USHealthNet, LLC

1. Business Plan - Capsule………….

2. Business Plan - Long Version……

3. Conceptual Design Document…...

4. DiagAssist - Point-of-Care tools…

5. Screen Shots of Prototype…….…

6. ScriptPAD Specificaions…….…….

USHealthNetRichard Lynes cto@mediaone.net 3 Acorn StreetFounder and Chief Technology Officer Scituate, MA 02066USHealthNet, LLC (781) 545 - 3938

USHealthNet’s ‘Executive Summary'

1 IntroductionUSHealthNet will provide a branded, integrated, Internet Application Service Platform (iASP) for the administrative, communications andinformation needs of healthcare professionals and for the healthcare information needs of consumers. USHealthNet’s Web destination willconsist of two distinctly different linked Web sites—a subscription-based site for healthcare professionals and a free Health, Wellness andself-service portal site for consumers. USHealthNet will be the single point of access to EDI services, enhanced communications services,branded healthcare content, and other Web-based offerings. For healthcare professionals, USHealthNet is designed to simplify healthcarepractices by integrating multiple administrative, communications and research functions into a single, easy to use Web-based solution.

USHealthNet will deliver rich content and application services through its vertical healthcare portal. This portal will be segmented byhealthcare professionals, culled by specialty, and targets a consumer strategy leveraging physician patients. The consumer portal is based onan AOL model building on the community theme. Through a strategic partnership with BroadVision USHealthNet will offer apersonalization engine allowing true 1-2-1 relationship management and InfoMediary services. USHealthNet plans to aggregate the largestnumber of physicians and their patients through an aggressive Merger and Acquisition strategy.

In an effort to facilitate a plug-&-play e-commerce platform for third party products and services USHealthNet will develop joint venturesand affiliate partnership alliances. This strategy will include various healthcare centric disciplines: content sourcing and publishing, PracticeManagement Systems, Clinical Information Systems, Backend EDI services, and Integrated Delivery Networks. The trend to consolidatethese operational silos will take a focused and phased implementation plan. The basis for these M & A transactions is to reach critical mass inInternet time, which will drive demand creation for both the B2B and B2C segments. Fueling the inertia created by USHealthNet’s channelstrategy will be the Company’s vision for deploying its iASP offering -- Point-of-Care Knowledge Delivery and Acquisition tools.

The value proposition for both the healthcare professional and consumer will be in the Company’s ability to lower physician operating costs,increase revenues and enable quality care through measurable clinical outcome analysis, improving care delivery and disease management.USHealthNet plans on building knowledge bridges that will forge improved relationships bonding physicians, patients and a fragmentedhealthcare system. USHealthNet’s portal will become a trusted brand and premiere destination for brokering healthcare information,products and services that differentiates and provides a sustainable competitive advantage ensuring future annuity business.

1.1 Market OverviewAccording to the Health Insurance Association of America, healthcare is the largest single sector of the U.S. economy, consumingapproximately $1 trillion annually, or 14% of the country’s gross domestic product. The healthcare industry consists of a complex mix ofparticipants, which includes:

• ”Providers”—physicians, medical practice groups, hospitals and other organizations that deliver medical care;• ”Payers”—the government agencies, insurance companies, managed care organizations and other enterprises that pay the bills for

healthcare, this includes PBMs and employers;• ”Suppliers”—clinical laboratories, pharmaceutical companies, and other groups that provide tests, drugs, x-rays and other services;• ”Consumers”—individual patients who receive medical care, and the government agencies, employers and other organizations that

represent groups of individuals.

All healthcare participants rely heavily upon information to perform their roles in the industry.

Individuals compare medical plans, choose physicians and submit claims for reimbursement. Employers select health plans, determinebenefit levels, enroll employees and maintain employee eligibility data. Providers verify patient eligibility, collect patient histories, orderdiagnostic tests and x-rays, receive and interpret test results, render diagnoses, make referrals and submit claims to payers. Payers managereferrals, establish medical care protocols and reimbursement policies and process claims. Suppliers analyze and process patient samples ortests, provide results, fill prescriptions and submit claims for reimbursement. These and many other healthcare transactions are also highlydependent on information, and each participant is dependent on the others for parts of that information. In sum, the finance and delivery ofhealthcare requires that consistent, accurate information be shared confidentially across a large and fragmented industry.

• Physicians control 85% of the national expenditures for healthcare.• The administrative costs for providing healthcare have been estimated at between $198 billion and $250 billion per year.• The physician market size in the U. S. is over 800,000 today.• Those physicians providing outpatient care average 1647 patients per year; each with an annual per capita expenditure of $3875,

representing an aggregate annual billing of $236 Billion for 735 million office visits per year.Factors contributing to these exorbitant expenses are:

USHealthNetRichard Lynes cto@mediaone.net 3 Acorn StreetFounder and Chief Technology Officer Scituate, MA 02066USHealthNet, LLC (781) 545 - 3938

• =Inappropriate diagnosis and prescription drug use, resulting in a significant number of hospitalizations—between 5 and 25 percent. Thecosts of treatment for inappropriate drug therapies are staggering - estimated at $100 billion each year1

• =The healthcare industry has become an information-intensive profession plagued by substandard methods of data collection, storage, andretrieval, propagating and reinforcing the dysfunctional characteristics of a fragmented healthcare system

• With over two thousand information technology vendors and systems integrators competing for their share of the healthcare industry,incompatible operational and technology silos are making it difficult to exchange vital information and critical life-saving knowledge.This need strains the resources of the healthcare community since information must be gathered from disparate sources.

• =A large part of healthcare waste is related to compliance red tape, paperwork and decentralized heterogeneous data sources.

1.2 The ProblemIn providing care to those patients the physicians face similar basic challenges of people, process and technology:

• =Management of patient data during the course of their relationship• =No access to patient data prior to their relationship• =Limited access to patient data throughout the extended healthcare enterprise• =Inconsistent processes and deteriorating relationships across providers, payers, and suppliers• =No communication and leverage of data beyond the practice walls and across the continuum of care• =The need to keep abreast of health findings, enable peer collaboration and review new treatment protocols• =Need to contain costs (administrative, compliance, fraud ) and expand revenue opportunities and measure quality of care and life

Several of the core applications needed by those physicians to manage their patients needs are currently not WEB enabled and less than 6%of the office based physicians population use any combination of the following Point-of-Care (POC) tools:

• =Electronic Medical Records (family and payer demographics, medication history, allergies, problem list, etc)• =New prescription orders and refills processing, with Internet fulfillment through Drugstore.com• =Lab Order Entry and Resource Scheduling (workflow processing)• =Diagnostic Decision Support (expert knowledge systems)• =Procurement applications (e-commerce and e-business and ERP)

Those core applications have not penetrated the undeserved portion of this market for the following reasons:

• They are primarily client server applications that are both expensive to implement (software licensing, hardware, training and backendintegration), but are also a large distraction to the practice staff and operations from a management perspective – Back Office versa FrontOffice - Practice Management versa Patient Management.

• Managed Care has driven costs to the lowest level in history, leaving caregivers to question the quality of care and their ability to earn aliving and compete in the growing Physician Provider Organization (PPO) space.

• =Those practices that do invest in these applications generally only leverage a small percent of their value due largely to the fact thatback-office-billing systems are complex data entry systems and do not extend themselves to support front-office POC functions.

• =Since the applications are local to each practice, they do not receive the benefits of a consolidated patient treatment profile andoutcomes data across practices

Studies show that 94% of this market is considered “under served” by the current applications on the market and unable to address the Point-of-Care information needs. The Total-Cost-of-Ownership (TCO) on a per seat (single-user) basis would exceed $150,000 dollars over fiveyears. With more than 325,000 physicians working in physician group practices, it is easy to see why the turnkey systems integration servicesmarket for this segment will double in revenue by the end of the decade. Its $10 billion mark today, according to leading analyst MikeKnepper of Volpe, Welty & Co. The domestic market for digital clinical information networks has been estimated at $350 billion dollars,international (including U.S.) at $1.2 - 1.3 trillion dollars yearly (the estimate based on data from the World Health Organization, the U.S.Census Bureau).

1 National Pharmaceutical Council.

USHealthNetRichard Lynes cto@mediaone.net 3 Acorn StreetFounder and Chief Technology Officer Scituate, MA 02066USHealthNet, LLC (781) 545 - 3938

1.3 The SolutionUSHealthNet’s iASP offering consists of an N-tiered application service strategy, which connects physicians and patients to USHealthNet’sportal through a single access point using a Web browser based Thin-Client interface. These services integrate critical Point-of-CareKnowledge Tools allowing secure global access over the Internet. A patient has access to a read only EMR and a Java Smart card containingvital healthcare data will be offered for free to consumers, and for healthcare professionals the full POC suite will be offered through theCompany’s premium subscription services. Extranet access is offered to branded affiliate partners, enabling local e-commerce transactionsmaximizing site stickiness while ensuring a consistent user experience and ensuring patient privacy and physician confidence.

USHealthNet’s Java Enterprise Beans and Corba application component framework supporting the iASP subscription service offering willconsist of nine integrated applications:

1. LifeTime (Longitudinal Electronic Medical Records)2. DiagAssist (Diagnostic Decision Support System)3. ScriptPad (Prescription and Drug Interaction Services)4. LabDirect (Lab Order and Results)5. Enterprise Workflow Engine and XFDL/XML based Forms Engine6. Enterprise Resource Planning (ERP)7. Enterprise Master Patient Index (EMPI)8. Clinical Data Repository and OLAP analytical reporting services9. Java and XML Search Engine, integrating (UMLS) Tools and semantic networks

The USHealthNet vision is to provide increased functionality to a broader cross-section of the physician’s market by breaking down thecurrent barriers to entry and providing the following benefits to the physician's practice, patients and consumers, and pharmaceutical industry:

1.3.1 Value Propositions – Physicians• Significantly lower cost of entry through a multi-tiered subscription model, effectively eliminating the Total-Cost-of-Ownership• More intuitive functionality, delivering a point and click information rich experience through Web based Thin-Client interface• Less intrusive infrastructure, remotely managed, eliminating hardware and software obsolescence (Outsourced to ASPs)• Guaranteed Quality of Service, by our national network operations center alliance partners• Clinical data repository management, providing analytical reporting services (InfoMediary service)• Leverage EMR database beyond the practice and across the continuum of care, location and technology independence• Reduced encounter documentation time (SOAP/Progress notes) enabling an increase in patient flow, as well as reduced liability

Additional benefits to the consumer and Pharmaceutical markets will be:

1.3.2 Value Propositions – ConsumersUSHealthNet provides healthcare consumers with a single point of access to premium and proprietary health and wellness content.Consumers can use the information to educate themselves on healthcare-related matters, allowing them to make better-informed healthcaredecisions. In addition, USHealthNet can e-mail updates based on a consumer’s profile and can search and retrieve member-specifichealthcare information from the Web. InfoMediary service affiliates will be marketing third party products and services using BoardVisionenabling a true 1-2-1 user experience. Affiliates target against high-level patient/consumer profiles, which do not compromise personal data,only segment level profiling data is available and this is secured in a BroadVision database behind USHealthNet’s data center fire-walls.

1.3.3 Value Propositions - Pharmaceuticals• Access to clinical data repository, reducing new drug time-to-market expense and risk• Provide direct to physician and patient/consumer (DTC)2 marketing channel, influencing prescribing behavior• Access to patient base for clinical trails and analytical reporting services (Data Mining) 3

• Direct link to Physicians Desktop for branded InfoMediary services• Access to patients and consumers of healthcare products through sponsorship programs on USHealthNet’s portal

2 Predicted spending on DTC advertising for 1998 is close to $1.6 billion, a 60% increase over 19973 All personal healthcare information is highly confidential and USHealthNet understands its commitments to patient privacy and will notunder any circumstances compromise a patient’s personal healthcare data.

USHealthNetRichard Lynes cto@mediaone.net 3 Acorn StreetFounder and Chief Technology Officer Scituate, MA 02066USHealthNet, LLC (781) 545 - 3938

1.4 Revenue ModelsThe Company’s delivery strategy for this vision is to raise the management of these applications up into the network, delivering subscription-based access to these applications for individual practices. The applications will be Internet based, providing the scale, security and ease ofuse that has been the hall-mark and success of the WEB today.

Key sources of revenue from this business will be:

• Subscript to Vertical Healthcare Portal (content and community only), targeting physicians, and segmented by specialty• Subscript services for Internet Application Service Platform (iASP – Point-of-Care Knowledge Delivery tools)• InfoMediary services allowing affiliate partners to participate in the Company’s e-Commerce platform and service offerings• Sponsorships, bounty and bundles (Up-sell and Cross-sell opportunities)• Transaction processing (EDI Claims, patient eligibility, transcription services and e-commerce)• Health Plan Auctions, giving PPOs and employers more control over contract negotiations with payer organizations• Advertising - using the Physicians Desktop the Company can use both a Push and a Pull model, supporting new off-line messaging

1.5 Capital requirements will be:• $10 - 30 million for sales, marketing and PR, operations, partnership acquisitions, technology licensing and development, and Merger &

Acquisition opportunities.• Outsource portal development and content sourcing to Agency.com.• Outsource infrastructure deployment to NaviSite, a CMGi company, and USinternetworking• Affiliates pre-paid or underwriting physician subscriptions (General content subscription levels, not premium, which offers iASP

services)4

• To fuel the Company’s consumer e-Commerce and InfoMediary service strategies USHealthNet’s market capitalization projections are$500 million with 10 % market penetration are not unrealistic

1.5.1 Investment OpportunitiesThis is an early stage opportunity for investors:

• The research has been done and the business case proven• Prototypes have been developed• Business plan has been drafted• Several key members of the management team have been identified, with an eager desire to identify additional members• Industry experts from both the medical and internet fields have committed to advisory roles• Technology partners have been identified and initial negotiations have begun• An initial venture partner has expressed a desire to participate if a second partner can be secured

1.6 ManagementRichard Lynes - is the founder and CTO of USHealthNet and has a proven track record serving as CIO and CTO for several successfulcompanies. To his credit Mr. Lynes brings more then twenty-four years of industry experience in Information Systems, Tele-communications, and business. His involvement with the Internet spans more then a decade and inspirers many of his visionary strategies,bridging e-commerce/e-business, integrating ERP and SCM, and his Thought-Leadership in the areas of converging business models andtechnologies is without question. Mr. Lynes is an experienced leader, mentor and team player, and understands the value of human capital.

1.7 ConclusionUSHealthNet ‘s charter and strategic vision is to provide e-commerce capabilities and service excellence for the healthcare industry bydeveloping Internet transport and Web-based clinical applications, management services, and a community healthcare information deliverynetwork. USHealthNet will be the premier provider of Point-of-Care knowledge tools and services for the healthcare industry.

USHealthNet’s strategy reflects the future state, vision and direction for the healthcare industry. This premise is based on the fact that allroads lead to the patient and physician, therefore all investment decisions, including IT capital and human resources need to be alignedstrategically across all points of patient and physician interaction.

4 The pre-paid or underwritten subscription services will be paid for in part from our shared revenue and joint marketing programs foraffiliate, and alliance partnerships

 The healthcare industry sits on a vast body of medical knowledge that it has failedto exploit. Practitioners and patients pay the price.

Dr. KnowBy Regina E. Herzlinger, DBA & Russell J. Ricci, MD

Healthcare is one of the world's most knowledge-intensiveindustries--yet the practitioners on its front lines are cut off from thenetwork connectivity tools that could deliver information to those whoneed it. Every day, physicians rely on their wits, their training, theirpast experiences with patients, and the information shared amongcolleagues to make critical medical judgments. And yet few attemptshave been made to codify systematically physicians' experience intreating patients so that the resulting body of knowledge could be moreefficiently shared among colleagues.

The healthcare industry, ofcourse, spews out "raw"information by the ton, but useful,meaningful information that couldinfluence patient outcomespositively and point to medicalbreakthroughs isn't sharedefficiently--if at all. Whilemedical bills are computerized,diagnosis and treatment recordslargely aren't. Likewise, little hasbeen done to track and studypatient outcomes methodically sothat physicians could identify themost successful treatments.

The answer, many believe, lies in evidence-based medicine. This newapproach has already demonstrated that it can deliver better care atlower cost--no mean feat in an industry plagued by escalating costs,

IBM Global Healthcare Industry News - Dr. Know

and in many parts of the world, increasingly dissatisfied customers.But it is not without controversy. In fact, it may be one of the mosthotly debated topics among medical practitioners today.

The problem is well known. "What has been referred to as a doublestandard of truth in medicine persists," says Dr John Wennberg, anepidemiologist and director of The Dartmouth Atlas of Health Care inthe United States, a 10-year study that has documented a widevariation in medical treatments. In the US, new drugs are tested todetermine clinical efficacy, he points out, but "the outcomes of othertreatment options...are not systematically subject to evaluation." Theresult, says Dr Wennberg, is unnecessary scientific uncertainty aboutmedical treatments.

For decades, practitioners have been concerned about wide variationsin medical treatment documented the world over. Demography-basedhealth patterns and differing health care systems contribute to thesedifferences, but what troubles many is the extent to which incompleteinformation may cause disagreement among physicians aboutdiagnoses and treatments.

Enter evidence-based medicine. Here's how it works: Physicians, inconcert with their colleagues, use data mining and relational databasesto sift through patient histories and clinical research data in order toglean knowledge--to understand the risks and benefits of variousmedical treatments and how they affect different "classes" of patients.The best practices--or optimal outcomes--that emerge are then used tocreate treatment guidelines for subsequent patients. Ideally, computernetworks could deliver these up-to-the-minute guidelines anddecision-critical data directly to the point of service. It is an iterativeprocess, with each new patient or clinical trial added so that constantlearning is assured and new ways of doing things are never stifled.Some call this real-time medicine.

"In the ideal world," says Dr Steve Shaha, a research director for theUS-based Gartner Group, "practitioners would have the data right attheir fingertips at the point of decision-making, like the heads-updisplay for a fighter pilot. To accomplish this, we'd need a lot ofcomputerization to capture electronic patient records and feed backcritical clinical data. These data repositories would be designed toallow people to make the best possible diagnoses and choose the besttreatment path."

Evidence in Practice

The efficient sharing of medical knowledge is probably bestpromulgated through an organizational approach known as the focusedfactory. Toronto's Shouldice Hospital is one such facility. It performs

just one procedure--hernia operations--but through sheer repetition anddedicated focus to the constant acquisition of knowledge, it appears toperform them better than anyone else. At Shouldice, a hernia operationtakes half the time and costs half as much as at the average hospital.What's more, it fails only 1 percent of the time, compared to a 10 to 15percent failure rate elsewhere.

Capture in computer databases whatcaregivers at Shouldice do right, andthat focused knowledge could becometreatment guidelines, exportable vianetworks to support physicians atfacilities worldwide. That's the goal atthe M.D. Anderson Cancer Center inHouston, Texas, a focused factory, andperhaps the most advanced user ofevidence-based medicine in the US.Using a network-based data programenabled by the clinical evidence

collected, grouped, and deemed critical by its doctors, the center'scomputer system currently tracks patients and suggests treatmentsalong 98 different treatment paths covering 8 diseases.

The results, according to Dr Mitchell Morris, associate vice presidentfor information services, are quality outcomes at lower cost. Forhysterectomies, Dr Morris cites a reduction of total hospital costs by20 percent, length of stay by 33 percent, medication costs by 35percent, and lab testing by 74 percent--all the while increasing patientsatisfaction. Comparable results have been achieved in lung resections,with a 30 percent drop in overall hospital costs, and most importantly,decreased readmissions, meaning the treatment was done right the firsttime.

The practice of evidence-based medicine is not confined to focusedfactories. It is being implemented at clinics and hospitals around theworld. At the Children's Hospital of Buffalo (CHOB) in New York, DrLinda Brodsky, director of CHOB's Center for Integrated OutcomesHealth Care, has led the institution's development of an outcome-basedapproach to medicine predicated on patient data. "We started bylooking at patient data historically," says Brodsky, "and then we askedourselves what we would like to see happen to these patientsmedically, and what would we like the outcome to be in terms ofpatient satisfaction and cost." The results were more far-reaching thanexpected, and from their initial 2 pilot programs, CHB is nowconducting over 20 studies.

"We saw a ripple effect," says Dr Brodsky. "We improved thesame-day surgery process and the use of anesthesia, we cut operating

IBM Global Healthcare Industry News - Dr. Know

room time, drug use, etc. And we've seen a slow change in the methodof practice--partly due to peer pressure and partly due to the fact thatthe results are compelling." For example, based on their training andexperience, individual surgeons at CHOB tended to practice one oftwo methods for a specific type of eye surgery. By sharing patient dataand studying outcomes, they learned that one method wasn't betterthan the other. Instead, different methods were warranted based on thepatient profile--and doctors now apply both in a different way.

Already, several large organizations in the US are convinced of themerits of evidence-based medicine. Among them are VHA, acooperative of 1,600 hospitals and facilities serving 26 percent of USpatients, and BJC Health System, the second-largest nonprofithealthcare system in the nation. VHA is building one of the country'slargest healthcare extranets, which expedites the sharing of bestpractices and will include a knowledge database to develop treatmentpathways for major conditions like pneumonia, asthma, and acutestroke. BJC has nearly finished its efforts to centralize informationwithin a network, with an eye toward improving patient care andoutcomes through computer-assisted treatment decisions.

Despite the momentum, success is hardly assured. Tens of thousandsof practitioners, clinics, pharmacies, and hospitals have amassed acornucopia of information in treating patients but have left it to molderaway in paper form. Moving it to databases will be a monumental task,requiring new outlays for IT. Second, the industry will have to pushhard for standards so that data can be shared. Third, patient privacyconcerns will have to be met through technology solutions (which doalready exist) and stringent organizational procedures. But the biggestbarrier could be the concerns raised by caregivers.

Evidence on Trial

Some doctors and patients protest that computer-driven medicine willnever be accepted. Doctors may balk at surrendering some of theirexpensively acquired diagnostic and treatment skills to a computer,and patients may not want to see their physicians pecking away atkeyboards like airline reservation clerks during consultations.

Physician resistance to evidence-based medicine has many sources.One is the old debate of man versus machine. Here, the computer hassome obvious advantages, including computational memory. At theLatter Day Saints Hospital in Salt Lake City, Utah, a computerdetermines which antibiotic should be administered to a patient byanalyzing 45 variables. A doctor typically considers three to five. Thecomputer-fed results have led to fewer complications and shorterhospital stays.

A computer's "judgment" can't be clouded from a bad night's sleep,

imperfect recall, or nerves aggravated byjangling phones. Of course, a computerdoesn't have judgment per se; it suggeststreatments based on algorithms and availableclinical data. Nor can computers take intoaccount the ineffable--a doctor'sunderstanding of how a patient's personalityor circumstances might affect treatment andrecovery, for example.

Moreover, healing, some argue, is an art, nota business process. To purists, computers mechanize--if notprofane--the sacred art of medicine. The art advocates have a point.The human body is not reducible to a machine. But then,evidence-based medicine is not intended to be medicine by computerfiat. Treatment guidelines only help to narrow therapeutic options; theydo not eliminate them. And guidelines aren't created out of whole clothby a computer: They are the sum total of physicians' expertise; theirprevious diagnoses and treatment decisions. But becauseevidence-based medicine is predicated on team decision-making andcollaboration--anathema to many professionals, not just medicalpractitioners-- such arguments sometimes fall on deaf ears.

Not surprisingly, the pursuit of evidence-based medicine has given riseto charges of cookbook medicine. "Cookbook medicine," says DrMorris, "is meant to imply a simplistic approach to care, somethingbeneath the skills of a trained doctor. People are not cups of sugar andcan't be quantified that way. But, in fact, we've long used cookbookmedicine in areas like clinical trials. And the reality is, the insuranceindustry is trying to develop its own medical cookbook from a purelycost-control standpoint. So we've worn down physician opposition bytelling them, 'The cookbook is coming. Whom do you want to write it?Insurance people or doctors?'"

Next in a long line of hurdles is the possibility that evidence-basedmedicine will be misused or abused. No physician will dare buck thecomputer, it's suggested. Or, more worrisome, no managed-careprovider or hospital administrator will allow a physician to do so.Health care driven by an institution's cost-control objectives alone isnot the desired outcome, and if physicians take the lead, is not theinevitable one.

As Dr Shaha points out, managed-care operations often stumble atattempts to institutionalize evidence-based medicine because theirmotives are suspect. But done correctly--which to Shaha necessitatesthat physicians lead the process--evidence-based medicine, hebelieves, facilitates a true patient-practitioner partnership, and "is thebest way to reduce unwanted or unproductive variation in practice and

optimize cost and clinical satisfaction."

Ultimately, pressures to leverage information in order to glean newmedical knowledge and share it may come from several quarters.Already, the Joint Commission on the Accreditation of HealthcareOrganizations, the predominant standards and accrediting body forhealthcare organizations in the US, has announced that assessingpatient outcomes will become part of the accreditation process by1999. As standards and criteria evolve sufficiently to facilitatecomparison, the data will be made public. And people are turning tothe web in record numbers to find out more about their medicalconditions and explore new treatments--all of which they want todiscuss with their doctors. The information explosion via all mediameans that paternalistic or arbitrary systems will be under increasingassault. In other words, "we know best" policies just won't cut it.Patients will be the judge of health care and they will demandproof--evidence in the form of usable information. Some practitionerswill be ready to provide it.

