt01.com/Update_Physicians_Internet.shtml.

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