Regina E. Herzlinger, DBA, is a professor at the Harvard Business School and isthe author of several critically acclaimed books, including Market-Driven HealthCare: Who Wins, Who Loses in the Transformation of America's Largest ServiceIndustry (Addison Wesley Longman, 1997).

Russell J. Ricci, MD, is IBM's General Manager of the global healthcare industry.Prior to joining IBM, Dr Ricci was the president of New Health Ventures at BlueCross and Blue Shield of Massachusetts.

Copyright (c) 1998 International Business Machines Corporation.Reprinted with permission from Think Leadership 1998

Volume 3 Number 2All rights reserved

 Illustrations by Sandra Dionisi

 Think Leadership magazine online edition: http://www.ibm.com/thinkmag

USHealthNet, LLCSeeking: $10,000,000 -$30,000,000 , Already Invested: $200,000:

 

Company:USHealthNet, LLC3 Acorn StreetScituate, MA 02066Web site: http://www.USHealthNet.com

Incorp: LLC, 7/15/99, DEIndustry 1: Physician-PracticeManagementIndustry 2: Internet Service Providers

Contact:Mr. Richard LynesCTO and FounderPhone: 781-545-3938Fax:Email:cto@mediaone.net

Referred by:Red Herring MagazineUSHealthNetBoston, MA

Table of Contents

Company Overview■

Business Description■

Product or Service■

Sales■

Marketing■

Management & Staffing■

Capitalization■

Financial Data■

Company Overview   (return to top)

USHealthNet, a visionary Community Healthcare Information Delivery Network.

USHealthNet will provide a branded, integrated, internet Application Service Platform (iASP) for theadministrative, communications and information needs of healthcare professionals and for the healthcareinformation needs of consumers. USHealthNet's Web destination will consist of two distinctly differentlinked Web sites--a subscription-based site for healthcare professionals and a free Health, Wellness andself-service portal site for consumers. USHealthNet is a single point of access to EDI services, enhancedcommunications services, branded healthcare content, and other Web-based offerings. For healthcareprofessionals, USHealthNet is designed to simplify healthcare practices by integrating multipleadministrative, communications and research functions into a single, easy to use Web-based solution

Business Description   (return to top)

MissionUSHealthNet 's charter and strategic vision is to provide e-commerce capabilities and service excellencefor the healthcare industry by developing Internet transport and Web-based clinical applications,management services, and a community healthcare information delivery network. USHealthNet will bethe premier provider of Point-of-Care knowledge tools and services for the healthcare industry.

Key GoalsUSHealthNet's strategy reflects the future state, vision and direction for the healthcare industry. Thispremise is based on the fact that all roads lead to the patient and physician, therefore all investmentdecisions, including IT, capital and human resources need to be aligned strategically across all points ofpatient and physician interaction.

USHealthNet expects to accomplish the following by the end of Q-4 99:

- Secure the appropriate level of funding and high profile investment partners- Develop strategic relationships with hosting companies, i.e. NaviSite, Digex and Usi in order to provide the data center infrastructure needed to support iASP services.- Develop syndicated content relationships with healthcare publishers.- Develop affiliate partners programs to support e-business and InfoMediary services.- Achieve milestones for Physician downloads of PDA to support service subscriptions.- Achieve milestones for Consumer B2C and B2ME InfoMediary services.

Stage: startup

Started working: October 1, 1996

Do you have a prototype or demo?

Search KeywordsiASP, IDN, CHIN, internet Application Service Platform, Point-of-Care Knowledge Delivery andAquisition Tools, Electronic Medical Records (EMR), InfoMediary Services, B2B, B2C and B2ME

Product or Service   (return to top)

Problem SolvedAll healthcare participants rely heavily upon information to perform their roles in the industry.Individuals compare medical plans, choose physicians and submit claims for reimbursement. Employersselect health plans, determine benefit levels, enroll employees and maintain employee eligibility data.Providers verify patient eligibility, collect patient histories, order diagnostic tests and x-rays, receive andinterpret test results, render diagnoses, make referrals and submit claims to payers. Payers managereferrals, establish medical care protocols and reimbursement policies and process claims. Suppliersanalyze and process patient samples or tests, provide results, fill prescriptions and submit claims forreimbursement. These and many other healthcare transactions are also highly dependent on information,

Application Review

and each participant is dependent on the others for parts of that information. In sum, the finance anddelivery of healthcare requires that consistent, accurate information be shared confidentially across alarge and fragmented industry.

Underlying TechnologyUSHealthNet's iASP offering consists of an N-tiered application service strategy, which connectsphysicians and patients to USHealthNet's portal through a single access point using a Web browser basedThin-Client interface. These services integrate critical Point-of-Care Knowledge Tools allowing secureglobal access over the Internet. These POC tools will be offered for free to consumers and through theCompany's premium subscription services for healthcare professionals. Further access is offered tobranded affiliate products and services, maximizing site stickiness while ensuring a consistent userexperience.

USHealthNet's Java Enterprise Beans and Corba application component framework supporting the iASPsubscription service offering will consist of nine integrated applications:

1. LifeTime (Longitudinal Electronic Medical Records)2. DiagAssist (Diagnostic Decision Support System)3. ScriptPad (Prescription and Drug Interaction Services)4. LabDirect (Lab Order and Results)5. Enterprise Workflow Engine and XFDL/XML based Forms Engine6. Enterprise Resource Planning (ERP)7. Enterprise Master Patient Index (EMPI)8. Clinical Data Repository and OLAP9. Java XML Search Engine, integrating (UMLS) Tools and semantic networks

Intellectual PropertiesDo to the nature of providing our outsourcing iASP offerings, several key technology partners have beenidentified and will require license agreements.

Manufacturing ProcessWe have an outsourcing agreement in place for all custom development and integration services throughour strategic partnership with a local Boston based developer.

Sales   (return to top)

Unique selling propositionThe Value Proposition - Healthcare Professional

A Web-based Thin-Client front-end application provides a Single Point of Access for healthcareprofessionals. This reduces the need for healthcare professionals to use multiple administrative,communications and information services by integrating these applications and services via the Internet.USHealthNet will enter into relationships to assist healthcare professionals in obtaining all hardware andancillary services necessary to use USHealthNet, including Internet access, computer hardware, training,and support. USHealthNet's Premium subscription access to iASP and Knowledge Management Servicesprovides a suite of Point-of-Care (POC) tools, including backend EDI services for healthcare

Application Review

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professionals', eligibility verification, and prescription processing. The Electronic Medical Recordmanages patients across the continuum of care, ScritpPAD, Lab Order Entry and DiagAssist a DiagnosticDecision Support tool, offer healthcare professionals unparalleled control throughout the life-cycle ofcare.

The USHealthNet vision is to provide increased functionality to a broader cross-section of the physician'smarket by breaking down the current barriers and providing the following benefits to the healthcareprofessionals:

Value Propositions - Physicians

- Significantly lower cost of entry (Multi-tiered subscription models)- More intuitive functionality (Web based Thin-Client)- Less intrusive infrastructure (Outsourced to ASPs)- Remotely managed through national network operations centers- Clinical data management and analysis (InfoMediary service)- Leverage of database beyond the practice and across the continuum of care- Freedom from hardware and software obsolescence

Additional benefits to the consumer market will be:

Value Propositions - Consumers

USHealthNet provides healthcare consumers with a single point of access to premium and proprietaryhealth and wellness content. Consumers can use the information that is provided through USHealthNetwithout charge to educate themselves on healthcare-related matters, allowing them to make betterinformed healthcare decisions. In addition, USHealthNet can deliver personalized content and e-mailupdates based on a consumer's profile and can search and retrieve member-specific healthcareinformation from the Web. InfoMediary service affiliates will be marketing products against high-levelpatient/consumer profiles, which do not compromise personal data, only segment level profiling data isavailable and this is secured in a BroadVision database behind USHealthNet's data center fire-walls.

Premium and Proprietary Content

Online Healthcare Communities.Through planned acquisitions, USHealthNet will provide access to online communities that provideconsumers with personalized information about their health conditions and allow them to participate inmessage boards, real-time chat rooms and support networks via the Web. In addition, onlinecommunities provide member-generated content based on shared experiences.

Convenience and Reliability.Through USHealthNet Web site, patients can obtain information regarding office hours, location andother matters without having to place a telephone call to the physician's office. In addition, patients canreceive healthcare information that is reviewed and approved by medical professionals under theirphysician's USHealthNet Web site -- a reliable and familiar source of information.

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Benefits to the pharmaceutical market will be:

Value Propositions - Pharmaceuticals

- Access to clinical data repository- Reduced new drug R & D life cycle- Improving Time-to-Market- Access to patient base for clinical trails- Direct link to Physicians Desktop for promotions and advertising- Access to consumers of healthcare products (Direct to Consumers)

USHealthNet's Vertical Healthcare Portal is segmented by specialty for physicians and personalized onthe consumers' B2C portal. USHealthNet uses a 1-2-1-personalization engine for physician profiling andpatients -- only branded affiliate products and services are offered and transacted within the sites,customized physician Intranets and knowledge delivery services are tailored based on a multi-tieredsubscription model. USHealthNet intends to add services and content in the future, including aWeb-enabled medical transcription service offering, hospital/physician referral services and insurancebenefits administration.

Ease of Use.USHealthNet will offer a bundled Thin-Client Application Suite and Knowledge Management servicesprovided by a standards-based Java Physicians Desktop interface integrated with a Web browser.Therefore, subscribers who use the USHealthNet 's services do not require training on multipleproprietary devices and require no knowledge of the Internet and it's navigation issues.

Cost Savings.USHealthNet will offer tiered InfoMediary services allowing affiliate partners to market products andservices targeted against confidential profiles achieving true personalization across all points of contactinsuring a consistent user experience. By aggregating physicians and reaching critical mass USHealthNetwill be uniquely positioned to offer procurement services, practice management service, and other thirdparty offerings through these affiliate partners. Physicians and patients will be offered financial incentiveawards for referring non-members and by participating in other marketing programs.

In-addition to the USHealthNet's POC tools a unified messaging platform, supporting chat, conferencingand email service will be rolled-out. USHealthNet's Web sites and premium research and educationalcontent will be priced competitively and healthcare professionals will pay no more for these services thanif purchased individually.

Distribution plansUSHealthNet plans to evolve demand creation by launching creative advertising campaigns acrosschannels and through strategic partners, Internet search engines, banners ads and more traditional mediaplays. The Company has started discussions with Omnicom subsidiaries that will lead to strong strategicpartnerships. These subsidiaries provide brand strategy, PR and media buys, campaigns, andUSHealthNet will partner with Agency.com for the development of the Company's Portal sites.

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Pricing strategyThe Company's delivery strategy for this vision is to raise the management of these applications up intothe network, delivering subscription access to these applications to individual practices. The applicationswill be Internet based, providing the scale, security and ease of use that has been the hall-mark andsuccess of the WEB today.

Key sources of revenue from this business will be:

- Subscript to Vertical Healthcare Portal (Segmented based on specialty)- Subscript service for Internet Application Service Platform (iASP - Point-of-Care tools)- InfoMediary services allowing affiliate partners to participate in the Company's e-Commerce- Sponsorships, bounty and bundles (Up-sell and Cross-sell opportunities)- Transaction processing (EDI Claims, patient eligibility and e-commerce)- Advertising (Using the PDA, the Company can us both a Push and a Pull model)

MarginsThe annuity service based model supporting multi-tiered revenue streams can not be compared to themore traditional product model companies, which report gross margins of only 30-60%.

Top 3 Products

Name Description Avg. Price

Tier-I, Point-of-CareKnowledge Acquisition &Delviery Tools 

Provides critical life savingknowledge at the point of service 

Subscriptions(tiered pricing) 

Tier-II, InfoMediaryServices 

InfoMediary services allowingaffiliate partners to market productsand services 

Variable andfixed pricing -- 

Tier-III, Extranet -Procurement 

iASP, shared e-commerce/e-businessplatform and vertical portal 

Transactionmodel - standardp 

  Year 1 Year 2 Year 3 Year 4 Year 5

Name1998units

1999units

2000units

2001units

2002units

Tier-I, Point-of-CareKnowledge Acquisition &Delviery Tools 

         

Tier-II, InfoMediaryServices 

         

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Tier-III, Extranet -Procurement 

         

Other Products:          

Marketing   (return to top)

Marketing StrategyUSHealthNet's channel strategy will be organized according to its four main customer segments:providers, payers, suppliers and consumers. USHealthNet's direct sales force will target significantpotential customers in each market segment by region. In certain instances, USHealthNet's direct salesforce will work with complementary brokers, value-added resellers and systems integrators to delivercomplete solutions for major customers. In addition, senior management plays an active role in the salesprocess by cultivating industry contacts. USHealthNet markets its applications and services throughdirect sales contacts, strategic relationships, the sales and marketing organizations of its strategicpartners, participation in trade shows articles in industry publications. USHealthNet will attend a numberof major trade shows each year and will sponsor executive conferences, which feature industry expertswho address the information systems needs of large healthcare organizations. USHealthNet will supportits sales force with technical personnel who perform demonstrations of USHealthNet's applications andassist clients in determining the proper hardware and software configurations.

The key to market dominance, is first mover advantage, value proposition, execution, and most importantaggregating users through acquisition and retention strategies. A parallel strategy is to make the cost ofentry to high for competitors and the switching costs for users to high for consideration.

Target MarketAccording to the Health Insurance Association of America, healthcare is the largest single sector of theU.S. economy, consuming approximately $1 trillion annually, or 14% of the country's gross domesticproduct. The healthcare industry consists of a complex mix of participants, which includes:

- "Providers" -- physicians, medical practice groups, hospitals and other organizations that deliver medical care;- "Payers" -- the government agencies, insurance companies, managed care organizations and other enterprises/employers that pay the bills for healthcare;- "Suppliers" -- clinical laboratories, pharmaceutical companies, and other groups that provide tests, drugs, x-rays and other services; and- "Consumers" -- individual patients who receive medical care, and the government agencies, employers and other organizations that represent groups of individuals.

All healthcare participants rely heavily upon information to perform their roles in the industry.Individuals compare medical plans, choose physicians and submit claims for reimbursement. Employersselect health plans, determine benefit levels, enroll employees and maintain employee eligibility data.Providers verify patient eligibility, collect patient histories, order diagnostic tests and x-rays, receive andinterpret test results, render diagnoses, make referrals and submit claims to payers. Payers manage

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referrals, establish medical care protocols and reimbursement policies and process claims. Suppliersanalyze and process patient samples or tests, provide results, fill prescriptions and submit claims forreimbursement. These and many other healthcare transactions are also highly dependent on information,and each participant is dependent on the others for parts of that information. In sum, the finance anddelivery of healthcare requires that consistent, accurate information be shared confidentially across alarge and fragmented industry.

- The U.S. Healthcare expenditure is $1.2 trillion and growing.- Physicians control 85% of the national expenditures for healthcare.- The administrative costs for providing healthcare have been estimated at between $198 billion and $250 billion per year.- The physician market size is over 800,000 today.- Those physicians provide care to an average of 1647 patients per year; each with an annual per capita expenditure of $3633, representing an aggregate annual billing of $236 Billion for 735 million office visits per year.

Forrester Research, Inc. reports that the overall market for outsourcing packaged software applicationswill grow from approximately $1 billion in 1997 to over $21 billion by 2001. These services includepackaged application software implementation and support, customer support and network developmentand maintenance. Reasons for the growth in outsourcing include:

- The scarcity of information technology professionals.- The challenges faced by a non-technical company in hiring, motivating and retaining qualified application engineers and information technology employees.- The desire by companies to focus on their core business.- The difficulties that businesses experience in developing and maintaining their networks and software applications.- The fast pace of technical change that shortens time to obsolescence and forces increases in capital expenditures as companies attempt to keep up with leading technologies.

These factors do not reflect the growth of more tranditional e-commerce/e-business projections.

CompetitionUpon first glance the competitive situation may be perceived as high risk due to the large number ofInternet healthcare content sites, vendor/systems integrators, and back office billing system vendors.USHealthNet sees short-term competition from Internet sites that have subscription models targetinghealthcare providers and consumers. USHealthNet is differentiating itself by offering premium servicesfor healthcare content alongside application services.

Many of the Company's current and potential competitors have greater resources to devote to thedevelopment, promotion and sale of their services; longer operating histories; greater financial, technicaland marketing resources; greater name recognition; and larger subscriber bases than the USHealthNetand, therefore, have a significantly greater ability to attract subscribers and advertisers. Many of thesecompetitors may be able to respond more quickly than the USHealthNet to new or emerging technologiesin the Internet and the personal communications market and changes in Internet user requirements and todevote greater resources than the USHealthNet to the development, promotion and sale of their services.

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In addition, USHealthNet does not have contractual rights to prevent its strategic partners from enteringinto competing businesses or directly competing with the USHealthNet. While these statements can bepositioned as a negative resulting in a high-risk investment, they represent the reality of marketconditions for every company today and well into the future.

Competitive AdvantageUSHealthNet's integrated Web service delivery model (iASP) positions the true competitive situationwith a more focused strategic value proposition.

Many of the more sessioned players in the healthcare market have been traditional product companies,which would prevent them from competing in the Internet service space in the short-term. Thesecompanies are not the usual first-movers and early adopters. They have funded business plans buildaround a product model company and operational structures to support them. Product development lifecycles constrain traditional product companies from the point of view that measures success bytime-to-market, mass customization, personalization, and elasticity to rapidly changing market dynamics.Many of these companies will seek security in partnership strategies that include them in the marketsnatural trends toward consolidation and disintermediation.

Management & Staffing   (return to top)

Full-time permanent employees: 1

Part-time employees: 0

Contractors: 7

Critical positions not yet filledCEO, COO, Chief Marketing Officer, SVP Business Development, VP Research & Development

Personnel

Richard Lynes

Role Founder

Title CTO 

Functions Provide IT vision and strategy alignment 

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Prior Experience Strategic Planning and Information Technology SolutionsThought-Leader, achieving improved operating efficiencythrough IT and business strategy alignment, and increasedshareholder value by leveraging technology as a competitivedifferentiator.Professional Competencies:- Strategic IT and Business planning for e-commerce,e-business and Knowledge Management as a competitivedifferentiation in the B2B, B2C and B2ME markets,integrating both buy-side, sell-side and customer facingprocesses- Mentoring companies executives in their migration fromtraditional mass marketing and operational practices to thoseof 1-2-1 personalization; Customer Relationship Marketing(CRM) utilizing interactive media, database marketing, andthe integration of legacy Line-of-Business applications,including SCM, OLR and ERP solutions- Guiding executives on the sweeping changes, trends andimpacts of technology on competitive strategies, businessobjectives and business transformation- Technical team lead on the design, development anddeployment of scaleable Enterprise-wide information,software and systems architectures. SupportingIntranet/Extranet application infrastructure components forMRO purchasing and e-catalog procurement, HumanResources, Sale Force Automation, Knowledge Management,and strategies for linking channel partners, suppliers andcustomers.

Serving as CIO and CTO for several market leaders, Mr.Lynes past successes have been achieved by developingvisionary technology strategies and facilitating informationflow within the senior management strategic planningfunction. By improving knowledge utilization through linkingcorporate stakeholder processes and objectives, clientbusiness strategies, and facilitating cooperation betweencross-functional teams, Mr. Lynes insights have created amore customer centric approach and methodology.

Colleagues have often described Mr. Lynes as anapproachable team player who has a proven knack offorecasting and keeping them abreast of critical changes in thedynamic, fast paced world of technology. His talent does notcome from a crystal ball, but from a substantial career offollowing the movements within both the Information

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Technologies and Tele-communications industries. 

EmploymentHistory

Company Title YearsSequitor MedicalTechnology, Inc.

EVP, CIO 2

Bronner SlosbergHumphrey

VP, CTO 3

CommSoft Technoloy,Inc.

VP, R & D 3

Education Institution Degree YearGeorgia Tech BS Computer Science 1980

Chris Bulter

Role Advisor

Other Boards Opus2 

Other Affiliations Agency.com 

Wendy Roberts

Role Advisor

Other Affiliations Agency.com 

Jack Barette

Role Advisor

Other Affiliations Agency.com 

Don Leavitt

Role Advisor

Other Affiliations Harvard Business School 

Pat Morand

Role Advisor

Kelly Mahoney

Role Advisor

Other Affiliations Essential.com 

Jeff Heywood

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Role AdvisorPart-time Employee

Title Chief Financial Officer 

Other Boards StarQuest Software, Inc. 

Other Affiliations Adobe Systems, Inc. 

Functions Responsible for Company's financal modeling, M & Astrategies, VC and partnership development. 

Capitalization   (return to top)

  Shares $ Invested

Founders: 10,000,000  $200,000 

Other Senior Managers:    

Other Employees:    

Outside Directors:    

Other Investors:    

Total: 10,000,000  $200,000 

Current investors?We currently have none.

Do you have any debt financing?No...

Total funding to date: $200,000

How have funds been used to date?I have bootstrapped all the research, prototype development, and strategy. No other funding vehicle hasbeen approached todate.

Now seeking: $10,000,000

How will the money you are now trying to raise be used?USHealthNet's working capital requirements for fiscal year 1999 and 2000 will be raised throughexternal private angle investors, partners and institutional equity funding vehicles in the amount of $10million, along with additional commitments to enable the Company's acquisition strategy. Projectedramp-up costs, operations, sales and marketing, and product/service development will be running at anestimated average monthly burn rate of $550,000 for the first eighteen months. As part of our strategy,year two revenue coupled with stock valuations and market capitalization, as well as a possible IPO, will

Application Review

be used to help fund the continued growth into international markets and additional merger / acquisitionopportunities

Do you have any preferred skills for your investors?USHealthNet seeks professional high profile investment partners that will provide assistance indeveloping a world class management team, board-of-directors and advisory board. The Company wouldalso expect our investment partners to actively solicit their network for opportunities in the area of M &A strategy and strategic partnerships. Furthermore, the Company would expect to have access to the rightinvestment bankers in order to build the relationships with analysis and others in preparations for takingthe Company public.

Dream investors?1. Pharmaceutical Companies2. AOL and Amazon.com3. Intel (as part of their data center strategy)4. Ericsson Inc., IBM, Sun5. CMGi Ventures, AT&T Ventures6. ibankers

What are you offering?Equity

How else have you tried to raise money?I have not started this process until now.

Exit StrategyUSHealthNet's exit strategy is simple, Longer term, as measured in Internet time (12-18 months),Healtheon/WebMD, Synetics, EMR (Electronic Medical Records) vendors and other competitors maybegin to view USHealthNet as a valued asset. USHealthNet views itself as a possible acquisitioncandidate for Healtheon/WebMD, Synetics or AOL. USHealthNet and its investors will evaluate both M& A and IPO strategies as a function of the Company's requirements for new capital and current capitalmarket conditions.

The downside to any investment needs to be articulated as a high risk and assess the leverage points toillustrate the high returns and value of the Company's tangible assets, Intellectual Property, partnershipsand subscriber-base. USHealthNet's investment in IT based assets will be evidenced by planned patentfilings, as well as the unique Web based Java/Corba framework, which delivers on the promise ofUSHealthNet's iASP offerings.

Understanding this, the worst case scenario is that the Company assets will be acquired by one of severalInternet based healthcare market leaders. This minimizes the risks as it is a win - win for those who canafford to stay in.

Top 3 ConcernsImmediate Goals

USHealthNet expects to accomplish the following by the end of Q-4 99:

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- Secure the management talent required- Secure the appropriate level of funding and high profile investment partners- Develop strategic relationships with hosting companies, i.e. NaviSite, Digex and Usi in order to provide the data center infrastructure needed to support iASP services.- Develop syndicated content relationships with healthcare publishers.- Develop affiliate partners programs to support e-business and InfoMediary services.- Achieve milestones for Physician downloads of Physician Desktop Applications to support service subscriptions.- Achieve milestones for Consumer B2C and B2ME InfoMediary services.

3 References or customers1. Malcom Speed, Chairman & CEO, Rapp Collins2. Wendy Roberts, Partner, Agency.com3. Kelly Mahoney, Chief Marketing Officer, Essential.com

Financial Data   (return to top)

Capital needed to break even: $30,000,000

Quarter to break even: 3/2000

Fiscal Year End: 12/31

Months of cash on hand: 0

Current revenues: $0 (per month)

Current expenses: $20,000 (per month)

($ numbers in000s)

Year 1 Year 2 Year 3 Year 4 Year 5

Year:  1998   1999   2000   2001   2002 

Revenues: $0  $0       

Cost of goods:          

OperatingExpenses:

         

Net income:          

Investmentreceived:

         

CapitalExpenditures:

         

End of yearcash balance:

         

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# of employees:          

General Counsel:Currently interviewing several Boston based firms.Bosotn, MATBD

Legal Disputes?"none"

Bank: Fleet and Bank BostonBoston, MATBD

Accountants: Thomas Britt, CPAWater Town, MATom Britt

Audited Financials? no

For how long? (in months)

Anything else?I do not wish to have any of this information shared with parties whom may have invested in Healhteonor WebMD.

The financial projections are not finished and therefore are not included because of the ambiguityinvolved in modeling these service based revenue streams. However, a ten- percent market sharerepresenting 80,000 physician subscribers and five-percent of the insured population or 12 millionpatient/consumer members represents a multi-billion dollar annuity based opportunity.

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USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only – June 11, 1999

USHealthNet

Business Plan for USHealthNet , a visionary

Health Care Information Delivery System.

June 11, 1999

Business Plan Copy Number [1 of 50 ]

This document contains confidential and proprietary informationbelonging exclusively to Richard Lynes

Richard LynesChief Technology Officer

3 Acorn StreetScituate, MA 02066

(781) 545-3938cto@mediaone.net

This is a business plan. It does not imply an offering of Securities.

USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only – June 11, 1999

TABLE OF CONTENTS

USHEALTHNET’S ‘BUSINESS PLAN’ .................................................................................................................. 1

1 EXECUTIVE SUMMARY ............................................................................................................................... 1

1.1 MARKET OVERVIEW........................................................................................................................................ 21.2 THE PROBLEM ................................................................................................................................................. 31.3 THE SOLUTION ................................................................................................................................................ 4

1.3.1 Value Propositions – Physicians........................................................................................................... 41.3.2 Value Propositions – Consumers .......................................................................................................... 51.3.3 Value Propositions - Pharmaceuticals.................................................................................................. 5

1.4 REVENUE MODELS .......................................................................................................................................... 51.5 CAPITAL REQUIREMENTS WILL BE: .................................................................................................................. 6

1.5.1 Investment Opportunities ...................................................................................................................... 6

2 INTRODUCTION ............................................................................................................................................. 7

3 THE BUSINESS ................................................................................................................................................ 9

4 THE STRATEGIC OPPORTUNITY.............................................................................................................. 9

5 THE MARKET POTENTIAL/MARKET SIZE/MARKET GROWTH RATES ....................................... 9

6 THE MARKET DRIVERS/KEY TRENDS.................................................................................................. 10

7 THE OPPORTUNITY .................................................................................................................................... 10

8 THE SOLUTION............................................................................................................................................. 11

9 THE PRODUCTS/OFFERINGS ................................................................................................................... 11

10 THE VALUE PROPOSITION — HEALTHCARE PROFESSIONAL..................................................... 12

10.1 EASE OF USE............................................................................................................................................. 1210.2 COST SAVINGS.......................................................................................................................................... 12

11 THE VALUE PROPOSITION — CONSUMERS ....................................................................................... 13

11.1 PREMIUM AND PROPRIETARY CONTENT ................................................................................................... 1311.1.1 Online Healthcare Communities ......................................................................................................... 1311.1.2 Convenience and Reliability................................................................................................................ 13

12 THE STRATEGIC GRIPPER: “THAT’S FANTASTIC” .......................................................................... 13

13 ADVERTISING AND PUBLIC RELATIONS............................................................................................. 14

14 THE BUSINESS MODEL .............................................................................................................................. 14

15 SALES AND MARKETING .......................................................................................................................... 14

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Confidential & Proprietary Property of Richard LynesDraft Only – June 11, 1999

16 IMMEDIATE GOALS.................................................................................................................................... 15

17 COMPETITION.............................................................................................................................................. 15

18 OUR DIFFERENTIATORS........................................................................................................................... 15

19 USE OF FUNDS .............................................................................................................................................. 16

20 EXIT STRATEGY .......................................................................................................................................... 16

21 FINANCIAL ANALYSIS/PRO-FORMA ESTIMATES ............................................................................. 16

22 MANAGEMENT TEAM................................................................................................................................ 17

23 DEVELOPMENT TEAM............................................................................................................................... 18

24 ADVISORY BOARD ...................................................................................................................................... 18

25 CONCLUSION................................................................................................................................................ 22

USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only – Page 1 - June 11, 1999

USHealthNet’s ‘Business Plan’

1 Executive SummaryUSHealthNet will provide a branded, integrated, internet Application Service Platform (iASP)for the administrative, communications and information needs of healthcare professionals and forthe healthcare information needs of consumers. USHealthNet’s Web destination will consist oftwo distinctly different linked Web sites--a subscription-based site for healthcare professionalsand a free Health, Wellness and self-service portal site for consumers. USHealthNet is a singlepoint of access to EDI services, enhanced communications services, branded healthcare content,and other Web-based offerings. For healthcare professionals, USHealthNet is designed tosimplify healthcare practices by integrating multiple administrative, communications andresearch functions into a single, easy to use Web-based solution.

USHealthNet will deliver rich content and application services through its vertical healthcareportal. This portal will be segmented by healthcare professionals, culled by specialty, and targetsa consumer strategy leveraging physician patients. The consumer portal is based on an AOLmodel building on the community theme. Through a strategic partnership with BroadVisionUSHealthNet will offer a personalization engine allowing true 1-2-1 relationship managementand InfoMediary services. USHealthNet plans to aggregate the largest number of physicians andtheir patients through an aggressive Merger and Acquisition (M & A) strategy.

In an effort to facilitate a plug-&-play e-commerce platform for third party products and servicesUSHealthNet will develop joint ventures and affiliate partnership alliances. This strategy willinclude various healthcare centric disciplines: content sourcing and publishing, PracticeManagement Systems, Clinical Information Systems, Backend EDI services, and IntegratedDelivery Networks. The trend to consolidate these operational silos will take a focused andphased implementation plan. The basis for these M & A transactions is to reach critical mass inInternet time, which will drive demand creation for both the B2B and B2C segments. Fuelingthe inertia created by USHealthNet’s channel strategy will be the Company’s vision fordeploying its iASP.

The value proposition for both the healthcare professional and consumer will be in theCompany’s ability to lower physician operating costs, increase revenues and provide quality carethrough measurable clinical outcome analysis. USHealthNet’s portal will become a trusted brandand premiere destination for brokering healthcare information, products and services thatdifferentiates and provides a sustainable competitive advantage ensuring future annuity business.

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Confidential & Proprietary Property of Richard LynesDraft Only – Page 2 - June 11, 1999

1.1 Market OverviewAccording to the Health Insurance Association of America, healthcare is the largest single sectorof the U.S. economy, consuming approximately $1 trillion annually, or 14% of the country'sgross domestic product. The healthcare industry consists of a complex mix of participants, whichincludes:

• "Providers" -- physicians, medical practice groups, hospitals and other organizations thatdeliver medical care;

• "Payers" -- the government agencies, insurance companies, managed care organizations andother enterprises that pay the bills for healthcare, this includes employers;

• "Suppliers" -- clinical laboratories, pharmaceutical companies, and other groups that providetests, drugs, x-rays and other services; and

• "Consumers" -- individual patients who receive medical care, and the government agencies,employers and other organizations that represent groups of individuals.

All healthcare participants rely heavily upon information to perform their roles in the industry.Individuals compare medical plans, choose physicians and submit claims for reimbursement.Employers select health plans, determine benefit levels, enroll employees and maintain employeeeligibility data. Providers verify patient eligibility, collect patient histories, order diagnostic testsand x-rays, receive and interpret test results, render diagnoses, make referrals and submit claimsto payers. Payers manage referrals, establish medical care protocols and reimbursement policiesand process claims. Suppliers analyze and process patient samples or tests, provide results, fillprescriptions and submit claims for reimbursement. These and many other healthcaretransactions are also highly dependent on information, and each participant is dependent on theothers for parts of that information. In sum, the finance and delivery of healthcare requires thatconsistent, accurate information be shared confidentially across a large and fragmented industry.

• The U.S. Healthcare expenditure is $1.2 trillion and growing.• Physicians control 85% of the national expenditures for healthcare.• The administrative costs for providing healthcare have been estimated at between $198

billion and $250 billion per year.• The physician market size is over 800,000 today.• Those physicians provide care to an average of 1647 patients per year; each with an annual

per capita expenditure of $3633, representing an aggregate annual billing of $236 Billion for735 million office visits per year.

Factors contributing to these exorbitant expenses are:

• Inappropriate diagnosis and prescription drug use, resulting in a significant number ofhospitalizations -- between 5 and 25 percent. The costs of treatment for inappropriate drugtherapy are staggering - estimated at $100 billion each year, National Pharmaceutical Council.

• The healthcare industry has become an information-intensive profession plagued bysubstandard methods of data collection, storage, and retrieval.

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• With over two thousand information technology vendors competing for their share of thehealthcare industry, incompatible operational and technology silos are making it difficult toexchange vital information and critical life-saving knowledge. This need strains the resourcesof the healthcare community since information must be gathered from disparate sources.

• A large part of healthcare waste is related to red tape, paperwork and decentralized datasources.

1.2 The ProblemIn providing care to those patients the physicians face similar basic challenges:

• Management of patient data during the course of their relationship• Lack of access to patient data prior to their relationship• Lack of access to patient date throughout the extended healthcare enterprise• Inconsistent processes and deteriorating relationships across providers• No communication and leverage of data beyond the practice walls• Need to keep abreast of health findings and new treatments• Need to contain costs and expand revenue opportunities

Several of the core applications needed by those physicians to manage their practices needs arecurrently not WEB enabled and less than 6% of office based physicians use any combination ofthe following Point-of-Care (POC) tools:

• Electronic Medical Records• New prescription orders and refills processing• Lab Order Entry and Results• Diagnostic Decision Support• Procurement applications

Those core applications have not penetrated the undeserved portion of this market for thefollowing reasons:

• They are primarily client server applications that are both expensive to implement (softwarelicensing, hardware, training), but are also a large distraction to the practice operation from amanagement perspective – Back Office versa Front Office.

• Managed Care has driven the cost to new levels, leaving caregivers to question the quality ofcare and their ability to earn a living and compete in the growing PPO space.

• Those practices that do invest in these applications generally only leverage a small precent oftheir value due largely to the fact that back-office billing systems are complex data entrysystems and do not extend themselves to support front-office Point-of-Care services.

• Since the applications are local to each practice, they do not receive the benefits ofconsolidated patient or treatment and outcome data across practices.

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Studies show that 94% of this market is considered "under served" by the current applications onthe market and unable to address the Point-of-Care information needs. The Total-Cost-of-Ownership1 on a per seat basis would be $150,000 dollars over five years. With more than325,000 physicians working in physician group practices, it is easy to see why turnkey systemsintegration services market segment will double in revenue by the end of the decade, from its$10 billion mark today, according to leading analyst Mike Knepper of Volpe, Welty & Co.

The domestic market for digital clinical information networks has been estimated at $350 billiondollars, international (including U.S.) at $1.2 - 1.3 trillion dollars yearly (the estimate based ondata from the World Health Organization, the U.S. Census Bureau).

1.3 The SolutionUSHealthNet’s iASP offering consists of an N-tiered application service strategy, whichconnects physicians and patients to USHealthNet’s portal through a single access point using aWeb browser based Thin-Client interface. These services integrate critical Point-of-CareKnowledge Tools allowing secure global access over the Internet. These POC tools will beoffered for free to consumers and through the Company’s premium subscription services forhealthcare professionals. Further access is offered to branded affiliate products and services,maximizing site stickiness while ensuring a consistent user experience.

USHealthNet’s Java Enterprise Beans and Corba application component framework supportingthe iASP subscription service offering will consist of nine integrated applications:

1. LifeTime (Longitudinal Electronic Medical Records)2. DiagAssist (Diagnostic Decision Support System)3. ScriptPad (Prescription and Drug Interaction Services)4. LabDirect (Lab Order and Results)5. Enterprise Workflow Engine and XFDL/XML based Forms Engine6. Enterprise Resource Planning (ERP)7. Enterprise Master Patient Index (EMPI)8. Clinical Data Repository and OLAP9. Java XML Search Engine, integrating (UMLS) Tools and semantic networks

The USHealthNet vision is to provide increased functionality to a broader cross-section of thephysician's market by breaking down the current barriers and providing the following benefits tothe physician practice:

1.3.1 Value Propositions – Physicians

• Significantly lower cost of entry (Multi-tiered subscription models)• More intuitive functionality (Web based Thin-Client)• Less intrusive infrastructure (Outsourced to ASPs) 1 Review http://www.fujitsu-computers.com/coo/main.html and http://www.info-edge.com/55090301.htm

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• Remotely managed through national network operations centers• Clinical data management and analysis (InfoMediary service)• Leverage of database beyond the practice and across the continuum of care

Additional benefits to the consumer market will be:

1.3.2 Value Propositions – Consumers

USHealthNet provides healthcare consumers with a single point of access to premium andproprietary health and wellness content. Consumers can use the information that is providedthrough USHealthNet without charge to educate themselves on healthcare-related matters,allowing them to make better informed healthcare decisions. In addition, USHealthNet candeliver personalized content and e-mail updates based on a consumer's profile and can search andretrieve member-specific healthcare information from the Web. InfoMediary service affiliateswill be marketing products against high-level patient/consumer profiles, which do notcompromise personal data, only segment level profiling data is available and this is secured in aBroadVision database behind USHealthNet’s data center fire-walls.2

Benefits to the pharmaceutical market will be:

1.3.3 Value Propositions - Pharmaceuticals

• Access to clinical data repository• Reduced new drug time-to-market expense• Access to patient base for clinical trails3

• Direct link to Physicians Desktop for promotions• Access to consumers of healthcare products

1.4 Revenue ModelsThe Company’s delivery strategy for this vision is to raise the management of these applicationsup into the network, delivering subscription access to these applications to individual practices.The applications will be Internet based, providing the scale, security and ease of use that hasbeen the hall-mark and success of the WEB today.

Key sources of revenue from this business will be:

• Subscript to Vertical Healthcare Portal (Segmented based on specialty)• Subscript service for Internet Application Service Platform (iASP – Point-of-Care tools)• InfoMediary services allowing affiliate partners to participate in the Company’s e-Commerce• Sponsorships, bounty and bundles (Up-sell and Cross-sell opportunities)

2 All personal healthcare information is highly confidential and USHealthNet understands its commitments topatient privacy and will not under any circumstances compromise a patient’s personal healthcare data3 Ibid.

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• Transaction processing (EDI Claims, patient eligibility and e-commerce)• Advertising (Using the PDA, the Company can us both a Push and a Pull model)

1.5 Capital requirements will be:

• $10 - 30 million for sales, marketing and PR, operations, partnership acquisitions, technologylicensing and development, and M & A opportunities.

• Outsourced portal development to Agency.com.• Outsourced infrastructure deployment to NaviSite, a CMGi ISP, and USinternetworking• Affiliates pre-paid or underwriting the first 100,000 physician subscriptions (General content

subscription levels, not premium, which offers iASP services)4

• To fuel the Company’s consumer e-Commerce and InfoMediary services strategies

USHealthNet’s market capitalization projections are $500 million with 10 % market penetrationare not unrealistic. Anticipated revenue growth will be:

1.5.1 Investment Opportunities

This is an early stage opportunity for investors:

• The research has been done and the business case proven• Prototypes have been developed• Business plan has been drafted• Several key members of the management team have been identified, with an eager desire to

identify additional members• Industry experts from both the medical and internet fields have committed to advisory roles• Technology partners have been identified and initial negotiations have begun• An initial venture partner has expressed a desire to participate if a second partner can be

secured

USHealthNet 's charter and strategic vision is to provide e-commerce capabilities and serviceexcellence for the healthcare industry by developing Internet transport and Web-based clinicalapplications, management services, and a community healthcare information delivery network.USHealthNet will be the premier provider of Point-of-Care knowledge tools and services for thehealthcare industry.

USHealthNet’s strategy reflects the future state, vision and direction for the healthcare industry.This premise is based on the fact that all roads lead to the patient and physician, therefore allinvestment decisions, including IT, capital and human resources need to be aligned strategicallyacross all points of patient and physician interaction.

4 The pre-paid or underwritten subscription services will be paid for in part from our shared revenue and jointmarketing programs for affiliate, and alliance partnerships

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2 IntroductionUSHealthNet will implement, operate, and support packaged Point-of-Care (POC) softwareapplications that automate the physician’s front-office processes, which can be accessed andused over the Company’s internet Application Service Platform (iASP) and vertical healthcareportal sites. The iASP services are based on packaged software applications from best-of-breedsoftware vendors. These iASP services will be deployed through USHealthNet, the Company’sbranded network operations center (NOC). The Company will target both single and a multi-physician practices; and further segmented these groups by specialty. USHealthNet’s healthcareportal has a consumer strategy reflecting trends in self-service, preventative care content andapplications.

USHealthNet’s service rollout strategy includes the following business functions in its initialrelease, which are bundled with a multi-tiered subscription service model, providing healthcareprofessionals a single point of access through USHealthNet and the World Wide Web:

• Electronic Medical Records, (consumers will have read only access).• Online Prescription Processing, (next day delivery by FedEx and UPS).• Lab Order Entry and Results, (push technology will deliver result in real-time).• Diagnostic Decision Support, (real-time feedback and differential diagnostic engine).• Relationship Management, (targeting 1-2-1 personalized InfoMediary services).• E-commerce, aggregating procurement transactions (consumer transactions as well).

USHealthNet will deploy these application services through affiliate partner data centers.USHealthNet will configure them to meet the needs of our clients, and package them withsecurity, Internet access, back-up and operational support. Our clients purchase these products aspart of a tiered subscription service model, paying us on a monthly basis as the services aredelivered.

The advantages our clients realize by subscribing to our iASP services rather than purchasing theapplication software directly and implementing it them-selves include:

• FASTER TIME TO BENEFIT. Because we have pre-configured our products and operatethem in an established environment, we can reduce implementation time significantly.

• REDUCED TECHNICAL AND INTEGRATION RISK. A single vendor, USHealthNet,takes full responsibility for delivering the service, including ongoing upgrades.

• REDUCED RELIANCE ON EXTERNAL MULTI-VENDOR SOLUTIONS. USHealthNetemployees implement and operate our applications and provide client support twenty-fourhours a day, seven days a week, allowing a Single-Point of Access.

• LOWER TOTAL-COST-OF-OWNERSHIP. USHealthNet offers its services at a lower costthan its clients would otherwise bear to implement these applications on a traditional basis,and we also reduce our clients' up-front investment.

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To deliver its services, USHealthNet will built strategic relationships with the following keynetwork providers through the development of Co-Branded Community Healthcare Portals:

• NaviSite• Digix• USInternetworking

Our secure network will incorporates a high level of redundancy, bypassing Internet congestionpoints, and enabling real time back up of client sites across dispersed geographies. As a result,we believe our clients benefit from superior response time, reliability and security.

Once an iASP contract is signed, we invest in the hardware, software and implementation neededto deliver client service. This will require a substantial investment in the early years to build ourclient base. We expect to benefit from rapidly growing annuity based revenue, which we believewill generate substantial positive cash flow in later years.

We will make substantial investments to pursue our strategy. These investments include:

• Building a global network of data center relationships• Allying with particular software providers• Investing to develop unique product features• Developing implementation resources around specific applications

Forrester Research, Inc. reports that the overall market for outsourcing packaged softwareapplications will grow from approximately $1 billion in 1997 to over $21 billion by 2001.These services include packaged application software implementation and support, customersupport and network development and maintenance. Reasons for the growth in outsourcinginclude:

• The scarcity of information technology professionals.• The challenges faced by a non-technical company in hiring, motivating and retaining

qualified application engineers and information technology employees.• The desire by companies to focus on their core business.• The difficulties that businesses experience in developing and maintaining their networks and

software applications.• The fast pace of technical change that shortens time to obsolescence and forces increases in

capital expenditures as companies attempt to keep up with leading technologies.

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3 The BusinessUSHealthNet provides a branded, integrated, internet Application Service Platform (iASP) forthe administrative, communications and information needs of healthcare professionals and forthe healthcare information needs of consumers. The Company's Web destination consists of twodistinctly different linked Web sites--a subscription-based site for healthcare professionals and afree Health, Wellness and self-service portal site for consumers. USHealthNet is a single point ofaccess to EDI services, enhanced communications services, branded healthcare content, andother Web-based offerings. For healthcare professionals, USHealthNet is designed to simplifyhealthcare practices by integrating multiple administrative, communications and researchfunctions into a single, easy to use Web-based solution.

For consumers, USHealthNet provides premium, branded content to assist consumers in makinginformed healthcare decisions, personalized information about specific health conditions targetedaccording to the medical profiles of individual consumers and content-specific onlinecommunities that allow consumers to participate in real-time discussions and support networksvia the Web. The Company's objective is to become the Web's premium brand for healthcare-related applications services, facilitating joint collaborative communications and knowledgemanagement services.

4 The Strategic OpportunityThe Company’s vision is to become the “Pre-eminent Leader” of information technology andknowledge delivery to the healthcare industry by offering client/server software applications,services, and relevant up to date information increasing productivity while managing risk.

This unique approach of mixing WEB hosted applications, services, and e-commerce capabilityresults in business opportunities forging new partnership models and marketing programs. Thesemodels and programs will maximize and leverage distribution channel affiliate partners, enablingjoint revenue sharing, joint marketing/co-branding, InfoMediary and advertising for bothUSHealthNet and its partners.

5 The Market Potential/Market Size/Market Growth RatesUSHealthNet’s iASP services allow physicians to automate their front office POC and back-office billing processes. Outsourcing these application functions through iASP services reducesthe barriers to entry for physicians. Current per physicians costs are estimated $25,000 with $5-10k for annual support just to implement Electronic Medical Records, the Total Cost ofOwnership (TCO) dilutes current ROI expectations. Estimates reveal that only 2-6% of thenations 800,000 physicians currently use an EMR system in the daily practice and a recentsurvey revealed that 67% of physicians currently use the Internet and 50% of all the Internet usescurrently search the net for up-to-date healthcare information.

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6 The Market Drivers/Key TrendsIn order to obtain service excellence, an integrated healthcare delivery system, similar to anIntegrated Delivery Network (IDN), must be developed encompassing Point-of-Care (POC)knowledge management tools: virtual medical records, diagnostic decision support, lab anddiagnostic orders, clinical pathways for disease management, drug interactions, prescriptionfulfillment, coding and billing.

We believe that the availability of Internet-enabled packaged software makes it possible, for thefirst time, to implement these applications on the Internet in predictable time frames, withpredictable costs, and without writing custom code.

The need for an integrated approach to providing these services.

Forrester Research, Inc. reports that the overall market for outsourcing packaged softwareapplications will grow from approximately $1 billion in 1997 to over $21 billion by 2001.Furthermore, according to Forrester Research, Inc., U.S. firms are now spending approximately aquarter of their overall information technology budgets on outsourcing services. These servicesinclude packaged application software implementation and support, customer support andnetwork development and maintenance.

Reasons for the growth in outsourcing include:

• The scarcity of information technology professionals.• The challenges faced by a non-technical company in hiring, motivating and retaining

qualified application engineers and information technology employees.• The desire by companies to focus on their core business.• The difficulties that businesses experience in developing and maintaining their networks and

software applications.• The fast pace of technical change that shortens time to obsolescence and forces increases in

capital expenditures as companies attempt to keep up with leading technologies.

7 The OpportunityWith healthcare expenditures in the U.S. totaling approximately $1 trillion each year andgrowing; physicians, payers, providers, pharmaceutical companies, and patients are searching fornew healthcare models that strive to contain costs and liabilities, while improving the quality ofcare through measurable outcomes, and new revenue opportunities.

Inefficiencies within the healthcare system consume enormous amounts of time, resources anddollars. It is estimated that over $250 billion, or 25% of every healthcare dollar, are wastedthrough the delivery of unnecessary care, performance of redundant tests and procedures, andexcessive administrative costs. USHealthNet believes much of this inefficiency and waste is adirect result of poor information exchange among healthcare participants. Consumers do not

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have easy access to the detailed information they need to compare health plans, select physicians,or manage their own healthcare and benefits.

Providers often lack timely access to relevant patient information, and this lack of informationcauses them to prescribe unnecessary tests or procedures and hinders their ability to diagnose andtreat patients. Providers and suppliers often rely on manual processes to share data, and errorsand information bottlenecks resulting from these manual processes cause delays in determiningeligibility, approving referrals, reporting test results and paying claims. These inefficienciescontribute to the rising cost of healthcare. As a result, the government and other purchasers ofhealthcare have increasingly placed pressure on the healthcare industry to improve the cost-effectiveness of healthcare while maintaining the quality of care.

8 The SolutionUSHealthNet believes a significant opportunity exists to leverage the power of the Internet toprovide secure, open, universally accessible network services that connect participants andautomate workflows throughout the healthcare delivery process. USHealthNet believes that sucha solution has the potential to create significant improvements in the way that information is usedby the healthcare system, enabling improved workflows, better decision-making and, ultimately,higher quality care at a lower cost.

9 The Products/OfferingsThese knowledge resources are provided and maintained, as part of USHealthNet’s syndicatedaffiliate program. A suite of Point-of-Care knowledge tools described below will be offeredbased of premium subscription services. USHealthNet will be the first Internet service to offerthese applications as a bundled service offering.

The three tiers of deployment for iASP services consist of the following:

1. Tier One is invaluable to a physician’s office. This Intranet tier integrates the front officePOC with back office billing systems, provides a POC decision-support system for thephysician, and automates all aspects of disease management, spanning the continuum of careand the extended healthcare enterprise. Tier One includes DiagAssist (Diagnostic Decisionsupport system) and ScriptPad (Prescription and Drug Interaction Database), LifeTime(Longitudinal Electronic Medical Records), LabDirect (Lab Order and Results) EnterpriseWorkflow Engine and XFDL/XML based Forms Engine, and care plan eligibility and payerformulary authentication.

2. Tier Two maintains the Master Patient Index, clinical data repository and data warehouseapplication services accessed through a secure Extranet. Tier Two is the USHealthNet ServiceCenter (NOC) which, in addition to providing the infrastructure to support practice managementservices (iASP), also handles billing, claims submission and benefits administration for eachprovider’s office transparently and automatically.

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3. Tier Three is a shared e-commerce/e-business platform and vertical portal supporting virtualcommunities on the Internet. This illustrates USHealthNet’s goal of becoming the mostefficient and comprehensive procurement and knowledge management service provider forthird party products and services in the healthcare industry.

10 The Value Proposition — Healthcare ProfessionalA Web-based Thin-Client front-end application provides a Single Point of Access for healthcareprofessionals. This reduces the need for healthcare professionals to use multiple administrative,communications and information services by integrating these applications and services via theInternet. USHealthNet will enter into relationships to assist healthcare professionals in obtainingall hardware and ancillary services necessary to use USHealthNet, including Internet access andcomputer hardware. USHealthNet’s Premium subscription access to iASP and KnowledgeManagement Services provides a suite of Point-of-Care (POC) tools, including backend EDIservices for healthcare professionals', eligibility verification, prescription processing. TheElectronic Medical Record, which manages patients across the continuum of care, ScritpPAD,Lab Order Entry and DiagAssist, a Diagnostic Decision Support tool, offer healthcareprofessionals unparalleled control throughout the life-cycle of care.

USHealthNet’s Vertical Healthcare Portal is segmented by healthcare professional andpatients/consumers, and culled by specialty. USHealthNet uses a 1-2-1-personalization enginefor physician profiling -- only branded affiliate products and services are offered and transactedwithin the site, customized physician intranets and knowledge delivery services are tailoredbased on a multi-tiered subscription model. USHealthNet intends to add services and content inthe future, including a Web-enabled medical transcription service offering, hospital/physicianreferral services and insurance benefits administration.

10.1 Ease of Use.USHealthNet will offer a bundled Thin-Client Application Suite and Knowledge Managementservices provided by a standards-based Java Physicians Desktop interface integrated with a Webbrowser. Therefore, subscribers who use the USHealthNet 's services do not require training onmultiple proprietary devices and require no knowledge of the Internet and it’s navigation issues.

10.2 Cost Savings.USHealthNet will offer tiered InfoMediary services allowing affiliate partners to marketproducts and services targeted against confidential profiles achieving true personalization acrossall points of contact insuring a consistent user experience. By aggregating physicians andreaching critical mass USHealthNet will be uniquely positioned to offer procurement services,practice management service, and other third party offerings through these affiliate partners.Physicians and patients will be offered financial incentive awards for referring non-members andby participating in other marketing programs.

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In-addition to the USHealthNet’s POC tools a unified messaging platform, supporting chat,conferencing and email service will be rolled-out. USHealthNet’s Web sites and premiumresearch and educational content will be priced competitively and healthcare professionals willpay no more for these services than if purchased individually.

11 The Value Proposition — Consumers

11.1 Premium and Proprietary ContentUSHealthNet provides healthcare consumers with a single point of access to premium andproprietary health and wellness content. Consumers can use the information that is providedthrough USHealthNet without charge to educate themselves on healthcare-related matters,allowing them to make better informed healthcare decisions. In addition, USHealthNet candeliver personalized content and e-mail updates based on a consumer's profile and can searchand retrieve member-specific healthcare information from the Web.

11.1.1 Online Healthcare Communities

Through planned acquisitions, USHealthNet will provide access to online communities thatprovide consumers with personalized information about their health conditions and allow them toparticipate in message boards, real-time chat rooms and support networks via the Web. Inaddition, online communities provide member-generated content based on shared experiences.

11.1.2 Convenience and Reliability

Through a physician's USHealthNet Web site, patients can obtain information regarding officehours, location and other matters without having to place a telephone call to the physician'soffice. In addition, patients can receive healthcare information that is reviewed and approved bymedical professionals under their physician's USHealthNet Web site--a reliable and familiarsource of information.

12 The Strategic Gripper: “That’s Fantastic”Wall Street has placed market caps of 5-20 billion plus on similar business strategies in the sameindustry segment for companies less than a year old with reported losses of more than $100million. The market potential for the segment that USHealthNet intends on pursuing is estimatedto be over $250 billion in 2000. The recent merge between Healtheon and WebMD created an800-pound guerilla with a market capitalization of $20 billion. Another one to watch is Synetics,which just completed the acquisition of Medical Manager PMS for $1.4 billion. The cat is out ofthe bag, the convergence of healthcare and the Internet will change the face of medicine forever,and the real paradigm shift has only just begun.

The reality of a $1.2 trillion dollar healthcare market with over-burdened administrativeoverhead and red tape provides a feeding frenzy for first-to-market movers and early adopters.

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The administrative and decentralized functional silos that make up the extended healthcareenterprise compound inefficiencies and are responsible for more than $250 billion in waist.

13 Advertising and Public RelationsUSHealthNet plans to evolve demand creation by launching creative advertising campaignsthrough strategic partners, Internet search engines, banners ads and more traditional media plays.The Company has started discussions with Omnicom subsidiaries that will lead to strongstrategic partnerships. These subsidiaries provide brand strategy, PR and media buy campaigns,and USHealthNet will partner with Agency.com for the development of the Company’s Portalsites.

14 The Business ModelUSHealthNet’s business model is based on the founding principle of establishing sustainablesources of annuity based revenue while exploiting business opportunities for the Company andits partners, as described.

USHealthNet offers network-based application services and information services on a transactionand subscription fee basis. The outsourced iASP model reduces the initial investment required toobtain the benefits of high-end information technology infrastructure, enabling physicians, smallorganizations and individuals to gain access to these systems for the first time. By enabling theshift from fixed information technology costs to variable costs and from a vendor/productmodels to a tiered service model, USHealthNet believes that it will be able to achieve criticalmass and broad-based adoption of the USHealthNet Community Healthcare Delivery Network.

15 Sales and MarketingUSHealthNet’s channel strategy will be organized according to its four main customer segments:providers, payers, suppliers and consumers. USHealthNet’s direct sales force will targetsignificant potential customers in each market segment by region. In certain instances,USHealthNet’s direct sales force will work with complementary brokers, value-added resellersand systems integrators to deliver complete solutions for major customers. In addition, seniormanagement plays an active role in the sales process by cultivating industry contacts.USHealthNet markets its applications and services through direct sales contacts, strategicrelationships, the sales and marketing organizations of its strategic partners, participation in tradeshows articles in industry publications. USHealthNet will attend a number of major trade showseach year and will sponsor executive conferences, which feature industry experts who addressthe information systems needs of large healthcare organizations. USHealthNet will support itssales force with technical personnel who perform demonstrations of USHealthNet’s applicationsand assist clients in determining the proper hardware and software configurations.

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16 Immediate GoalsUSHealthNet expects to accomplish the following by the end of Q-4 99:

� Secure the appropriate level of funding and high profile investment partners� Develop strategic relationships with hosting companies, i.e. NaviSite, Digex and Usi in order

to provide the data center infrastructure needed to support iASP services.� Develop syndicated content relationships with healthcare publishers.� Develop affiliate partners programs to support e-business and InfoMediary services.� Achieve milestones for Physician downloads of PDA to support service subscriptions.� Achieve milestones for Consumer B2C and B2ME InfoMediary services.

17 CompetitionUpon first glance the competitive situation may be perceived as high risk due to the large numberof Internet healthcare content sites, vendor/systems integrators, and back office billing systemvendors. However, understanding USHealthNet integrated Web service delivery model (iASP)positions the true competitive situation with a more focused strategic value proposition.USHealthNet sees short-term competition from Internet sites that have subscription modelstargeting healthcare providers and consumers. USHealthNet is differentiating itself by offeringpremium services for healthcare content alongside application services.

Many of the Company's current and potential competitors have greater resources to devote to thedevelopment, promotion and sale of their services; longer operating histories; greater financial,technical and marketing resources; greater name recognition; and larger subscriber bases than theUSHealthNet and, therefore, have a significantly greater ability to attract subscribers andadvertisers. Many of these competitors may be able to respond more quickly than theUSHealthNet to new or emerging technologies in the Internet and the personal communicationsmarket and changes in Internet user requirements and to devote greater resources than theUSHealthNet to the development, promotion and sale of their services. In addition, USHealthNetdoes not have contractual rights to prevent its strategic partners from entering into competingbusinesses or directly competing with the USHealthNet. While these statements can bepositioned as a negative resulting in a high-risk investment, they represent the reality of marketconditions for every company today and well into the future.

18 Our DifferentiatorsUSHealthNet’s value is not that it necessarily has a technological advantage, which provide asustainable differentiation. Although the USHealthNet plans on filing patents to protect itstechnology and intellectual assets, more correctly it’s the assemble of the parts, along withknowledge management services and the valuable Clinical Data resulting from the use of theUSHealthNet’s WEB Based applications at the Point-of-Care. The key strategic advantages forUSHealthNet will be its strong management team, board of Directors, advisory board, strategicpartners and the measured execution of the Company’s business plan.

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19 Use of FundsUSHealthNet’s working capital requirements for fiscal year 1999 and 2000 will be raisedthrough external private angle investors, partners and institutional equity funding vehicles in theamount of $10 million, along with additional commitments to enable the Company’s acquisitionstrategy. Projected ramp-up costs, operations, sales and marketing, and product/servicedevelopment will be running at an estimated average monthly burn rate of $550,000 for the firsteighteen months. As part of our strategy, year two revenue coupled with stock valuations andmarket capitalization, as well as a possible IPO, will be used to help fund the continued growthinto international markets and additional merger / acquisition opportunities

20 Exit StrategyUSHealthNet’s exit strategy is simple, Longer term, as measured in Internet time (12-18months), Healtheon/WebMD, Synetics and EMR (Electronic Medical Records) vendors andother competitors may begin to view USHealthNet as a valued asset. USHealthNet views itselfas a possible acquisition candidate for Healtheon/WebMD, Synetics or AOL. USHealthNet andits investors will evaluate both M & A and IPO strategies as a function of the Company’srequirements for new capital and current capital market conditions.

21 Financial Analysis/pro-forma estimatesThe following Business section contains forward-looking statements, which involve risks anduncertainties. The Company's actual results could differ materially from those anticipated inthese forward-looking statements as a result of certain factors, including those set forth under"Risk Factors" and elsewhere in this prospectus.

USHealthNet’s projected P&L statement is outlined in the table below merely as a placeholder.These projections are based on a revenue projection model and budget assumptions. Additionalassumptions are stated in the Detailed Financial Plan, available and accompanying the businessplan. This is available upon requested and upon signing a non-disclosure.

1999Forecast

2000Forecast

2001Forecast

2002Forecast

2003Forecast

Revenue 3,000,000 25,000,000 36,000,000 78,000,000 160,000,000COGSGross MarginOperating Exp.R&D% of RevenueM&S% of RevenueG&A

% of RevenueTotal Operating Exp.% of RevenueEBIT% of Revenue

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If we fail to execute our strategy in a timely or effective manner, the Company’s competitorsmay be able to seize the marketing opportunities we have identified. Our business strategy iscomplex and requires that we successfully and simultaneously complete many tasks. In order tobe successful, we will need to:

• Build and operate a highly reliable, complex global network.• Negotiate effective partnerships and develop economically attractive products.• Attract and retain iASP customers.• Attract and retain highly skilled employees.• Integrate acquired companies into our operations.• Evolve our business to gain advantages in an increasingly competitive environment.• Expand our international operations.

22 Management TeamRichard Lynes – Founder and Chief Technology Officer

Strategic Planning and Information Technology Solutions Thought-Leader, achievingimproved operating efficiency through IT and business strategy alignment, and increasedshareholder value by leveraging technology as a competitive differentiator.

Professional Competencies:

� Strategic IT and Business planning for e-commerce, e-business and KnowledgeManagement as a competitive differentiation in the B2B, B2C and B2ME markets,integrating both buy-side, sell-side and customer facing processes

� Mentoring companies executives in their migration from traditional mass marketingand operational practices to those of 1-2-1 personalization; Customer RelationshipMarketing (CRM) utilizing interactive media, database marketing, and the integrationof legacy Line-of-Business applications, including SCM, OLR and ERP solutions

� Guiding executives on the sweeping changes, trends and impacts of technology oncompetitive strategies, business objectives and business transformation

� Technical team lead on the design, development and deployment of scaleableEnterprise-wide information, software and systems architectures. SupportingIntranet/Extranet application infrastructure components for MRO purchasing and e-catalog procurement, Human Resources, Sale Force Automation, KnowledgeManagement, and strategies for linking channel partners, suppliers and customers.

Serving as CIO and CTO for several market leaders, Mr. Lynes past successes have beenachieved by developing visionary technology strategies and facilitating information flow withinthe senior management strategic planning function. By improving knowledge utilization throughlinking corporate stakeholder processes and objectives, client business strategies, and facilitating

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cooperation between cross-functional teams, Mr. Lynes insights have created a more customercentric approach and methodology.

Colleagues have often described Mr. Lynes as an approachable team player who has a provenknack of forecasting and keeping them abreast of critical changes in the dynamic, fast pacedworld of technology. His talent does not come from a crystal ball, but from a substantial careerof following the movements within both the Information Technologies and Tele-communicationsindustries.

23 Development TeamWorldmachine Technologies Corporation is a leading information technology consulting firmthat provides innovative solutions for your organization's business communication needs. Usinga structured process, we leverage best-of-breed Internet, intranet and extranet technologies tooffer you a variety of services and packaged systems. Our ultimate goal is to help you to bettermanage information and improve the way you communicate.

Our team of professionals provides you with a wealth of experience in many important areas ofinformation technology. These include Internet, intranet and extranet development, web design,database design, system administration, and system integration.

24 Advisory BoardChris Bulter –

Mr. Butler was founder and President of Interactive Solutions, an interactive strategy, interactivebranding and web systems integration firm. Mr. Butler grew IS into a 150 person company with$20m in revenue and recently sold it. Mr. Butler has 24 years experience in high technology (PCapplications, CASE tools, electronic publishing, networking). Mr. Butler is a graduate ofHarvard College (AB Computer Science 1976) and the Harvard Business School (MBA 1980).

Donald Leavitt -

Donald > Leavitt is the founder of Concord Associates, a firm devoted to the development andnurturing of seed-stage venture investments. Mr. Leavitt is also President of Dynographics, Inc.,an Internet-focused management and marketing consultancy specializing in the creation oforganizationally and strategically aligned:

• Customer acquisition, development, and retention plans,• Internet-compliant strategic marketing plans,• Internet-driven brand-building initiatives,• Interactive marketing and sales scenarios,• Strategic operating plans for new Internet-based e-commerce initiatives, and

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• Resolution and workout plans for Internet-generated channel conflict widely consideredthe single most significant barrier to success for large legacy-driven enterprisestransforming from traditional to electronic commerce channels.

Many of these issues are analyzed in depth in a case Mr. Leavitt co-authored on BronnerSlosberg Humphrey for the Harvard Business School with David E. Bell, Royal LittleProfessor of Business Administration at HBS. Most recently, Mr. Leavitt collaborated withProfessor Bell on an HBS case that focuses on donor acquisition and retention issues confrontingthe United Way of Massachusetts Bay.

Both before and after the emergence of the Internet as the channel of choice for the newmillenium, Mr. Leavitt has been providing strategic product management, M&A analysis, marketassessment, and technology evaluation services to senior management at such marquee clients asFujitsu, Ltd., Merill Lynch, Lehman Brothers, Canon USA, Worldwide Volkswagen, CBS,Eastman Kodak, Jones Day Reavis & Pogue, Ziff Davis, and the Government of thePeople's Republic of China.

In 1987, Mr. Leavitt started Spectra Sciences, a designer and manufacturer of high value added,internationally patented specialty chemicals. During his tenure as founder, CEO and CFO of thecompany, he raised nearly $3 million in seed-stage venture capital financing. Today, SpectraScience is redefining laser technology through its work with Nanocrystals.

An honors graduate of Brandeis University, Mr. Leavitt began an extensive involvement in theadvanced imaging technology at NASA's Photographic Research Laboratory in the late1960's. At NASA, he co-designed the world's first digital image enhancement system for picturestaken in space and on the lunar surface by Apollo astronauts.

After a number of successful R&D forays covering a variety of rapid access imaging systems,Mr. Leavitt went on to become the Technology Editor of Popular Photography, and theAdvanced Technology consultant for Time Magazine.

Mr. Leavitt has also written and produced major stories for Time, New York Magazine, andThe New York Times, where he was one of the first to help chronicle the painstakingrestoration of the Leonardo da Vinci's The Last Supper. In the book publishing field, he waspublicity and marketing consultant for Ansel Adams' Yosemitt and the Range of Light, one ofthe best selling big-ticket art books of all time; consulting editor for The NEw Ansel AdamsPhotography Series; and creative consultant for The Great Ladies of Jazz.

USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only – Page 20 - June 11, 1999

Wendy Roberts -

Vice President of Business Development- AGENCY.COM

Wendy brings over 18 years of marketing experience to her work at AGENCY.COM. She has

focused for the past 8 years on the interactive medium and electronic commerce, working with

many Fortune 500 companies worldwide, including IBM, NCR/AT&T, Federal Express, and

General Motors.

As vice president of business development, Wendy directly manages the stimulation of new

client opportunities.

Prior to joining AGENCY.COM, Wendy served as the Vice President of Business Development

and Marketing at Tech 2000, the leading developer of interactive communities of interest in both

the Motor Sports and Energy industries on the Internet.

Wendy pioneered the Electronic Strategies Consulting capability at Bronner Slosberg Humphrey,

which was responsible for consulting both current and new clients on the impact of interactivity

on their business landscape. Wendy’s role focused on interactive marketing and database

initiatives as well as helping Fortune 1000 clients understand the impact of interactive supply

chain, distribution management, internal process and re-engineering their business plan as

competitive differentiators.

Additionally, Wendy also served as the co-founder and chief operating officer of CommSoft

Technologies, a company that developed client-server based electronic catalog applications even

before the Internet was a commercial platform. She developed a custom application for a

software catalog and fulfillment system for NCR’s finance group’s internal, worldwide network.

USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only – Page 21 - June 11, 1999

Jack Barrette -Practice Leader

Health & Medical Practice

A seasoned management consulting professional, Jack has created total strategies from bothagency and client perspectives. He is an ardent proponent of integrated business interactivestrategy planning for healthcare and medical organizations worldwide, with over 18 years ofindustry experience.

Jack heads the health and medical practice of AGENCY.COM, one of the nation's leadinginteractive strategy, creative and technology firms. AGENCY.COM has provided Web strategyconsulting and developed interactive applications for Bard Surgical Products, Eli Lilly, Glaxo-Wellcome, Novartis, Pfizer, Kaiser Permanente, SmithKline Beecham, Harvard Pilgrim HealthCare, Columbia/HCA and a host of other medical and health organizations.

Jack joined AGENCY.COM in 1997, after engineering its merger with ECHO Strategies Group,which he founded in 1994. As a specialist in health and medical applications of interactivity,Jack helped create the nationally-recognized Six Senses Healthcare & Medical Web Site ReviewProgram. He has also led the development of interactive programs, from CD-ROMs to laptopand kiosk presentations to Web and intranet applications, on behalf of managed care,pharmaceutical, medical device and health delivery organizations.

Prior to founding ECHO, he was Director of Marketing for a national rehabilitation company,with responsibility for management of all aspects of marketing communications, as well as adedicated national sales force of over 200 professionals. Earlier, he developed the healthcaredivision of Agnew, Carter, McCarthy, Inc., one of New England's leading marketingcommunications agencies.

Jack has trained at Harvard University/M.I.T. School of Negotiation in facilitation and conflictresolution. A graduate of Tufts University, he is an active member of the American Society forHealthcare planning and Marketing, the Medical Marketing Association, and the AdClub ofGreater Boston and the New England Society for Healthcare Communications.

USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only – Page 22 - June 11, 1999

25 ConclusionIn an Innovative-Growth Paradigm, a company does something that is different from itscompetitors and that its customers perceive to be of significantly superior value. By sharing partof its superiority with its customers, generally in terms of better value, and by capturing the restas profitability, a successful company in the Innovative-Growth Paradigm simultaneously createsrapid growth in revenue, profit and shareholder value. The "something different" at the heart ofthe paradigm -- the growth engine -- can be either a strategic innovation or a stream ofproduct/service innovations, or both.

A strategic innovation engine involves a distinct approach to serving customers grounded in amore efficient and effective way of doing business. The consolidation and convergence ofoperational silos in the current healthcare market space is void of any real vision and substantivestrategy. USHealthNet has made clear its intentions and strategies for reaching its objectives.

In summary, USHealthNet’s Internet service strategy proposes to make healthcare in the U.S.more affordable and effective by bridging information systems and telecommunications,enabling the timely delivery of healthcare knowledge, while allowing authorized ubiquitousaccess across the continuum of care. Marketing, selling and developing the USHealthNetapplications and services aggressively makes USHealthNet a potential player in a trillion-dollargrowth market.

Filename: USHealthNet Business PlanDirectory: D:\NewCo\BusPlanTemplate: D:\program files\microsoft office\Templates\Normal.dotTitle: Major Bullet Points for US Healthcare Business Plan

presentation to CMGISubject:Author: Richard LynesKeywords:Comments:Creation Date: 06/07/99 12:55 AMChange Number: 61Last Saved On: 06/11/99 2:58 AMLast Saved By: ctoTotal Editing Time: 932 MinutesLast Printed On: 06/11/99 2:59 AMAs of Last Complete Printing

Number of Pages: 25Number of Words: 7,928 (approx.)Number of Characters: 48,361 (approx.)

March 21, 1999Confidential

Richard Lynes

USHealthcare, LLC ..

DestinationsDestinationsYahoo Portal

Yahoo

Portal

Yahoo

Portal

Amazon

AOL

Internet

Judy

Sam

Dave

Erick

Bill

LL. Bean

Amex

CnetCentral

MSN CNN

@home

Internet

March 21, 1999Confidential

Richard Lynes

..

B2C ModelB2C Model Portal USHealthNet Portal

PPO

AOL

Judy

Sam

Dave

Erick

Bill

CVS

ImagingCenter

Pharma

RiteAid CHIN

HMO

USHealthNet InfoMediary Revenue Model

PersonalizationXML/Engine 1-1

Rx

Dx

Rx

Dx

Channels

EMR

EMR

EMR

EMR

EMR

Physician Provider

Organization

Health

Maintenance

Organization

-

Internet

Push/Pull

USHealthcare, LLC

March 21, 1999Confidential

Richard Lynes

..

B2C ModelB2C Model

PPO

AOL

Judy

Sam

Dave

Erick

Bill

CVS

ImagingCenter

Pharma

RiteAid CHIN

HMO

PersonalizationXML/Engine 1-1

Rx

Dx

Rx

Dx

Channels

EMR

EMR

EMR

EMR

Physician Provider

Organization

Health

Maintenance

Organization

-

Internet

Push/Pull

EMR

• Rx - Over thecounter, andPrescription drugs• Dx - Diagnosis & DiseaseManagement

Scenario:Patient’s EMR ismined for patternsand compared withtheir profile (basedon heuristics poles,surveys,, andpersonality types).A patient that hasKidney stones mayreceive informationon local resourcesthat specialize inthe treatment ofthis disorder. OTC& prescriptiondrugs may beavailable or apharma companymay be conductingClinical Trails.

USHealthcare, LLC

USHealthNet InfoMediary Revenue Model

USHealthNet Portal

B2ME Model

Worldmachine Technologies Corporation

http://www.worldmachine.com/ [6/11/1999 3:14:50 AM]

Welcome!Worldmachine Technologies is a leading consulting andengineering firm specializing in the development ofhighly-functional Internet, intranet, and extranet web sites.We provide businesses with innovative and effective ways tomanage their information and improve their communications.

Our web site provides current information about our companyand the services and solutions that we offer, so please usethe links to the left to navigate throughout our site. Wesuggest that you view the company overview as well as ourseries of online solution demonstrations.

A full web site directory and search engine can also be foundon our site map (to the upper right).

Be sure to give us a call at (617) 357-4040, or email us atsales@worldmachine.com if you would like to learn moreabout what Worldmachine can do for you.

company | solutions | technology | resources | careers | contact | extranet

© 1999 · Worldmachine Technologies Corporation44 Winter Street · Boston, MA 02108 · (617) 357-4040

[Home] - Internet, intranet, extranet web development

http://www.worldmachine.com/index.html [6/11/1999 3:15:06 AM]

 

Total Cost of OwnershipFujitsu Ergo$ave - The first quantitative analysis

 Introduction

What are the real costs of owning your PC?It is a lot more than just the initial purchase price.According to the Gartner Group, the initial purchase priceof a PC accounts for only 14% of the Total Cost ofOwnership (TCO) over its average lifetime.

This is a very significant figure andone which has resulted in TCO being akey agenda item for senior ITmanagers. Many PC vendors have triedto market TCO as part of their productoffering in a vague manner - Fujitsu isthe first company to actually quantifyTCO for large companies.

By developing Fujitsu Ergo$ave,Fujitsu has taken TCO one stagefurther by developing a tool thatclearly demonstrates the savings thatcan be made specifically for yourorganisation - a quantifiable audit ofyour PC strategy.

 

Fujitsu aims to remove the jargon andexplain what TCO really means for you.

     What is Total Cost of Ownership?

    

 What do the expert researchconsultants say?

     Fujitsu Ergo$ave, what is it ?

     Fujitsu Ergo$ave in practice

     Conclusion... I want an Ergo$ave demo

 

Fujitsu - Total Cost of Ownership Introduction

http://www.fujitsu-computers.com/coo/main.html [6/14/1999 4:09:48 PM]

Filename: USHealthNet Business PlanDirectory: D:\NewCo\BusPlanTemplate: D:\program files\microsoft office\Templates\Normal.dotTitle: Major Bullet Points for US Healthcare Business Plan

presentation to CMGISubject:Author: Richard LynesKeywords:Comments:Creation Date: 06/07/99 12:55 AMChange Number: 31Last Saved On: 06/09/99 11:54 AMLast Saved By: ctoTotal Editing Time: 448 MinutesLast Printed On: 06/09/99 12:20 PMAs of Last Complete Printing

Number of Pages: 24Number of Words: 7,507 (approx.)Number of Characters: 45,798 (approx.)

Worldmachine Technologies Corporation

http://www.worldmachine.com/ [6/9/1999 12:55:05 PM]

Welcome!

Worldmachine Technologies is a leading consulting andengineering firm specializing in the development ofhighly-functional Internet, intranet, and extranet web sites.We provide businesses with innovative and effective ways tomanage their information and improve their communications.

Our web site provides current information about our companyand the services and solutions that we offer, so please usethe links to the left to navigate throughout our site. Wesuggest that you view the company overview as well as ourseries of online solution demonstrations.

A full web site directory and search engine can also be foundon our site map (to the upper right).

Be sure to give us a call at (617) 357-4040, or email us atsales@worldmachine.com if you would like to learn moreabout what Worldmachine can do for you.

company | solutions | technology | resources | careers | contact | extranet

© 1999 · Worldmachine Technologies Corporation44 Winter Street · Boston, MA 02108 · (617) 357-4040

[Home] - Internet, intranet, extranet web development

http://www.worldmachine.com/index.html [6/9/1999 12:55:15 PM]

March 21, 1999Confidential

Richard Lynes

USHealthNet, LLC ..

DestinationsDestinationsYahoo Portal

Yahoo

Portal

Yahoo

Portal

Amazon

AOL

Internet

Judy

Sam

Dave

Erick

Bill

LL. Bean

Amex

CnetCentral

MSN CNN

@home

Internet

March 21, 1999Confidential

Richard Lynes

..

B2C ModelB2C Model Portal USHealthNet Portal

PPO

AOL

Judy

Sam

Dave

Erick

Bill

CVS

ImagingCenter

Pharma

RiteAid CHIN

HMO

USHealthNet InfoMediary Revenue Model

PersonalizationXML/Engine 1-1

Rx

Dx

Rx

Dx

Channels

EMR

EMR

EMR

EMR

EMR

Physician Provider

Organization

Health

Maintenance

Organization

-

Internet

Push/Pull

USHealthNet, LLC

March 21, 1999Confidential

Richard Lynes

..

B2C ModelB2C Model

PPO

AOL

Judy

Sam

Dave

Erick

Bill

CVS

ImagingCenter

Pharma

RiteAid CHIN

HMO

PersonalizationXML/Engine 1-1

Rx

Dx

Rx

Dx

Channels

EMR

EMR

EMR

EMR

Physician Provider

Organization

Health

Maintenance

Organization

-

Internet

Push/Pull

EMR

• Rx - Over thecounter, andPrescription drugs• Dx - Diagnosis & DiseaseManagement

Scenario:Patient’s EMR ismined for patternsand compared withtheir profile (basedon heuristics poles,surveys,, andpersonality types).A patient that hasKidney stones mayreceive informationon local resourcesthat specialize inthe treatment ofthis disorder. OTC& prescriptiondrugs may beavailable or apharma companymay be conductingClinical Trails.

USHealthcare, LLC

USHealthNet InfoMediary Revenue Model

USHealthNet Portal

B2ME Model

USHealthNet

Confidential & Proprietary Property of Richard LynesDraft Only - Page 13 - May 21, 1999

USHealthUSHUSHUSHUSHealthealthealthealthNetNetNetNet, LLC, LLC, LLC, LLC

USHealthUSHealthNetCommunity Healthcare Information DeliverySystems

Prepared by

Richard D. Lynes

Executive Vice PresidentChief Technology Officer

A Conceptual Design Document forUSHealthcareNet , a visionary Healthcare

Information Delivery System.

USHealth

A ConceptualDesignDocument

USHealthcare, LLC 19993 Acorn Stree

Scituate, MA 02066Phone 781-545-3938

Email cto@mediaone.net

Community Healthcare Information Delivery Systems, DiagAssistMEDNET, and USHealthNet are trademarks of Richard Lynes.

iiiiiiiiiiii

USHealthTABLE OF CONTENTS

FOREWORD ...........................................................................................................................VI

PURPOSE................................................................................................................................. VIWHAT IS USHEALTHNET?....................................................................................................... VIWHY USE USHEALTHNET?..................................................................................................... VIDOCUMENT STRUCTURE ......................................................................................................... VI

THE CURRENT DILEMMA IN HEALTH CARE................................................................ 1

HEALTHCARE IN THE INFORMATION AGE................................................................................. 1HEALTHCARE DELIVERY TRENDS ............................................................................................ 2SUMMARY................................................................................................................................ 3

THE USHEALTHNET SOLUTION........................................................................................ 5

OVERVIEW OF USHEALTHNET................................................................................................. 5USHEALTHNET BENEFITS........................................................................................................ 6THE USHEALTHCARE VISION .................................................................................................. 7REALIZING THE VISION............................................................................................................. 8

Outpatient Encounter Scenario .......................................................................................... 8Patient Registration ...................................................................................................................... 8Appointment Scheduling.............................................................................................................. 8The Office Visit............................................................................................................................ 9Billing Process.............................................................................................................................. 9

Specialist Collaboration Scenario...................................................................................... 9ADOPTING A PATIENT-CENTRIC MODEL................................................................................. 11ELECTRONIC COMMERCE....................................................................................................... 12SUMMARY.............................................................................................................................. 13

TIER 1: PHYSICIAN/PROVIDER GROUPS ...................................................................... 15

OVERVIEW............................................................................................................................. 15ELECTRONIC MEDICAL RECORDSSYSTEM (EMR).................................................................. 15

Background ...................................................................................................................... 17Computer-Based Patient Record...................................................................................... 17Information Processing .................................................................................................... 18

Compilation of a Comprehensive Record of Care ...................................................................... 18Patient Care Processes................................................................................................................ 19

Information Presentation ................................................................................................. 20Related Data and Knowledge Bases ................................................................................ 20EMR Summary ................................................................................................................. 21

DiagAssist™.................................................................................................................... 22Drug Dose Determination ................................................................................................ 22Preventive Care Reminders.............................................................................................. 23Active-Care Advice........................................................................................................... 23Health Maintenance Tracking.......................................................................................... 24Laboratory Data............................................................................................................... 24Medical Tracking with Drug Interaction Database ......................................................... 24Electronic Signatures ....................................................................................................... 25Managed Care and Outcomes Management .................................................................... 25Summary of Medical Consult ........................................................................................... 25

PRACTICE MANAGEMENT SYSTEM......................................................................................... 25Billing and Accounts Receivable...................................................................................... 26Practice Management Reporting...................................................................................... 26Custom Templates ............................................................................................................ 26Electronic Claims............................................................................................................. 26

iviviviv

USHealth.......................................................................................................................................... 27Appointment Scheduling................................................................................................... 27Financial Accounting ....................................................................................................... 27Document Processing....................................................................................................... 27Medical Practice Consulting............................................................................................ 28Individualized Charts ....................................................................................................... 28Tracking the Insurance Plan ............................................................................................ 28.......................................................................................................................................... 29Profitability Reporting ..................................................................................................... 29RBRVS Tracking and Analysis ......................................................................................... 29Diagnostic Coding Software ............................................................................................ 30Practice Management System Summary .......................................................................... 30

SUMMARY.............................................................................................................................. 31WHAT’S NEXT?...................................................................................................................... 31

Tier 2: USHealthNet SERVICE CENTER PLATFORM .................................................... 32

OVERVIEW............................................................................................................................. 32TIER 2 FEATURES................................................................................................................... 32DATA STORAGE ..................................................................................................................... 33

Data Warehouse............................................................................................................... 34On-line Analytical Processing (OLAP) ...................................................................................... 35

ELECTRONIC MEDICAL RECORDSSYSTEM.............................................................................. 36Application Functions (EMR) .......................................................................................... 36Knowledge Acquisition Functions.................................................................................... 36

Data Sources............................................................................................................................... 37Data Entry Devices..................................................................................................................... 37Data Import ................................................................................................................................ 38Data Definition ........................................................................................................................... 38Input Identification..................................................................................................................... 38Input Validation ......................................................................................................................... 39

Storage Functions ............................................................................................................ 39Permanence ................................................................................................................................ 39Ongoing Maintenance ................................................................................................................ 39Backup and Recovery................................................................................................................. 40Durability ................................................................................................................................... 40Sabotage Precautions.................................................................................................................. 40Updating Obsolete Systems........................................................................................................ 40Administrative Processes............................................................................................................ 41

Security Functions............................................................................................................ 41Access Control ........................................................................................................................... 41Data Protection........................................................................................................................... 42Integrity ...................................................................................................................................... 42Operational Processes................................................................................................................. 43Legal and Administrative Characteristics ................................................................................... 43

PRACTICE MANAGEMENT SERVICES ...................................................................................... 44.......................................................................................................................................... 45Central Administration of Multiple Practices .................................................................. 45

ENTERPRISE-WIDE INDEXING ................................................................................................. 45Enterprise Master Patient Index (EMPI) .................................................................................... 46

Master Patient Index Requirements ................................................................................. 46Benefits of MPI .......................................................................................................................... 47Components of the EMPI ........................................................................................................... 47

MPI Functional Modules ................................................................................................. 48MPI Data Base ........................................................................................................................... 48MPI Patient Identification .......................................................................................................... 48MPI Records Management ......................................................................................................... 48

CLINICAL REPOSITORY........................................................................................................... 49SUMMARY.............................................................................................................................. 50

vvvv

USHealthTIER 3: INTERNET HEALTHCARE COMMUNITY ....................................................... 51

VIRTUAL ENTERPRISE ............................................................................................................ 52THE DIGITAL ECONOMY ........................................................................................................ 52MEDNET: THE USHEALTHCARE SOLUTION......................................................................... 53SUMMARY.............................................................................................................................. 57

USHEALTHNET TECHNICAL DESCRIPTION................................................................ 58

USHEALTHNET SYSTEM IMPLEMENTATION........................................................................... 58ENABLING TECHNOLOGIES FOR USHEALTHNET .................................................................... 59

Information Sharing System............................................................................................. 60Architecture for Information Sharing............................................................................... 60

Interface or Event Manager ........................................................................................................ 60Session Manager......................................................................................................................... 60

Gateways .......................................................................................................................... 60Models .............................................................................................................................. 61Meeting On the NET (MONET)........................................................................................ 61Future Extensions............................................................................................................. 61Value-added Agents for USHealthNet............................................................................ 61

Monitoring Agents ..................................................................................................................... 62Prioritization Agents................................................................................................................... 62Scheduling Agents...................................................................................................................... 63Filing Agents .............................................................................................................................. 63Information Access Agents......................................................................................................... 63Agent Implementation ................................................................................................................ 64An Example of Agent Implementation ....................................................................................... 65Enhancements to Browsers......................................................................................................... 65High Performance Distributed Web Servers............................................................................... 65Logical URLs ............................................................................................................................. 65URL tables.................................................................................................................................. 66Virtual URLs .............................................................................................................................. 66Groupware Applications............................................................................................................. 67Smarter Servers, Smarter Clients................................................................................................ 67Prefetching Strategies................................................................................................................. 68Hot Directories ........................................................................................................................... 68

DATA WAREHOUSING AND REAL-TIME ANALYTICAL PROCESSING........................................ 68Understanding Multi-dimensional Data .......................................................................... 68Real-time Analytical Processing (RAP) ........................................................................... 68

Other considerations about RAP: ............................................................................................... 69

REFERENCES......................................................................................................................... 70

GLOSSARY ............................................................................................................................. 71

vivivivi

USHealth

F O R E W O R D

PurposeThis paper introduces the concept of a unified healthcare delivery network,USHealthNet™, a patient-centric healthcare information system for the 21stcentury created by USHealthNet.

What is USHealthNet?USHealthNet is a collaborative, fully distributed, Internet-based service forphysicians, group practices, patients, providers, payers and other members of thehealthcare community. USHealthNet will enable physicians to free themselves ofadministrative duties and devote more time to patient care in the constantlychanging world of medicine.

Why use USHealthNet™?The mandate for USHealthNet stems from the weaknesses of the current U.S.healthcare system. This paper highlights the major shortcomings of the existinghealthcare system and describes the key factors that led to the need forUSHealthNet. The next phase in the development process is for USHealthNet tofinalize the details to progress from strategic concepts to the implementation ofUSHealthNet.

Document StructureThis paper consists of the following chapters:

� Chapter 1 presents the background research that explains the evolution ofUSHealthNet and describes the flaws in the current healthcare delivery systemfrom business and healthcare perspectives.

� Chapter 2 describes the features and benefits of USHealthNet and discusses thebusiness vision and strategy.

� Chapters 3, 4, and 5 present the three tiers of service USHealthNet offers tophysicians and group practices, healthcare networks and pharmacies, and otherprofessionals in the healthcare community.

Appendixes are attached to this document. Appendix A is a technical descriptionof USHealthNet. Appendix B is a list of references, and Appendix C provides aglossary of relevant abbreviations and concepts.

D R A F T C O N F I D E N T I A L

1111

T H E C U R R E N T D I L E M M A I N H E A L T HC A R E

espite the superb skills of U. S. physicians and advanced medical technology, out-of-control costs due largely to the lack of a comprehensive, computerizedmanagement system present the healthcare industry with a serious dilemma.

Key factors driving these escalating costs include:

� Lack of easily retrievable data about operating expenses and real costs;

� Patient records still stored on paper, which precludes the simple electronicsharing of patient information; and,

� Inadequate or out-of-date financial systems.

Another component of the spiraling costs of healthcare is the dramatic increase inmalpractice suits. Patients sometimes perceive that they have been ignored ormistreated, often because of poor record keeping and lack of time on the part ofthe physician. This sometimes results in malpractice suits.

USHealthNet proposes solving these problems with a patient-centric healthcareinformation system called USHealthNet. This system is a collaborative, fullydistributed, network-based hosting service for physicians, group practices,patients, providers, payers, and other professionals within the healthcarecommunity.

Healthcare in the Information AgeThe healthcare industry is an information-intensive profession plagued bysubstandard methods of data collection, storage, and retrieval. Sharinginformation efficiently and effectively is critical to patient care. This need strainsthe resources of the healthcare community since information must be gatheredfrom disparate sources. A large part of healthcare waste is related to red tape,paperwork, and decentralized data sources. In addition to the need to sharepatient-related information, physicians are required to routinely upgrade theirknowledge, usually from paper media, to remain abreast of developments in theirspecialties.

Chapter

D

D R A F T C O N F I D E N T I A L

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Many sectors of the U.S. economy have focused their operations aroundcomputerized systems for many years. Banks, airlines, stock markets, and evensalvage yards use computers to communicate, maintain inventory control, allocatecosts, bill, and manage major activities in an integrated, seamless manner. Theseindustries have experienced enhanced operating efficiency, improved products andservices, and, more importantly, increased customer satisfaction.

In contrast, most hospitals and clinics have computers, but relegate them toperforming isolated, administrative tasks. These tasks include billing and patientadmission, discharge and transfer functions. However, few hospitals and clinicslink caregivers over networks to facilitate electronic communication and thesharing of patient information and other clinical data. For the healthcarecommunity to benefit from the technology of the information age, they need tointegrate a comprehensive, computerized enterprise management system into theirorganizations.

Healthcare Delivery TrendsThe administrative costs for providing healthcare in 1991 have been estimated atbetween $108 billion and $135.1 billion per year.1 The rising cost of healthcarethroughout the world has created an urgent need to improve healthcareproductivity and quality. This sense of urgency has led to the development of newhealthcare delivery models, organizational transformation and restructuring, andthe redesign of healthcare businesses and clinical processes. Not only are thesechanges redefining the healthcare environment, they are also creating a demandfor a new healthcare information delivery system: USHealthNet.

The creation of this new healthcare information infrastructure requires theintegration of new and existing systems and services. One core element of thisinfrastructure includes the Electronic Medical Record (EMR) system, which willenhance and encourage the continuity of patient care through the sharing ofpatient information across networks.

Figure 1-1 illustrates current relationships between organizations within thehealthcare industry. Although electronic data sharing (Electronic DataInterchange-EDI) is a common practice in organizations that supply healthcareproviders (i.e., pharmaceutical companies), physicians have been slow to embracethis technology.

1 Lewin-VHI, “Reducing Administrative Costs in a Pluralistic Delivery System Though Automation.”

D R A F T C O N F I D E N T I A L

3333

Medical/ productsurgical

manufacturers

Medicare fiscalintermediariesand carriers

Health CareFinancing

Administration

Medical/surgicaldistributors

Electronic medicalcompanies

Claims payers-Indemnity Managedcare- Self-insured

HEALTH CAREPROVIDERS

Purchasing groups

Wholesaledistributors

Medicalprocessors

Pharmaceuticalmanufacturers

Medicaid

Self-pay

Figure 1-1: Current Relationships in the Healthcare Industry

SummaryThe U.S. health care’s current dilemma, spiraling costs due largely to the lack of acomprehensive, computerized management system, has resulted in inefficientoperations, financial waste, and frequent patient dissatisfaction.

.

D R A F T C O N F I D E N T I A L

4444

Community Health Care Information DeliveryNetwork , The Foundation of Care

Knowledge Acquisition Engine

USHealthNet Data Center

EMR/CPR

Enterprise Master Patient Index

Physician Groups Practice Services•Computer-based Patient Records•Resource Scheduling•Medical Consult

Business to BusinessBusiness to Consumer

Insurance ProductsRisk Management

Healthcare Delivery

Information DistributionElectronic Commerce

Customer Service

Re-InsuranceMarket

Technology Development

Internet Health Care Community

EPMSPoint-of-Care Services

Strategy

Clinical Data Repository

Data Warehouse & OLAP

EPMS

Knowledge Management

D R A F T C O N F I D E N T I A L

5555

T h e U S H e a l t h N E T S o l u t i o n

s illustrated in Chapter 1, the healthcare industry needs to embrace acomprehensive, computerized management system to meet costcontainment challenges.

Although most physicians and group providers believe they are using computertechnology to automate their practices, they are still frustrated by the number ofpaper- and people-intensive transactions. These tasks include appointmentscheduling, patient record management, patient referrals and consults with otherspecialists. Physicians may wish to consider how the Internet and World WideWeb can be utilized to better manage costs and patient information within theirpractices.

USHealthNet proposes a novel solution to these and other issues confrontingmedical practitioners and the healthcare community: the USHealthNet system.

The basic premise of USHealthNet is that more affordable and effectivehealthcare can be achieved by applying information systems andtelecommunications technologies and services to improve collaboration amongproviders in the healthcare industry.

This chapter introduces the USHealthNet system--the vision, features, andconcepts fundamental to the development of the project: electronic commerce,Internet-based infrastructure and patient-centric models.

Overview of USHealthNetUSHealthNet is a service that manages the information network for healthcareproviders, minimizing capital equipment purchases by local primary carephysicians. Data is collected and entered into the network through an intuitive,point-of-care device that is either kept in the examination room or carried by thephysician. An On-line Transaction Processing (OLTP) system provides fault-tolerant disaster recovery functions minimizing outdated error-prone datamanagement methods.

Chapter

A

D R A F T C O N F I D E N T I A L

6666

The USHealthNet system consists of three tiers:

� Tier One is invaluable to a physician’s office. This tier computerizes patientrecords, provides a decision-support system for the physician, and automates allaspects of practice management.

� Tier Two maintains the database and links with other physicians. Tier Two is theUSHealthNet Service Center, which handles accounting, billing and claimssubmission for each provider’s office transparently and automatically.

� Tier Three is a virtual community on the Internet, USHealthNet’s VirtualHealthcare Portal. This illustrates USHealthNet’s goal of becoming the mostefficient and comprehensive e-commerce, communications and informationprovider. Internet Application Service Platform ( iASP ) is a component basedinfrastructure for third party products and services in healthcare space.

USHealthNet BenefitsWith USHealthNet, physicians can:

� Treat patients using Electronic Medical Records (EMR) and an expert systemthat provides treatment management, reminders, alerts, and feedback (such asprotocols and clinical pathways and research findings) from distributed servicesand resources.

� Consult with remote specialists using telecommunications with enhancementsand desktop conferencing technologies in areas such as radiology (i.e., the use ofmultimedia in tandem with x-rays, scans, and ultrasound with voice-annotationscapability).

� Collaborate with groups of primary care and specialized-care providers to meet acommunity's healthcare needs through multimedia enabled healthcare deliverysystem.

Using USHealthNet, clinical administrators can:

� Schedule patient appointments, diagnostic testing and reminders.

� Track and evaluate patient outcomes.

� Interact with payers for billing, collection and formulary

Using USHealthNet, a patient can:

� Input the entire family’s medical history directly into the USHealthNet datarepository.

� Make appointments for office visits electronically or via the telephone.

� Use an optical card containing longitudinal electronic medical record heuristics.

D R A F T C O N F I D E N T I A L

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The USHealthNet VisionThe USHealthNet vision is based on the belief that information sharing,communication, and coordination are vital elements of any collaborative endeavor.

Within the healthcare domain, collaboration entails healthcare providers workingtogether to deliver quality care to their patients in a timely and cost-efficientmanner. Communication among providers and access to patient records willenable healthcare providers to make timely, informed decisions about theirpatients. The USHealthNet system will enable providers to use information fromthe most recent episode of care in the patient record. This patient-centricperspective is fundamental to quality health care.

Information sharing, communication, education and coordination — crucialaspects of collaboration — need to be integrated in a transparent manner. Weneed facilities that respond to a user request or events on a timely and consistentbasis (such as voice−database query response), and also facilities that query thenetwork for information or keep track of data and provide automatic notification.

Agent technologies are designed to provide these services. In this document, weoutline specific agents relevant to patient-centric healthcare and have integratedvarious technology frameworks that facilitate collaboration.

Standards-compliant healthcare networks must provide primary care providers,payers, and managed care organizations the infrastructure and impetus for change.Some of these organizations include a full service Community HealthcareInformation Delivery Network integrated with Community Health InformationNetwork Systems (CHINS), Community Health Management InformationSystems (CHMIS), and Hospital Information Systems (HIS).

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H e a lth C a r e C o m m u n ity :• In fo rm a t io n D is tr ib u tio n• E le c tro n ic C om m e rc e• S u p p o r t O p e ra tio n s

Figure 2-1: Information Delivery Value Chain

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A uniquely integrated expert system can operate behind the scenes, enforcing aQuality Assurance Process for care/treatment management. This is achieved bymonitoring the Electronic Medical Records encounter form and other functionalareas.

At the point-of-care contact, the physician or medical staff can invokeMediAssist , a Diagnostic Decision Support agent, by direct query or duringroutine examinations. Attending caregivers may be prompted if standardguidelines and Best Practices are being compromised. This could includeInternational Classification of Diseases (ICD-9/CPT) coding, formularycompliance, cross-referenced insurance plans, drug interactions, disease treatmentprotocols, and diagnostic test ordering.

Realizing the VisionWith the implementation of the USHealthNet vision, the following point-of-carescenarios will become routine. These situations illustrate some of the features ofUSHealthNet.

Outpatient Encounter ScenarioThe following narrative will examine a typical outpatient encounter in the nearfuture using the USHealthNet system.

Patient RegistrationIndividuals may scan on-line physician referral listings, reading profiles of localhealthcare providers, through an Interactive-TV interface or personal computer.After selecting a physician, they can interface with USHealthNet’s local ElectronicMedical Records Registry (EMRR) and provide their medical history. This modelallows all authenticated users, on local and national levels, to have access toinformation that is appropriate for their function and role. The EMRR thenprocesses the information and issues intelligent optical cards containing a detailedsynopsis of the individual’s medical history.

Appointment SchedulingWhen an individual becomes ill and needs to see his physician, he can interact withUSHealthNet’s Intelligent Scheduling Agent through the interactive-TV, PC orIVR interface. The Scheduling Agent is linked to healthcare facilities throughUSHealthNet’s secure Extranet (VPN). This software will trigger a programmedevent, which is queued with a workflow engine. Using business logic (rules) andthe expert systems agent services, the availability for the date, time and physicianrequested will be determined. Reminders are sent electronically and they may bereceived through interactive-TV interface, PC or phone mail box in either voice,video or text formats, depending on the patient’s profile. Patient-physiciancorrespondence, from lab test results to pre-natal videos and video-conferencingwill also be accessed in this way.

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The Office VisitAt the end of each business day, USHealthNet systems generate an electronicchart pull list based on the following day’s scheduled patient appointments. Theworkflow agent then queries the local Computer-based Patient Records Registryand replicates a Java EMRR container to the NT-Intranet Server in the doctor’soffice. When the patient arrives for his scheduled appointment, his intelligentoptical card signals a small transceiver, in much the same way Caller-ID works.This provides the front office staff with a screen-pop detailing encounterinformation. This information is then queued and sent over a wireless LAN to apoint-of-care (POC) device in the examining room. The POC device collects andtransmits data in the Electronic Medical Records to USHealthNet’s EMRR datacenter repository for processing. The caregiver now has the most current medicalrecord information possible on this patient.

During the office visit, the physician uses a Java-based pen tablet, NC or PDAwith voice and handwriting recognition to interact with a web browser to navigatethe encounter, billing slip, and Computer-based Patient Record. While reviewingthe patient’s medical history, lab test results and referral notes, the physicianformulates a working diagnosis. During this time, USHealthNet’s MediAssist candiagnose and present the physician with approved procedures, treatment plans andformularies based on scripted screen prompts and input from the physician.

Using the POC device the physician and authorized staff can schedule diagnostictesting, prescribe medications, and send the prescription to any pharmacy or toUSHealthNet’s virtual druggist for next day delivery.

Billing ProcessUSHealthNet can trigger the billing process by printing or electronicallysubmitting UB-92 insurance forms and invoices. This can be viewed remotely bypatients from their home or on the road, as can most other private healthcareinformation. The USHealthcare data center will process all receivables andcollections, as well as providing performance measurements and continuousimprovement to ensure quality healthcare delivery and efficient practicemanagement.

Another advantage is USHealthNet’s data warehouse repository, which uses On-Line Analytical Processing (OLAP) tools to mine the data for patterns andbehaviors that can be used for clinical trials and outcomes, process improvementsand disease management.

Specialist Collaboration ScenarioUSHealthNet allows/provides for computer-based collaboration of primary carephysicians with specialists. For example, the primary care physician is in a clinicand the specialist is in a regional hospital.

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The USHealthNet system will have the following capabilities:

� A primary care physician can order an x-ray or an ultrasound scan viamultimedia mail by attaching a specialist’s required forms (i.e., when ordering anultrasound scan, the primary care physician typically includes the prenatal flowsheets and the POPRAS form).

� A specialist can respond to a test ordered by the primary care physician viamultimedia mail by including his evaluation with the test results. In the case ofan x-ray, the radiologist would respond with the x-ray image and hisinterpretation.

� A specialist and a primary care physician can discuss a case in real-time viadesktop conferencing. The MONET system has been customized for thehealthcare scenario. In this system, the physicians will be able to see each other,talk to each other and share compound documents, type from the keyboard orinclude portions of the patient record and other important documents for pearfeedback.

� Physicians can share an application such as a x-ray viewer and jointly discuss thedata being observed. Physicians can mark up the x-ray during their discussion.The conference minutes can be archived. Voice recognition, speech-to-text andtext-to-speech methods will enable digital transcribing of consultations withautomatic soap notes updates.

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Figure 2-2: USHealthNet Infrastructure

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Adopting a Patient-Centric ModelA Patient-Centric Model (PCM) describes how operations that affect the patientare perceived, and whether those functional areas are adding value, consistency,and resolution.

The single most important feature of a patient-centric system is the ability tocommunicate seamlessly, at any time, any place, and in any way. The key to this isUSHealthNet’s dynamic and fluid communications infrastructure, shown in Figure2-2.

Developing USHealthNet’s™ infrastructure requires:

� Defining the core elements (information, systems and application architecture);

� Describing the functionality (information requirements);

P LA N N E D “IT ” IN F R A S T R U C T U R EIn te rn et/In tra ne t S trate gies

e tc . . .

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Figure 2-3: Organizational Structures

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� Identifying environmental characteristics (operational, legal, administrative,socio-political, etc.);

� Applying the model to specific domains (health care); and,

� Applying the model to a specific enterprise.

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The healthcare industry represents a model of communication, consultation andcollaboration. The USHealthNet vision is to work with the innovators in globaltelecommunications to maximize the potential of these networks. Over time wewill develop a repository of data for an international audience, thus building aGlobal Healthcare Community, cross-indexed by culture, language and geography.

This concept of communities will be replicated across our communicationsbackbone, first by focusing on an extensive Intranet strategy linking localphysician practices to an Extranet Virtual Private Network (VPN). This VPN willinsure confidentiality on the network by connecting to the Internet through asecure gateway. The USHealthNet web site will consist of local, regional, andnational communities. USHealthNet’s™ partners in the telecommunicationsindustry will provide the content, products and services, and to be configuredsimilar to an N-tiered Electronic Commerce model. USHealthNet iASP datacenters will route transactions through intelligent electronic catalogs representingsuppliers wholesale merchants, distributors and retailers.

The transaction model illustrating the transition from the current distributionchannels and supply chain logistics to the New Media vehicles and channels of theInternet is depicted below.

The Virtual Private Network will be the gateway for providing practicemanagement services to physicians, providers and payers. This includes thefollowing functional areas:

� Computer-based Patient Records;

� Billing, receivables and collections;

� Resource scheduling; and,

� Staffing and payroll.

USHealthNet will provide additional products and services in the area ofInformatics/Telemedicine. This will include video conferencing and imaging, andworkflow and document management.

Electronic CommerceElectronic Commerce is the automation of business transactions and the directcomputer-to-computer exchange of information, business documents, and money.Electronic commerce can free information from paper, allow it to be processedand re-used with little human intervention for a multitude of purposes.

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The USHealthNet vision believes that electronic commerce can be used for thecommunication between providers and payers. This includes interactions withelectronic medical claims companies, value-added networks, clearinghouses, andother organizations.

USHealthNet Electronic Commerce

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Figure 2-4: Electronic Commerce Model

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The USHealthNet system also links healthcare providers, medical/surgicalmanufacturers and distributors, pharmacies, pharmaceutical distributors andclaims payers, electronically.

SummaryIn summary, USHealthNet system proposes to make healthcare in the U.S. moreaffordable and effective by bringing information systems and telecommunicationstechnologies to the healthcare industry through a three-tiered service patient-centric model.

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The patient-centric model reflects the future state vision for the high performanceenterprise and learning organization. It operates on the premise that all roads leadto the patient and therefore all investment decisions, including capital and humanresources, need to be aligned strategically across all points of patient contact.

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T I E R 1 : P H Y S I C I A N / P R O V I D E R G R O U P S

he physician’s office will be the area most obviously affected byUSHealthNet from the perspective of the patient and the staff. It is in thissetting that USHealthNet will show its advantages most clearly.

OverviewFrom the time the patient enters the physician’s office, USHealthNet servicesstreamline the physician/patient encounter process, thereby invoking patient,physician, and office staff satisfaction. With USHealthNet, patients and physiciansneed no longer waste time using outdated methodologies or be concerned withrecalling diagnoses and prescription dosages.

Tier 1 of the USHealthNet hierarchy features three integrated services:

� Provides a migration path from a paper-based record keeping system to aElectronic Medical Record System (EMR);

� Provides a decision-support system to the physician (MediAssist); and,

� Automates all aspects of practice management using the Practice ManagementSystem.

Physicians and administrators access USHealthNet services through a workstationconnection to a wireless Intranet LAN and gateway to the USHealthNet VirtualPrivate Network (VPN). A Point of Care (POC) device, located in the treatmentroom or carried by the physician, provides information about the patient. Allpatient information is stored in a Computer-Based Record System (EMR). TheEMR comes with an innovative Clinical Decision Support System, MediAssist.

Electronic Medical Records SystemCurrent health information systems do not adequately reflect appropriateness ofpatient care treatment decisions nor the ability to analyze the real costs associatedwith that care. This lack of support is reflected in the incomplete capture ofpatient data and the sometimes inaccurate coding of patient medical diagnoses forreimbursement.

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The USHealthNet Electronic Medical Records System (EMR):

� Facilitates the capture, storage, processing, security, and presentation ofelectronic medical records

� Supports all healthcare provisioning and organizational processes

� Provides a communications link to related data and knowledge systems

� Meets all clinical, legal, and administrative requirements

Figure 3-1: EMR System Components

The EMR system provides for the collection, merging and processing ofinformation from multiple, diverse sources. For example, text, audio, video,images, graphics, and digitized x-rays can all be stored as part of the patientrecord.

The flexibility of the EMR system allows each department, service, specialty, orcaregiver to create views, reports, graphs, and other on-screen and hard-copyoutput custom tailored to the individual or function.

Inference Engine & Natural Language ProcessorInference Engine & Natural Language Processor

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ScriptPAD :•Drug Query Services•Drug - Interactions•Drug Side Effects•Drug Dosages•Patient Information

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BackgroundCurrent information systems merely describe the patient's ailments and thetreatment rendered. Data is stored in ways that hinder retrieval and makingcomparisons between patient groups with similar complaints/symptoms difficult,if not impossible. In many healthcare settings, patient information is stored onpaper because of “quill pen laws” that require handwritten signatures.

Another problem with the current state of medical record keeping is that, in manycases, patients have insufficient information to make informed choices about thehealth insurance plans, health institutions, and providers available to them.Conversely, providers of care have insufficient means to keep abreast of all thecurrent information generated in their specialty fields. Moreover, they are oftenunable to garner all relevant information on a patient when making medicaldecisions. Health organization administrators are hampered in their ability tomerge administrative and clinical information to make rational choices concerningresource allocations, quality of care, and product and service pricing. Payers haveinsufficient information to determine which formularies and which providers yieldthe best value and measured outcomes for their clients.

A Electronic Medical Records (EMR) system includes all the elements thatfacilitate the capture, storage, processing, communication, security, andpresentation of patient information. The EMR system supports healthcareprovisions and organizational processes and provides communication links torelated data and knowledge systems.

Specific functions must be in place for Electronic Medical Record System tosupport the provision of healthcare in any organizational context. The EMRsystem provides these functions, as well as links to domain-specific operationalprocesses.

Electronic Medical RecordAn EMR contains information about an individual's lifelong medical history, fromboth structured and unstructured data. Three things characterize this information:

1. Content (categories of data from multiple sources for different uses by multipleusers);

2. Representation (structure – natural language or an abstraction thereof, and form –text, voice, image, etc.); and,

3. Time continuum (providing a chronology of health information across anindividual's life).

The EMR replaces the paper medical record as the primary record of care whilemeeting clinical, legal, and administrative requirements. The EMR is also morecomprehensive than today's medical record because it integrates information frommultiple sources and provides decision support. The EMR is the primary sourceof information for patient care.

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Information technology now permits much more data to be captured, processed,and integrated. The Electronic Medical Record is not a single repository ofinformation, but a collection of health information from disparate sources. Forexample, x-ray images previously stored separately from the medical record can bestored digitally with their interpretation in the computer-based patient record.Likewise, technology may enable the digital storage of a videotaped consultation inlieu of a separately compiled report; summarization can occur through theabstraction of key elements.

The Electronic Medical Record integrates health information from externalknowledge bases to supply rules-based, logic-driven decision support. Thisdecision support illustrates the significant impact the EMR system has onhealthcare process and outcomes.

A Electronic Medical Record is most beneficial when users actively integrate itwith patient care. The EMR’s point-of-care, real-time use provides the mostcomplete and accurate data resource available, as well as the opportunity torespond to reminders and alerts as they are generated. The EMR is also a resourcefor use beyond direct patient care. Patient data contributes to healthcare bypromoting the evolution of data on the effectiveness and efficiency of clinicalprocesses, procedures, and technologies. The EMR contributes significantly to theenhancement and management of the healthcare system’s discipline of datacollection and its subsequent use.

Information ProcessingApplication functions enable the effective processing of data from all sources intouseful information. This ensures the compilation of a comprehensive record ofcare that may be used in patient care and administrative processes. Thesefunctions include the planning of care, resource scheduling and deployment,decision support, caregiver problem solving, rationales for clinical decisions, aswell as the continuity and completion of patient care processes.

Compilation of a Comprehensive Record of CareA comprehensive record of care incorporates all types of patient care services andprovides information for patient care, business management, complying withthird-party requirements, and scientific advancement. Information is presented ina systematic and uniform manner, which is also flexible for localization.

Information compiled through the EMR system is comprehensive. It includeshealth data about illness and injuries, as well as genetic background,immunizations, risk factors, behavioral data, environmental factors, and healthstatus. This information is drawn from an array of sources: administrative (patientdemographics), provider identification, financial data, and legal documentation(i.e., consents, authorizations, and advanced directives). Information is integratedlogically from any unit in the healthcare organization that collects data: anemergency department, inpatient/outpatient hospitalization, an ambulatory careclinic, home health care, or a nursing home.

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Patient Care ProcessesThe EMR system fosters the integration of clinical information withadministrative data to schedule events, assign responsibility, project resourceutilization and costs, initiate processes, and coordinate associated events.

Specifically, the EMR system enables:

1. The use, monitoring, customization, and evaluation of care protocols.

2. Problem lists development, maintenance, and updating in real-time.

3. The integration of patient data with external data from knowledge sourcesto supply rules-based, decision-support for condition-predicated actions.These include notifications, alerts, prompts and reminders about duplicateservices, conflicts, interactions, scheduled events, and required follow-up.

4. The EMR system documents healthcare provided and the rationale forclinical decisions.

Retrospective data management is provided through the EMR system to conductproductivity assessments, variance analyses, standards compliance, performancereviews, epidemiological surveillance, ad hoc queries, and audit trails. The systemcould also supply selected information for community, state, and regionaldatabases, third-party payers, communicable disease reporting, accreditationrequirements, as well as education and research.

The EMR system provides not only for the creation of an individual patient'shealth record, but also the ability to link multiple patient populations whereappropriate. For example: mother and child, multiple births, next of kin, familygroups, guarantors, insured and subscriber, and emergency contacts.

Information processing displays quantitative data, as well as tabulating, arranging,graphing, collating, comparing and contrasting, summarizing, and performingother mathematical analyses. It would also index, code, classify, and formatqualitative data. As a multimedia record, it would integrate text, audio, video,image/graphics, and waveforms.

Figure 3-2 shows how USHealthNet’s™ Electronic Medical Record linksinformation to users in the medical community, including the provider’s office.

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Figure 3-2: Process and Information Links

Information PresentationThe wealth of information available through the EMR system will be managed sothose authorized users receive the information they need in a format they prefer.Providers, for example, may desire customized views of data by patient, source,provider, encounter, problems, dates, or other variables. Data can be presented indetail or summary form. Graphical user interfaces and other emerging ease-of-usetechnologies can accommodate tables, graphs, narratives, and other formats forthe display of information.

The EMR system will be sufficiently flexible so that each department, service,specialty, or provider can create customized views, personal order sets, patient-centered care plans and critical paths, special notifications, and tailored work lists.

Selective retrieval also helps maintain patient confidentiality. For example, someusers may need to know only of the presence or absence of certain data, not thenature of the data. Identifying information could be removed so that the datacould be used for education or research. This is accomplished through

USHealthNetNet’s™ clinical workstation which is the front-end to our repository.

Related Data and Knowledge Bases

Access to related data and knowledge bases which contain medical literature,clinical guidelines for diagnosis and treatment, outcomes studies, and medicationalternatives is integral for the EMR to enhance the healthcare process and results.There is a continuum of sophistication in information processing regarding relateddata and knowledge bases. Specifically, this includes the ability to displayaggregated data in multiple formats, accessing similar cases for comparativestudies, as well as decision-support systems (comprehensive rules-based, logic-driven alerts, reminders, and forecasts).

Basic use of data and knowledge bases can be found in an EMR system that plotslaboratory test results over time in a table or graph. A more sophisticated processcould integrate laboratory data with vital sign and medication information.

The EMR system could also compile patient information characterized by similardiagnoses and treatment protocols. Data and knowledge bases could also displaypricing information for medications, or instructional material for alternativetreatments for common conditions (i.e., prostrate problems).

The computer can integrate data from external sources and effectively display thisinformation. Information from these resources can provide significant value to theuser.

Examples of useful external resources include:

Patient BillingPatient Billing

Office AutomationOffice Automation

SchedulingScheduling

Medical ConsultMedical Consult

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� Procedure pricing database;

� Pharmaceutical formulary database;

� Physician referral database;

� Medline;

� Videotape resource library; and,

� Scheduling system.

Consumer health education may also be included in data and knowledge basesupport. Access to the Internet and its forums, chat rooms, bulletin boards, lists,and e-mail provide a growing and important source of information for patients.Some patients may access Medline and other scientific information; however,much of this information is "unfiltered." This means that there may not be ascientifically recognized authority associated with the information. The influenceof this information could be significant.

EMR SummaryThe USHealthNet Electronic Medical Records Management System is a vital toolto augment the accuracy, efficiency, accessibility, and control of patient recordmanagement.

Below is a summary of the main features:

� Allows for complete progress notes;

� Maintains problem lists;

� Provides user-definable patient medical , social and family histories;

� Tracks patient medications and allergies;

� Stores patient vital signs, immunization record and health maintenance status;

� Maintains complete laboratory data;

� Stores correspondence, including consultations and letters;

� Provides user-definable categories of patient information;

� Tracks patient prescriptions and identifies harmful interactions andcontraindications;

� Prints patient records and summary sheets;

� Stores x-ray, EKG, pathology, special studies, and microbiology data;

� Contains highly selective progress note retrieval capabilities;

� Exports selected data for statistical analyses (useful for research or education);and,

� Allows remote access (i.e., from home, hospital, or clinic).

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This comprehensive system allows the collection and storage of complete progressnotes, problem lists, past medical history, laboratory data, vital signs, medications,and health maintenance status without changing how medicine is practiced.The EMR user interface is sophisticated, yet easy-to-use. Most patient data isentered directly from progress notes; the EMR automatically updates new patientinformation, entered directly or through transcriptions. This means that all patientrecord data is the most current information available on the patient’s medicalstatus.

The EMR system maintains complete progress notes, allowing the user to decidewhat information should be contained in the patient's medical, social and familyhistory and in what order it should be displayed. Problem lists, medications andallergies are displayed on the chart summary screen for quick reference. Completehealth maintenance and immunization status is recorded using either standard orcustomized templates, depending on each patient's requirements.

As rich as these requirements may appear, their impact is not fully realized withoutthe integration of other components, which are detailed in the following sections.

MediAssist™MediAssist is a Clinical Decision Support System (CDSS) designed to assist theclinician in determining the patient’s diagnosis or the condition underlying his orher complaint. MediAssist can suggest one or more possible diagnoses based onthe patient’s medical records, signs and symptoms, physical findings, test results,and background information.

MediAssist functionality includes patient diagnosis, drug dosage determination,preventive care reminders, and active (diagnostic or therapeutic) care advice.MediAssist may be invoked by direct query by any caregiver. It is tightlyintegrated with the USHealthNet EMR module.

Drug Dose DeterminationThe MediAssist system can assist the clinician in determining the proper dosage ofa specific drug, either as an exact quantity or as a recommended range, for aparticular diagnosis and patient, cross-referencing data points in medical recordswith health plan/payer formularies. The algorithms in the knowledge base thenascertain the proper dosage of the drug being prescribed. MediAssist also providesa hyperlink to an on-line Physician’s Desk Reference (PDR) and drug-interactionsknowledge base.

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Preventive Care RemindersMediAssist is designed to remind the clinician to administer preventive healthmaintenance services when necessary; examples include retinal examinations fordiabetic patients and routine immunizations. Computer-aided diagnosis and drug-dose determination are usually designed to provide a single report on a specific setof data on a patient; a preventive care reminder module, however, requiresrepeated input of data on the patient over a period of time. This includes not onlythe patient’s diagnoses and other clinical characteristics, but also the treatmentsand tests administered and their dates.

Additional examples of preventive care reminders include blood pressuremonitoring and cervical cancer screening. MediAssist elicits backgroundinformation and risk factors from patients, then compares this information todetailed preventive care guidelines, identifies potential problems, and recommendsappropriate interventions.

Active-Care Advice MediAssist is designed to assist the clinician with preventive diagnostic ortherapeutic procedures (including pharmaceutical treatments), particularly forpatients suffering from chronic health problems. MediAssist’s active-careadvisory module requires input from the EMR system on the patient’s healthproblems, tests, and treatments over a period of time. MediAssist specifieswhich diagnostic and therapeutic procedures should be performed at each stageof the health problem presented. MediAssist computer-based clinical advice cantake five basic forms:

1. TREATMENT RECOMMENDATIONS (including pharmaceuticals).MediAssist can provide diagnostic and treatment advice. For example, aDSS would recommend the appropriate antibiotic for patients withmeningitis, based on any known allergies of the patient and the organism’ssensitivity. This information would be derived from an EMR.

2. REMINDERS to perform specific diagnostic or therapeutic procedures forpatients with chronic health problems, such as adult respiratory distresssyndrome.

3. ALERTS regarding potentially adverse events based on abnormal testresults. An example might be a deterioration of the patient’s condition.

4. FEEDBACK and PROMPTS regarding testing and treatment options,physician orders, and the entry of information on the patient’s medicalhistory. Specific Feedback and Prompts include:

� Possibly injurious effects from drug and dietary supplement interactions;

� Possible conflict or redundancy between diagnostic tests ordered for apatient;

� Projected test results based on the patient’s history and current clinicalcondition. If the probability of an abnormal result is low, the provider canreconsider whether the test is appropriate at that time;

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� Results of previous tests that are similar to the one being ordered; this allowsthe provider to reconsider whether the test needs to be repeated at that time;

� The cost of a test or treatment; this allows the provider to do a risk-benefitanalysis and reconsider whether it is appropriate at that time; and,

� Alternative tests or treatments that would be less expensive than the oneordered.

5. PROGNOSES of intensive-care unit patients. These prognoses are basedon the severity of the illness (using vital signs and other physical measures)and physiological reserve (age and general health). MediAssist is also used todetermine the severity of the illness and risk-adjusting outcome measures.An expanded prognostic model is designed to predict survival to 180 days(rather than to discharge); it includes patients who are not acutely ill.

Health Maintenance TrackingThe Health Maintenance module is invaluable for improving patient care.Standard health maintenance templates, based on age and gender, comprise astandard dataset within the system. These templates may be customized to trackhealthcare requirements for groups of patients or individuals more closely. TheHealth Maintenance Tracking system reminds the user about a patient's healthmaintenance needs on each visit. It also generates patient reminder cards for pre-and post-visit follow-up.

Laboratory DataThe USHealthcare Medical Records System stores complete laboratory dataincluding CBC, urinalyses, blood chemistries, microbiology, special studies, andmiscellaneous tests. Abnormal results are flagged and are easily distinguished fromresults in the normal range. The system also records the results of diagnosticprocedures such as EKG, pathology, and x-ray reports.

Medical Tracking with Drug Interaction DatabaseThis system tracks current and previous medications, presenting collectedinformation chronologically in a multi-date inquiry. Prescriptions are printedquickly and accurately, enhancing patient relations and ensuring precise results.Prescriptions are printed on standard prescription forms. They include refilltracking, drug allergies, and contraindication information.

A complete drug interaction database is integrated with the Computer-basedPatient Records System; this feature allows the provider to maximize accuracy andefficiency when prescribing medications. The system supports full Electronic DataInterchange protocol standards for electronic transmission through the InternetHealthcare Community’s virtual pharmacy (EDI. x.12 and x.435).

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Electronic SignaturesWhether a progress note is entered directly by the physician or dictated and thentranscribed, the physician is required to sign the note electronically. Thiselectronic signature is password-protected as well as encrypted for completesecurity. Digital certificates and authentication mechanisms enable additionalsecurity levels to be implemented depending on the organization’s policies.

Managed Care and Outcomes ManagementUSHealthNet’s Managed Care System offers administrative functionality formanaging relationships with managed care carriers and for monitoring andanalyzing the profitability of individual contracts. This Managed Care System letsoffice staff handle the requirements of participating in managed care withoutdisrupting the practice. This results in significantly enhanced informationmanagement through more efficient data collection techniques.

Summary of MediAssistDecision support provides interpretive information processing. It is based onlogical conditions or rules, but still displays practicable results for the provider andpatient to use when making healthcare decisions. For example, the medicationpricing display could be expanded to include providing alternative medicationsbased on a patient's profile. This provides the ability to make choices that are bothefficacious and cost effective.

Practice Management SystemUSHealthNet Practice Management System performs powerful billing andaccounts receivable functions that meet the requirements of solid financialmanagement. This service can meet a diverse array of requirements for all types ofmedical practices: single physician offices as well as large multi-physician, multi-specialty group practices.

The USHealthcare Practice Management System is integrated with the EMRsystem and the MediAssist module to provide the following functions:

� CPT/ICD-9 reimbursement coding, billing, accounts receivable and collections;

� Electronic claims submission and EFT through factoring of receivables;

� Practice management reporting and clinical outcome analysis;

� Appointment, resource and facility scheduling;

� Medical records, treatment and disease management ;

� Financial and cost accounting;

� Document, image and workflow processing

� Medical practice management consulting;

� Managed care and outcomes management;

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� Insurance tracking; and

� Process re-engineering.

Each of these features has been designed for simplicity of operation, ease of chargeentry, audit control, and on-demand reporting to provide the highest level offunctionality and operations.

Billing and Accounts ReceivableThe USHealthNet billing and accounts receivable function includes open-itemprocessing, which is the most critical feature for maximum utilization of anypractice management system. It also features split billing capabilities for insuranceand self-pay services, automatic printing of third-party forms, account aging basedon billing dates, and report generation capabilities that include Collection Reports,Unpaid Claims Reports, and Procedure Analysis.

Practice Management ReportingThe reporting function of practice management represents one of the mostcomprehensive sets of management reports available to medical practices. Itprovides a true analysis of a practice’s financial history, its current position, as wellas projections for the future. This practice analysis is available through reports thatmonitor patient movement, physician productivity, collection ratio by payer, andcontractual receipt analysis.

Custom TemplatesThe USHealthNet Custom Templates function enables medical and clericalpersonnel to record and analyze medications, treatments, test results, and otherdata related to patient care.

Electronic ClaimsThe Practice Management System is designed to submit claims electronically anddirectly to Medicare, Medicaid, Blue Cross, or an HMO. Electronically submittedclaims are paid more quickly, and the possibility of data entry errors is eliminated.Sophisticated file transfer and error checking routines ensure data integrity; hardcopy reports maintain a clear audit trail.

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Claim Transaction Flow

Data Center FacilityManagedCare Facility

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Appointment SchedulingThe USHealthNet Appointment Scheduling function is a fully integratedcomponent that helps provide consistency and accuracy in scheduling patientappointments. It can be tailored to the requirements of individual providers andlocations and is completely integrated with patient demographic information.

Financial AccountingIn order to meet the financial reporting requirements of medical practices,USHealthNet’s financial accounting functions include payroll, general ledger, andaccounts payable. These sub-systems enable a practice to produce operatingstatements, balance sheets, payroll checks/registers, W-2 forms, and vendoranalyses.

Document ProcessingThe USHealthcare approach to a practice’s word processing needs isWordPerfect . WordPerfect’s word processing, formatting features and user-friendly interface allows users to quickly and efficiently produce crisp,professional-looking letters and documents.

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Medical Practice ConsultingUSHealthNet 's Practice Review Analysis contains a variety of graphs depictingvital statistics culled from the practice's month-end reports. The presentationreport will contain analyses of both practice and individual provider totals. Thesegraphs and statistics provide analyses for the following:

Practice Totals� Practice by provider;

� EM service levels against a bell curve;

� Payer mix of practice (pie chart);

� Aging by payer mix (pie chart);

� Aging of services and payments by payer mix;

� Chart comparison of the number of new patients in a given time period;

� Chart comparison of the number of patients seen in a given time period; and,

� Chart referral analysis information by dollar volume for the top 15 referringphysicians.

Individual Provider Totals� EM service levels against a bell curve;

� Payer mix of provider;

� Aging by payer mix; and,

� Aging of services and payments by payer mix.

Each physician would receive a copy of the practice totals report, as well as his orher own totals. A master copy of all the analyses will also be included.

Individualized ChartsEach physician or user may enter progress notes in a way that works mostefficiently for him or her. Templates may be used to standardize or customize thedata entry process, or the entire note may be entered in free-form text. Thetemplate process uses a building block methodology, where the user chooses theorder in which the data appears. This allows templates to be as simple or ascomplex as the user prefers.

Tracking the Insurance PlanThe USHealthNet Managed Care System tracks critical information at theinsurance plan level. This allows the system to accurately track capitated, fee-for-service, and non-covered services on a procedure basis for each benefit plan.

The system maintains eligibility dates for insurance coverage, alerting the operatorfor non-covered services due to ineligibility. This allows the user to bill the patientor a carrier to expedite reimbursement.

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A practice may develop and maintain custom screens and reports for entering,tracking and printing referral authorizations.

Provider Transaction Flow

D ata Center FacilityM anagedCare Facility

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(future)

Profitability ReportingThe USHealthNet Managed Care System also offers comprehensive managementreporting for analyzing the profitability of health plan participation. Through detailor summary reporting, the system compares standard fee-for-service rates againstcapitated payments. Capitation methods include per member visit per month, permember per month, and flat fee per month. These reports provide administratorswith concise management data on each individual plan.

RBRVS Tracking and AnalysisA complete RBVRS system is included with the USHealthNet Managed CareSystem. RBRVS fee schedules may be maintained in addition to standard fee-for-service fee schedules, with an RBRVS calculator for checking calculations. Thesystem maintains historical payment information and allows RVS fee maintenancefor any carrier.

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Diagnostic Coding SoftwareThe keys to reimbursement are fully describing patient encounters with accurateand medically specific diagnoses and coding bills correctly. The emergence ofRBRVS and the new Medicare coding regulations have made coding accuratelyessential in order to avoid arbitrary down-coding and rejected claims.

Until recently, ICD-9 codes did not affect reimbursement; most practices thoughtof their diagnostic coding as a simple "fill-in-the-blanks" process. In the ever-changing coding game, however, Medicare and other carriers have linkedreimbursements to the ICD-9 codes submitted for reimbursement.

By avoiding not-otherwise-specified (NOS) codes and using the most accurate andspecific code available, a practice will maximize reimbursements from insurancecarriers build a more accurate practice profile and greatly reduce the chances ofhaving a Medicare audit. Previously, coding from a superbill was adequate fordiagnosis coding; however, with the new coding regulations, Medicare hasannounced it will audit the inordinate use of NOS codes. Because of spacelimitations, superbills traditionally have relied heavily on the use of NOS codes.Physician’s practices now need to code more accurately and thoroughly in order toproperly document every patient encounter and maximize reimbursement.

USHealthNet’s ICD-9 codes use a Ranking System that assists in coding the"Code Underlying Disease" and "Use Additional Code" schema as well asaccurately sequencing multiple diagnoses to the AHA guidelines. This results inthe most appropriate diagnosis for reimbursement being ranked first.

A few key strokes is all that is needed to specify codes for more than 55,000diagnoses in a fraction of the time it takes to identify them in a book or acomputer file. A 4th or 5th digit menu is shown for any diagnosis code that musthave a digit or digits appended to the base code to achieve the highest level ofaccuracy.

“E-Codes”, "Code Underlying Disease," "Use Additional Codes," and “AIDSCodes” are pre-programmed to make the process of coding easier and less timeconsuming for the coder. The automatic prompts save the coder time and energybecause the additional information needed is accessible with a single keystroke.

Integrating USHealthNet’s ICD-9 codes directly into the Practice ManagementSystem maximizes the benefits of this system. This integration allows data entryoperators to code completely and accurately during the charge entry process; thisensures that the correct codes are submitted for reimbursement.

Practice Management System SummaryFor cost reduction and more efficient use of personnel and equipment, thePractice Management System is an essential component of USHealthNet It is asolid financial management tool with billing and accounting functions, electronicclaims submission, financial and cost accounting, and much more.

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SummaryFrom increasing accuracy, efficiency, and accessibility, to controlling all aspects ofpatient record management, USHealthNet Tier 1 services is a vital component inthe healthcare provider’s office.

The comprehensive Electronic Medical Records System allows storage ofcomplete progress notes, problem lists, past medical history, laboratory data, vitalsigns, medications, and health maintenance status without changing the way aphysician practices medicine.

The EMR system maintains complete progress notes, allowing the user to decidewhat information should be contained in the patient's medical, social and familyhistory, and in what order it should be displayed. Problem lists, medications andallergies are displayed on a chart summary screen for quick reference. Completehealth maintenance and immunization status are recorded, using either standardtemplates or by customizing for an individual patient's unique requirements.

The MediAssist system provides true decision support, adding the dimension ofprocessing that offers treatment advice and recommendations based on logicalconditions or rules. This support system enhances the physician’s ability to makechoices that are both productive and cost effective.

The Practice Management System provides functions needed to manage anefficient, cost-effective medical practice. For cost reduction and more efficient useof personnel and equipment, the Practice Management System is a vitalcomponent of the Tier 1 services at the provider office.

What’s Next?Although physicians and administrative personnel access Tier 1 services from theirpractice location, these services will be stored and managed at the USHealthNetService Center.

The USHealthNet Service Center forms the Tier 2 service offering in theUSHealthNet solution. USHealthNet’s Service Center will handle the accounting,billing, and claims submission for each provider office transparently andautomatically.

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T i e r 2 : U S H e a l t h N e t S E R V I C E C E N T E RP L A T F O R M - ( I A S P )

he last five years have seen the shift to managed care drive healthcareproviders from a hospital-centered focus to a patient-centered focus.

More than 80 percent of the 5,500 acute-care facilities in the United States arenow affiliated with some type of health-care network. This figure is expected toincrease to 100 percent by the year 2000, when experts predict the market will beconsolidated into just a few hundred large, affiliated, integrated-delivery systems(IDS).

OverviewThe shifts in the health-care market mean that potentially most providers will joinextended enterprises, which will seek to differentiate themselves in order to attractphysicians to their networks. To be successful, many enterprises will re-engineerthe healthcare process by emphasizing the sharing of clinical information.Information systems, once limited to bill processing, will focus on patient-centered computing to support the analysis and improvement of patient care andto effect cost reductions.

To support the challenges of increasingly complex and heterogeneous computingenvironments in the healthcare industry, enterprise information technologyinfrastructures require higher levels of inter-operability between applications.

USHealthNet is meeting these challenges through the services of USHealthNetService Center, the second tier and the kernel of the USHealthNet infrastructure.

Tier 2 FeaturesThe USHealthNet Service Center maintains the data and applications that supportthe EMR system and the Practice Management system used by the provideroffices. It also maintains a data warehouse, clinical repository, Enterprise MasterPatient Index (EMPI), and a front-end/back-end electronic commerce system toprovide services across the Internet to the international medical community.

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The data warehouse stores all patient information, both clinical and financial. Dataflows between the data warehouse, the Enterprise Master Patient Index, the EMRand PMS databases as information is accumulated at the point-of-care. In addition,USHealthcare extracts data from the data warehouse into a clinical repository foranalysis by various members of the healthcare community.

All members of the healthcare community, from providers to payers, will benefitfrom these services through:

� More efficient clinical management;

� Increased quality control;

� Reduced costs;

� More accurate billing; and,

� Support for clinical and health services research.

Data StorageThe health sector has lagged far behind other sectors of the economy in applyinginformation and communication technologies. As a result, valuable patientinformation is entered multiple times and it is not widely shared. Paper output ismanually filed into patient records.

Patient records stored on paper do not provide for efficient clinical management,quality control, cost allocation, accurate billing, or easy access for clinical or healthservices research. The paper record is often not available to the clinician whenneeded.

The course of the patient through the health system is frequently obscured by thelack of documentation on decisions, consultations and the sequence ofinterventions the patient experiences. Thus, it is difficult to trace a patient’smedical history and it is impossible to aggregate data across a large number ofsimilar patients. In addition, it is unlikely that all useful medical knowledge can beextracted from the ongoing treatment of the patient.

Without reliable and comparative performance feedback to the healthcareprovider, it is unlikely that improvements in care can be effected. Reliablefeedback requires uniform vocabulary and coding standards for healthcareconditions, diagnoses, and procedures.

Furthermore, without an active communications interface among providers, it isdifficult to bring the rapidly growing knowledge from biomedical research toproviders and patients, especially in under-served urban and rural areas.

The ultimate goals of data storage are to generate knowledge about the treatmentsand technologies that work best for specific clinical conditions, to have thisknowledge available at the point of service, and to provide medical decisionsupport to providers and their patients.

USHealthNet can help attain these goals by:

� Supporting patient and administrative data analysis;

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� Assisting in data evaluation;

� Disseminating data;

� Converting data into useful knowledge; and,

� Protecting data confidentiality.

The geographical variations in medical practices regarding the best treatment forpatients with similar conditions have elevated concern about the quality of carebeing delivered. Analyzing patient data from communities and providing feedbackabout these findings to providers and consumers can help improve the quality ofcare. It can also help promote life-long learning for healthcare providers who findit difficult and time-consuming to keep up with the flood of new information inbiomedical research and clinical practice guidelines.

Data WarehouseToday's competitive business environment combined with more affordablecomputing power has had a significant impact on business systems, creating aneed for ever more complex analyses of increasing volumes of complex data.

GLOBAL INFORMATION WAREHOUSEARCHITECTURE

Government, int’ llocations, etc.

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Figure 4-1: Data Warehouse Architecture

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On-line Analytical Processing (OLAP)One of the technologies resulting from the need to turn the vast amount ofbusiness data into meaningful business intelligence is data warehousing and on-line analytical processing (OLAP).

OLAP data storage optimizes decision support and keeps this data separate fromthe operational data from which it is derived. This technology offers manyadvantages:

� Data can be managed to support fast, parallel and multi-dimensional queries;

� Derived metrics can be effectively computed; and,

� Data integrity can be assured when loading the data into the warehouse as partof an archival process.

Figure 4-1 illustrates the data warehouse architecture. Figure 4-2 illustrates theapplication tools that create and access the data warehouse.

Figure 4-2: Data Warehouse Application Suite

New information systems

Transaction and messaging middleware

Development toolsAccess and OLAP tools

Decision SupportSystems

On-Line complexprocessing systems

Transactionprocessing systems

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Retrieving data from a data warehouse often receives less attention than it meritsfrom warehouse architects. Fortunately, OLAP technology allows accessingbusiness data in a meaningful, intuitive way. In this respect, OLAP is a knowledgemanagement technology.

Understanding the significance of OLAP requires an understanding of the multi-dimensional nature of today's healthcare data. One of the key features of OLAP isthat users can navigate through data in any way that makes sense to them, withoutplanning the navigation route.

OLAP tools should also be capable of embedding complex business logic in themulti-dimensional model and be capable of responding to changing assumptionsin real time. This allows analysts to explore and interact with the data in a way thatexploits its multi-dimensional structure.

Electronic Medical Records SystemAt the USHealthNet Service Center tier, the EMR system consists of thefollowing:

� Electronic Medical Records;

� Application functions;

� Operational processes and workflows;

� Related data and knowledge bases; and,

� Legal and administrative characteristics

Application Functions (EMR)The EMR system includes functions to capture, store, process, communicate, andsecure existing health information. To accomplish these inter-related functions,the EMR system may be considered as a set of existing healthcare informationsystems of various ages and capabilities, as well as new applications that drive itsfull functionality.

The EMR system integrates all components across an enterprise, and requiresthem to be interoperable with minimal connectivity. This permits authorizedaccess to specific information for legitimate purposes in disparate componentsexternal to the organization.

Knowledge Acquisition FunctionsKnowledge Acquisition refers to the end-point or process, data collection, anddata entry into a computer system. Knowledge Acquisition functions include:

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� Data sources;

� Data entry devices;

� Data import;

� Data definition;

� Input identification; and,

� Input validation.

Data SourcesData sources are many and varied. Caregivers have traditionally compiled medicalrecords by questioning the patient and others and entering the information inprogress notes; making and recording observations about the patient; and,documenting the results of diagnostic tests and treatment procedures.

Each provider, and in some cases each caregiver within a provider setting,compiled separate records that were not integrated with one another. The level ofintegrity and redundant data collection was high as was the likelihood of nothaving a comprehensive set of data about the patient. The EMR system affordsthe ability to collect the data once and access it from disparate locations.

Healthcare recipients have become a direct source of information as well, bymaintaining electronic logs, responding to health surveys, or using patientmonitoring devices. Some patients may access their own EMR to verify theaccuracy of health information; supplement their understanding of care processes;and, become better informed for consenting to the release of information fordependents.

While the right to access one's own health information varies among the states,many lawmakers are advocating increased rights to access, particularly for use bynon-providers. Increased access to health information brings the need forincreased commitment to proper documentation, patient education, andadherence to the best healthcare practices.

Other less direct sources of information include schools, employers, public healthdepartments, family members and friends. They may contribute information suchas test scores, speech and hearing screening results, environmental data, andcompliance with safety requirements (i.e., the use of goggles or protectiveclothing).

Data Entry DevicesData entry devices include keyboards, point-and-click devices, touch screens,pattern recognition (voice and handwriting) software, document imaging, barcodes, and image scanners.

Monitoring devices that provide alarms based on changes in vital signs or otherprocesses are also frequently found in intensive care situations. These devices areusually provided to patients who are connected to a monitor at home and use thedevice to initiate an alarm, or create an alarm by virtue of the absence of aspecified signal.

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Although regulations vary with respect to these monitoring systems, they shouldbe investigated thoroughly by the provider implementing them. Generally, devicesthat provide support to caregivers without direct patient intervention areconsidered information systems. Devices that act on behalf of a caregiver may beconsidered drugs or medical devices and are strictly regulated.

Data ImportIn addition to direct data entry, information is often electronically transferredfrom various systems or entered through automated devices such as patientmonitors and laboratory instruments.

The provider may have multiple clinical and administrative systems that contributeinformation. External data sources contribute data through electronic datainterchange (EDI). Data imported from other systems depends on standardmessaging protocols and data formats to ensure that it is accurately received andable to be integrated.

Data DefinitionData entry entails more than the source and method of entering the data. Dataentry also encompasses the ability to capture the data in a meaningful way. Manyhealthcare information systems are being initiated with data repositories thatmerely store scanned documents with limited structured data.

To minimize non-redundant data collection that integrates data from multiplesources, the EMR system uses a standard data dictionary. This dictionary isdesigned according to uniform datasets with comprehensive standardterminologies or vocabularies (ontologies). The EMR possesses common datadefinitions, naming conventions, formats, and coding schemes.

There may also be an explicit data model that defines the objects, their attributesand relationships among them. One uniform dataset may be an identifier set thatprovides universal patient, provider, and location identification.

Data processing is affected by the way data is structured at the time it is entered.Specifically, data that is highly structured facilitates processing. Text processing isexpected to enhance narrative entry, but is expected to take considerable time todevelop.

Input IdentificationData capture also encompasses identifying the source of the data. A uniqueidentifier provides the ability to attribute data to its source, whether the source is aperson, system, or device.

Input identification should also include the date, time, location, and role of thesource. The EMR system maintains the ability to identify all transactions by who,what, when, and where such transactions were performed.

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Input ValidationValidation refers to the ability to identify the person, system, or device makinginput or having access to the data in the EMR system. There are different meansof validation for different types of data entry.

Storage FunctionsStorage refers to the physical location and maintenance of the data. In theultimate form of the EMR system, patient data may be distributed across multiplesystems based on multiple encounters within the healthcare delivery system. Thismakes it possible to compile a lifetime continuum of care record for an individual,or to access any subset of that data.

These systems do not yet exist. There are still significant technological,governmental, ownership, and privacy issues that have not been fully addressed orresolved.

Because records of many businesses are computerized, courts have developedstandards for establishing their admissability as evidence in court.

The following are considerations in the storage of an EMR:

� Permanence;

� Ongoing maintenance;

� Backup and recovery;

� Durability;

� Sabotage precautions; and,

� Updating obsolete systems.

PermanenceHealth information must be stored in a permanent and protected mannerregardless of its location. Retention schedules must afford maintenance of theinformation, at least minimally, throughout a person's lifetime.

The extent to which information may be retained from conception through deathmay depend on institutional policies or regulations. The extent to whichinformation is considered active or inactive also depends on institutional policies.

The ultimate EMR system requires continuous availability of data with a responsetime adequate to support its use as the primary source of patient care information.

Ongoing MaintenanceClearly, permanence requires ongoing maintenance. It is essential that systemsoftware and hardware be properly maintained and thoroughly debugged.

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Performance standards should be included in any lease or contract with a vendor,as well as guarantees of reliability, maintenance, and support. Access to sourcecodes for software is vital to a provider's ability to support and maintain patientrecord application software.

Backup and RecoveryDisaster prevention requires system and file backup and data archiving, as well aspolicies, educational programs, and monitoring of all EMR system components.

Disaster recovery is the process whereby an enterprise restores data loss in theevent of fire, vandalism, natural disaster, or system failure. Parallel backupsystems, alternate power supplies and routine drills contribute to timely andorderly recovery. Backup and recovery mechanisms are essential for maintaining apermanent protected EMR.

DurabilityEMR systems must be durable for a number of reasons. These include the needto:

� Support the future care of the patient;

� Notify patients who have received treatment that creates health risks for them ortheir descendants;

� Meet regulatory and accrediting requirements;

� Provide evidence in a lawsuit; and,

� Support research efforts.

Durability may be difficult to assess with new technology so extra precautionsshould be taken. Copying records from an old system to a new system may beappropriate, but reliable evidence of the chronology of copying must be preservedin the event the copied records are required as evidence in court.

Sabotage PrecautionsControlling sabotage contributes to permanence. This is a function of vigilance,ongoing maintenance, security precautions, and taking swift and decisive action inthe event of any attacks.

Updating Obsolete SystemsEMR systems should be designed to support future expansion with regard to newtypes of information, new features and capabilities, and new procedures.

The EMR system must be extendible and scaleable to meet the expanding needsof the healthcare delivery system. As such, updating obsolete systems alsocontributes to the permanence of health information. As with copying records forarchival purposes, changing to new systems must be done with a well-documentedchain of events and procedures.

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Administrative ProcessesAdministrative operations and financial considerations are also included in theEMR system design. For example, the EMR system performs:

� Quality assurance;

� Utilization review;

� Risk management;

� Workload allocation;

� Unedited information flagging; and,

� Claims support.

Other examples of communication possibilities include using electronic mailsystems and other Internet features for consultations, referrals, patient triage,patient education, and patient follow-up.

Security FunctionsProperly developed and monitored EMR systems provide better protection ofconfidential health information than do paper-based systems. This is due largely toEMR systems controls support and ensure that only authorized users withlegitimate uses have access to health information.

Security functions address confidentiality of private health information throughaccess control and protection and integrity of the data.

Access ControlOwnership of the patient record is established by statute in some states and byregulation in others (i.e., hospital licensing regulation).

Generally, in the absence of statutory or regulatory authority, some courts haveheld that a medical record is the property of the provider, subject to the limitedproperty interest of the patient.

Provider ownership of patient records, however, does not imply that the providerhas a right to use, disclose, or withhold data in the record at will.

Access to data in the EMR system should be properly controlled through policiesthat explicitly state who may have access and under what authority.

For every access, the EMR system should:

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1. Certify the user's identity, role and authorization level.Authentication provides assurance regarding the identity of a subject orobject. Authentication may be accomplished through the use of multi-levelpassword assignment and entry, biometric means of identification (e.g.,retinal scan, voice recognition), or sophisticated technology (e.g.,public/private key encryption). Once a user has been authenticated,ensuring that no other user may access the system under that authenticationrequires strictly enforced policies, automatic log-off after a period ofinactivity, and other similar security methods and policies safety measures.

Authorization provides that an authenticated user has access to the function,information, and privileges that the user is requesting the system provide.One method of authorization is based on global rules surroundingsensitivity and is applied to all users. Another method is identity-based. Thisconsiders the characteristics of a user, what they interact with, the content ofthose interactions, and the environment.

2. Record the date, time, and location of the access.

3. Record the nature of the access (i.e., view, create, amend, or copy to externalmedia).

4. Record the scope of the access.

The system should provide for periodic review of such accesses.

Data ProtectionThe EMR system requires the use of many source systems for capturing healthinformation and providing the information to many users. To accomplish this, theEMR system should maximize the use of open technologies and architectures.These architectures must be fault tolerant and the networking andcommunications systems must support reliable data transport.

Data encryption should be considered when it is not possible to maintain controlof the physical storage media or the transmission network. Additionally, directconnection to systems on non-dedicated networks (i.e., the Internet) require theimplementation of a "firewall" as a control point and filtering mechanism.

IntegrityIntegrity refers to the property of an object that is in an unimpaired state andrelates to data (its accuracy and completeness), programs, systems, and thenetwork.

Data integrity requires data preservation so that any entry does not alter theoriginal data or its context. Mechanisms should ensure that the information putinto the EMR system is not irrevocably altered and does not carry unexplainedcontradictions or conflicting data within the limits specified by the enterprise.

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Data integrity also requires authentication that includes visual confirmation of thedata entered, including review of any data entered via automated means. Whencorrections are necessary, the system should preserve both the original entry andthe correction, along with the identity of the person making the correction.

Operational ProcessesDifferent organizations and different parts of organizations have distinctoperational processes for healthcare delivery. The EMR system must besufficiently flexible to address each of the processes that an organization needs.For example, the processes used by a radiology department differ from those usedby a specimen laboratory or a counseling clinic. The integration of healthpromotion and wellness activities adds new operational processes to organizations.The EMR system must also be able to address future processes in order to captureand disseminate appropriate information for the delivery of future health care.

Operational processes are sets of procedures established by an organization toaccomplish its goals. The procedures may include actions, communicationprotocols, and related administrative policies. For example, operational processesassociated with a clinic visit for a new patient may include registration at thefacility’s central location to verify the patient's universal identifier and insuranceinformation. Other operational processes might include: accessing patientinformation through a master patient index from another providers' ElectronicMedical Recordssystems and the patient's own direct entry log; conducting andrecording a physical exam; ordering laboratory tests; prescribing medications thatmay be transmitted remotely to a retail pharmacy of the patient's choice;maintaining a tickler file for lab work follow-up; or, initiating a call-back reminder.

Alternatively, the processes associated with a home healthcare visit may requirethe caregiver to register at the home through telephone call-back, linking amonitoring device from a hospital base to the patient; reporting specificprocedures performed and the results using a wireless data transmission device;accessing an instructional videotape from a remote medical library that can betransmitted directly to the patient's television; or scheduling a follow-up visit.

Legal and Administrative CharacteristicsThe EMR system should meet all legal, administrative, and clinical requirements.Legal characteristics of the system include compliance with federal and localregulations and adherence to accreditation mandates and professional guidelines.Administrative characteristics include various aspects of developing,implementing, and maintaining the system.

The EMR system brings into play laws of many kinds. For example, systemhardware may be patented and system software may be copyrighted. Medicaldevice laws may apply when decision support systems are used. Tort liability canresult in the event of system failure or when there are unauthorized accesses andbreaches of confidentiality. Criminal liability may be imposed on hackers. Variousprivacy laws limit disclosure or re-disclosure of information stored in the EMRsystem.

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Other laws include licensing laws applicable to caregivers, reimbursement andinsurance laws, and public health laws that require reporting of vital statistics andvarious injuries and diseases. Contract law and the Uniform Commercial Codecome into play in contracts for the EMR system. Bankruptcy laws may even beinvolved if a vendor is unable to continue supporting an EMR system.

Likewise, each enterprise will have its own business and clinical practice rules;clinical and operations processes; staging and continuity of process tasks; criteriaconditions and actions; resource management, cost management, data collectionand quality assurance requirements; concurrent surveillance, metrics, and analyses;and master indexes for equipment, charges and medications.

As healthcare providers come closer to implementing a EMR system, managingcomponents within an application, across applications, within an enterprise, andacross enterprises will require close attention to the EMR environment,application requirements for system architecture, and confidentiality and securityissues.

Today's mergers and acquisitions are just a hint of the large-scale efforts required.Clearly, the healthcare delivery system will go through various stages ofimplementation, ultimately resulting in a national health information infrastructurethat supports a fully integrated EMR system.

Although EMR systems are recognized requirements for building integrateddelivery systems, the cost of developing a EMR is still an issue for providers.Improving the access and quality of care and reducing costs may require that theEMR system be implemented in phases. A gradual implementation providesvarying returns on investment and should be considered a strategic cost of doingbusiness.

Practice Management ServicesUSHealthNet’s Practice Management Services are physically located at theUSHealthNet Service Center to provide for centralized billing, collections, andreporting. This aspect of the USHealthNet solution isolates individual provideroffices from operational complexities and reduces costs by using economies ofscale.

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PBM

B illing Transaction Flow

D ata C enter FacilityM anagedCare Facility

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Central Administration of Multiple PracticesMany providers have their own dataset. A multiple provider interface enables theservice data center to easily access all provider and patient accounts. Since eachprovider has access to only their dataset, providers are guaranteed independenceand complete security. In addition, USHealthcare automatically runs reports andcalculates totals for each provider.

Enterprise-wide IndexingIncreasing demands to share data from multiple healthcare facilities has ledUSHealthcare to plan the development of a Master Patient Index (MPI). The MPIsolution accommodates patient movement throughout the network while reducingrecord misidentification and duplication.

As healthcare organizations form integrated delivery networks and large multi-faceted alliances, information systems infrastructures must adapt to meet theincreased demands of data sharing between organizations.

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This new requirement for integration goes beyond the hospital walls and hospitalinformation systems and extends throughout the healthcare community.USHealthcare will offer solutions that allow data sharing between organizationsand accommodate patient movement throughout the network.

Enterprise Master Patient Index (EMPI)A key goal of the USHealthcare infrastructure design is to provide a singlemember/patient identification for all applications on the network.

The Enterprise Master Patient Index (EMPI) system will support systems oftomorrow, while adding value to inherited legacy systems.

EMPI correlates each patient's data from disparate application systems andorganizations. Because it is vendor neutral and legacy system independent, itprovides the flexibility to choose and interchange future systems and repositories.

Master Patient Index RequirementsThis section describes the functional requirements of the Enterprise MasterPatient Index and a CORBAMed standard EMPI object interface.

The EMPI facility correlates and cross-references patient identifiers from multipleidentifier schemes, or “domains” by matching patient parameters such as name,birth date, and SSN. Additionally, it will be configurable to handle new identifierdomains and to perform its matching function with high accuracy in an unattendedmode.

The healthcare industry is aggressively pursuing EMPI capabilities to correlate orconsolidate disparately keyed patient data in applications such as clinical datarepositories and analytical data warehouses. Since the EMPI must integratepatient data among highly diverse and distributed environments, we expect that aCORBA EMPI standard will provide the interface as effectively generalizedservices.

Implementations of EMPI’s matching function range from “direct-hit” matchingusing simple fixed criteria to statistical matching by weights and thresholds for anynumber of parameters. Therefore, there will be some necessary variations inconfiguration interfaces. The runtime EMPI interface for correlation, assignment,and conversion, however, can be made to be both simple and generally applicable.The requirements described below will reflect these interface characteristics.

Figure 4-3 provides a closer look at EMPI’s role. It shows how EMPI correlatesidentifiers for John Doe and maintains its index (the real EMPI can use more thanname and birth-date for matching criteria).

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Patient 223 is John Doe,birth date 6/9/59 That’s

My 2601

A 123 2601B 222 2602C 438 2601EMPI correlates John Doeacross systems.

Patient 222 is Bob Smith,birth date 2/12/22 Have’nt

SeenBefore

A 123 2601B 222 2602EMPI assigns anothernew Enterprise ID

System APatient 123 is John Doe,birth date 6/9/59 Have’nt

SeenBefore

A 123 2601EMPI assigns a newEnterprise ID

Contents of The Enterprise MPISourceSystem

SourceID

EnterpriseID

Sequence of Messages Sent tothe EMPI by Source Systems

EMPIMatchingProcess

System B

System C

Matching Process

Figure 4-3: EMPI Index Processing

Note that systems B and C might be the same “system.” However, they may beseparate installations of that system, independently assigning patient IDs that arenot comparable to each other. Therefore, it is more precise to say that the EMPIcorrelates identifiers among multiple “domains” of identifiers, rather than multiple“systems”.

Benefits of MPI� Accurate member/patient identification

� Correlates member/patient data from disparate sources

� Provides accurate data routing for Clinical Data Repository solutions

� Minimizes duplication of records through sophisticated search algorithms

� Provides efficient functions for identifying and correcting duplicates

� Supports heterogeneous application system environments

Components of the EMPIUSHealthNet’s EMPI is a server-based decision support system that providesenterprise-wide, on-line access to member/patient identification derived from andshared by various departmental or application systems. The EMPI data modelincorporates key patient identifiers as well as other demographic data typicallyemployed to help identify patients:

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� Member/patient name;

� Date of birth, address, etc.;

� Social security number;

� Medical record number;

� Encounter numbers; and,

� Member number (managed care).

MPI permits rapid identification of patient information by supplying uniqueidentifiers, such as social security numbers. In addition, MPI provides expertsearch algorithms that allow patient lookups based on limited or impreciseidentification information.

MPI Functional Modules

MPI Data BaseThe MPI Data Base is a system of server-based functions that is typically pre-loaded with data from member enrollment rosters and key registration systemswithin the enterprise.

The data is analyzed to identify suspected duplicate records. Duplicates arereported for user review and special user tools are provided for further analysisand resolution. Once on-line, the MPI Data Base is maintained in synchrony withinformation "feeder" systems through the MPI Interface, and duplicate reviewtools are used for periodic data review and maintenance.

MPI Patient IdentificationThe MPI Patient Search module is the main desktop user interface for patientlookup and identification.

The patient lookup is based on unique identifiers or other imprecise means ofidentification such as patient name, date of birth, and phonetic matches. Suspectedduplicates are flagged. The Patient Search module may be executed in "stand-alone" mode, or it may be integrated with legacy systems at the desktop.

MPI Records ManagementMPI Records Management tools include an automatic duplicate-records detectionmodule and a desktop-based duplicate records review module for Medical RecordsQA personnel. Suspected duplicate records are automatically marked and madeavailable for user review. User actions on the duplicates are reversible and can beimplemented without loss of data. Site-definable statistical reports and qualityassessments of MPI data are also available.

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Clinical RepositoryThe value of data on patient treatment and outcomes (particularly data that isautomated, uniformly defined, linked, and anonymously aggregated) is increasinglyrecognized and demanded throughout the healthcare sector.

This data is needed for clinical research, quality assurance, utilization review,business planning, administrative, and public health purposes. For example,computerized ambulatory patient care data is scarce and not uniform in definition,coding, or content. Computerized hospital clinical care data is collected onhospitalized patients in a small number of settings, but it is not often stored forlong in a retrievable form after the patient has been discharged.

The USHealthcare Clinical Repository contains a distillation of the information inthe data warehouse. It contains only medical data that has been abstracted frompatient records for use by clinicians and researchers.

With the repository, USHealthNet offers data to the world-wide medicalcommunity that can be used to prepare studies such as:

� Demographics of patient populations;

� Patterns of disease outbreaks; and,

� Distributions of health-care users.

In addition, physicians, biologists, researchers, pharmaceutical companies, andenvironmentalists can extract information for use in clinical trials and return theirfindings to the repository.

Insurance companies can use the clinical repository for outcome analyses ofpatient treatments and feed the information back to the repository to providecontinuous improvement in health care.

Public health officials will be able to more rapidly detect sharp increases in theincidence of influenza, specific bacterial infections, and other public healthproblems and to act quickly in health crises.

Public health policymakers often have insufficient information for offeringsolutions to healthcare problems. As a result, public health decisions are madewithout the advantage of timely, relevant information using technology that couldreduce the costs of healthcare and improve patient outcomes and the health statusof populations.

As valid methods for assessing the quality of care proliferate, so will the value ofcommunity patient care data. When the benefits from this information are shownto exceed the costs of producing it, society must find a way to pay for theresources necessary to produce it.

Confidentiality and privacy are key concerns. Society must deal with perhaps itsmost vital information issue, assuring the privacy, confidentiality, and security ofhealthcare data about identifiable individuals. Even though patient care data canlead to important information for healthcare providers and their patients, it alsohas the potential for personal harm if it is disclosed inappropriately.

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Clinical repositories aim to extract patient, provider, and service data from claimsand encounters and store them in a shared community data repository. Therepository may be enhanced to include condition-specific data and patient-centered surveys.

SummaryThe USHealthNet Service Center is the heart of the USHealthNet system. Ithouses the data repository and the applications that are fundamental to theUSHealthcare vision.

The Service Center allows physicians and providers to access the computer-basedpatient records vital to their work. Additionally, administrative personnel canefficiently and cost effectively manage a busy practice with better and more timelycare for their patients and reporting and billing for the insurers and HMOs.

The entire healthcare community will also benefit from the services provided bythe USHealthNet Service Center by having ready access to data necessary forresearch into new pharmaceuticals, medical protocols, disease trends, and otherdata-intensive functions.

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T I E R 3 : I N T E R N E T H E A L T H C A R EC O M M U N I T Y

irtual Communities entail three concepts that are of tremendoussignificance to the Internet Healthcare Community. These are VirtualEnterprise, Electronic Commerce, and Customer Service Operations.

USHealthNet is the culmination of these three ideas. This chapter will discussUSHealthNet and the components that gave it expression.

Chapter

V

EVOLVING ELECTRONIC ENVIRONMENTS

Electronic Operations

InteractiveSystems

Telecommunication

Media/Advertising

Database & InformationMarketing Teleservices

CommunicationsServices

MarketingServicesCustomer Tracking &

Usage Metering On-line Services

PurchaseAdvisoryServices

EvolvingElectronic

EnvironmentsSatisfaction

Measurement�Services

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Virtual EnterpriseThe Virtual Enterprise is a collection of individual enterprises that cooperate("trade") in order to deliver an end product or service. These cooperatingenterprises are continuously knocking down the walls that obstruct the optimalfulfillment of their collective goal. For the enlightened management driving thesechanges in their own enterprises and industries, Electronic Commerce is clearlyassumed to be essential.

Virtual Enterprise is based on the following assumptions:

� Competition to satisfy the end consumer requirement for products and serviceswill force a collection of diverse enterprises to cooperate in the delivery of thoseproducts and services.

� In order to meet customer demands in an increasingly competitive market,enterprises will explore new strategies for conducting business. Although thegoals of these initiatives may sound familiar (reducing costs, increasingproductivity, etc.), the tools will be new.

� Electronic Commerce is an integrated arrangement of business practices andprocesses, technical application configurations and organizational structures thatutilize electronic information exchange. These exchanges occur inter- and intra-company, and are based on a variety of data exchange and communicationstandards and technologies.

� ASC X12 will continue to be the responsible body within the United States fordeveloping, maintaining, and publishing national EDI standards and forrepresenting the community of users in the United States in the developmentand maintenance of international EDI standards.

� ASC X12 will also be vitally involved with the rapid development, ease ofimplementation, and standards-compliance issues as essential dimensions ofenabling EDI to realize its full potential.

The Digital EconomyImagine a time in the future when routine business operations such as paying billsand making reservations or purchases can be carried out with a minimum ofaggravation and customer involvement. Imagine a cooperative trading partnershiparrangement where the emphasis is on meeting a mutually beneficial goal, such asinventory control, rather than the "implementation of technology."

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Think about a time when a relationship is established in the morning and theelectronic support systems are executing that agreement by the end of the day.Envision the most complex operation being completed with as much ease ascalling your pharmacy to place an order. Suppose that the information required tomeet a patient’s need, perhaps one not yet anticipated, can be unobtrusivelygathered and made available to an enterprise that can utilize it on the patient’sbehalf at some future point in time. This is the potential of Electronic Commerce,pursuing cooperative advantage by sharing discernable information providedthrough electronic channels.

The digital revolution has already started; the convergence of communications,computing and content technologies will undoubtedly transform societies inprofound and unexpected ways. The global web of inter-dependencies in theinformation age will facilitate new ways of doing business and spawn newindustries that will determine the future landscape of the digital economy.

MEDNET: The USHealthNet SolutionMEDNET, a Virtual Community based healthcare portal on the Internet, is thetop tier in USHealthNet’s strategy to become the most efficient andcomprehensive communications, information, application and procurementdelivery channel for third-party content, products and services in the healthcareindustry.

IPAs that aggregate procurement for economies of scale are targeting costs as ameans to improve the bottom-line ratio. These groups are excellent prospects fordigital commerce services over the Internet. Twenty percent of each dollar spenton products and services is up for grabs. Dis-intermediation is a direct result ofeconomics that drive the supply-chain models.

USHealthNet will be a highly functional and high-profile aggregator of third-partyproducts, services and information, specifically designed to address the rapidlychanging needs within health care. As the aggregator, this community will deliverlayered services on the Internet for professionals involved in the delivery of healthcare. This aggregation of services will deliver content to the medical professional’scomputer desktop, PDA, and hand-held communication appliances usingpush/pull models.

This virtual community will be made available to the general public via theInternet, and it will also feature secure private areas for the delivery of premiumfee-based services. This community will address the total informational, productand service needs of the healthcare industry, while integrating its own membershipand profile repository to capture and store user preferences, usage behavior andtransaction heuristics. This information will be used for the personalization ofcontent, products and services. This knowledge acquisition capability will allowUSHealthNet to develop closer and more profitable relationships with its users,partners and merchants by addressing needs on a personalized level. This level ofservice will be the impetus for long-term customer loyalty.

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USHealthNet couples this market demand for more comprehensive and richercontent with an increasing willingness to utilize new, more intelligent technologies.It creatively brings these products, services, and information into one virtualspace. The USHealthNet infrastructure also provides increased levels of utility forthe user in Internet meeting rooms, discussion forums, and collaborative virtualworkspaces. This will allow many more healthcare professionals to take part ingroup discussions.

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Developing this virtual community will involve leveraging each of the four keystakeholders: healthcare professional users, primary care provider groups, content-providers and merchants of products and services. We will work directly witheach of these stakeholders to specify the most appropriate tactical and strategicofferings to our primary target market: physicians and consumers. We will solicitfeedback and improve service and product strategies based on market datathrough several planned in-market field tests and pilots. Throughout this ongoingresearch, we will continue working toward the goal of delivering the mostappropriate third-party products, services and information mix to address thismarket’s total healthcare needs.

Figure 5-1: Procurement Transaction Trading Network

PROCUREMENT TRANSACTIONTRADING NETWORK

Administrator

workstation

Create TPprofiles

Direct link

Business documents•Price lists•Advanced shippingnotices/purchaseorders

•Technical manuals

One-time setup•Standard•Mapping rules•Edits

Assembly/disassembly

Document data

E-forms/E-mail

E-forms asuser

interface

ApplicationApplication/database

TranslatorTradingpartner

VANs

Internet

Central ECrepository

Stds.compliancecheckingSemantics DB

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We will work closely with medical associations to understand their businessobjectives and to emulate them through our Internet community to develop themost exclusive relationships possible. Our strategy will leverage significant brandsponsorship, funding and joint revenue opportunities targeting premier healthcareassociations. We will use this funding to develop complementary web andInternet sites for these associations; this will enable them to conduct their businessexclusively on our network at no development or maintenance cost to them. Witha long-term exclusive contract, we will effectively create significant barriers for anyexisting or emerging competition.

When partnerships with these key brand sponsors and associations have beenforged, we will pursue other third-party content providers, including medicaljournals and product and service marketeers. Leveraging these key strategicpartnerships enables USHealthNet to create premium content areas, which arebrand equity segment opportunities for the healthcare community advertisers.

PARTNER ENTERPRISE LINKAGES

Packaged queryPackaged query Query generatorsQuery generators Scheduled updateScheduled update Request to updateRequest to update

Shared (or standards-compliant) data dictionary (meaning)Shared (or standards-compliant) data dictionary (meaning)

Your Partners’ Views of Your Data

Enterprise Data ArchitectureShared (or standards-compliant) data dictionary (meaning)

Security GatewaySecurity Gateway

Public DataGateway

EC ClearinghouseDirect access

for specificapps.

Direct accessfor specific

apps.

Integrity checkerIntegrity checker Integrity checkerIntegrity checker

SecurityGatewaySecurityGateway

ODBC or IDAPI

External data gateway

Business application(e.g., inventory mgmt.)

Business application(e.g., transportation)

ODBC or IDAPI ODBC or IDAPI

Functional-specificdata

Functional-specificdata

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USHealthNet will develop community products and services that providemarketeers and third-party product companies the tools to exploit this channel.These products will form the basis for our revenue streams, which will bediscussed in the Product Strategy Document and also in the Business Plan.

These revenue models reflect opportunities for high margin sales in:

� Brand advertising and Sponsorship programs;

� Transaction Management Services for the sales of the third-party products;

� Paid For Access to high value content;

� Community Developed Products such as web sites and electronic catalogs; and,

� InfoMediary services, providing 1-2-1 personalization and dynamic content

� Affiliate alliance partnerships

� Custom Development.

SummaryUSHealthNet is the third tier of the USHealthNet solution for a computerizedmanagement system for the healthcare industry.

USHealthNet will be the most efficient, comprehensive communications,information, application and procurement delivery channel for third-party content,products and services in the healthcare industry. USHealthNet stems from theconcept of Virtual Enterprise, a collection of individual enterprises that willcooperate in order to deliver a product or service to meet consumer requirements.

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U S H e a l t h N E T T e c h n i c a l D e s c r i p t i o n

USHealthNet System Implementationhe USHealthNet vision of a healthcare service system encompasses all areasof the healthcare community, from individual providers to national andworld-wide medical users of the Internet. To realize this vision, USHealthNet

is exploring application-rich and service-oriented environment based onnetworking that includes the Intranet in providers’ offices to the Internet servingthe world.

The initial conceptual design of the USHealthNet environment will continue toevolve. It has the following distinguishing features:

� Adoption of the ‘HTTP’d’ and IIOP protocol for client-end interoperability.

� Adoption of the CORBA, ORB and IIOP specifications for server-endinteroperability using Orbix.

� Gateways to a commercial relational database (Oracle or Informix) fortransactions, heuristics and DSS/EIS.

� Back-end support for electronic publishing and digital content warehousingthrough the use of an OODBMS (GemStone).

� Adoption of the ‘Kerberos’ standard for authentication and secure certificates

� Model-based on wide-area access to patient records and update capabilities tostructured and unstructured information through message-based middlewareand replication.

� Federated access control mechanisms, where the information provider decideswho can access information.

� Adoption of a hyper-media based document metaphor (Browser) to supportease of use.

� Desktop conferencing among healthcare providers using the MONET (Meetingon the Net) system.

Appendix

T

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� Synchronous information sharing for patient information and images (forexample, x-rays).

� Notification and asynchronous communication based on MIME-compliantmulti-media mail for ordering laboratory tests, prescriptions and referrals.

Figure A-1: OSI 7-Layer Model

Enabling Technologies for USHealthNetThe core enabling technologies for the USHealthNet system consist of threetechnologies. These are the Information Sharing System (ISS) for integratingheterogeneous, distributed databases; the MONET desktop conferencing system;and, the MIME-compliant multimedia mail system with a browser user-interface.

These systems are linked through an open architecture that combines the DCE,OSI 7-Layer Model and the OMG CORBA ORB. These systems integrate JavaBeans, Jini and IIOP for interoperability.

Physical Network

SNAAPPN

Common Transport Semantics

PresentationServices

Data AccessServices

Component Development Frameworks

OpenDoc & Java & ActiveX

Application Services

TCP/IP OSI NETBIOSIPX

Object Mgmt.Services

MultimediaMultimedia

Print/ViewPrint/View

User InterfaceUser InterfaceFilesFiles

TransactionMonitor

TransactionMonitor Workflow Manager MailMail

Communication ServicesConver-sationalModel

Communication Services

CORBA/ORB

Directory X.500 /LDAP

WAN Channel EmergingLAN

Database DigitalLibrary

Database DigitalLibrary

Security SET SSL

Time Transaction Manager

RemoteProcedure

Call

MessagingQueuing

MPI

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Information Sharing SystemPatient records may be stored in a variety of databases. These records areaccessed transparently and transported across systems using the CORBA standardfor object exchange. The information-sharing sub-component provides access toinformation in diverse formats and systems. In order to effectively deal withheterogeneous legacy environments, interoperability is required. Specifically, astandardized method for communicating with these diverse repositories must bedevised. The CORBA specification has been adopted in the current model forserver level interoperability. We are also supporting the HTTP’d and IIOP-protocols as a mechanism to support client-level interoperability.

Architecture for Information SharingThe components associated with the information server for our healthcareapplication. The components associated with this figure are explained below.

Interface or Event ManagerThe Interface or Event Manager communicates with the browser-compliant clienton one side and the CORBA-compliant server on the other side. This modulehandles log-ins and translates URL requests from browser clients to documentpages.

The module handles log-ins by validating the user name and password usingstandard UNIX mechanisms. The URL translation processes are handled by acombination of state information sent with the URL (i.e. session information), thetype of document requested (i.e. flowsheet, POPRAS form, referral form), thelayout page associated with the document type, and queries to information servers.The Interface/Event Manager is a mechanism that can handle queries frommultiple users simultaneously.

We can also use digital certificates in an authentication process - one needs tounderstand the ramification of this on all the servers of the system.

Session ManagerThe Session Manager instantiates a new session thread for each user and eventwithin the system. This process involves instantiating a specific set of gateways(such as Oracle gateway and file archiver), setting up sessions to these as the userwho has just logged on and instantiating models (see next section) that interface tothese gateways. The session manager is also responsible for closing theseconnections at the time of closing or log-out using a time-out mechanism.

GatewaysThe gateways are Corba ORB servers that interface to information repositories.The gateways have standardized interfaces but their implementations varydepending on the type of repository they are connected to.

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ModelsThere are collections of user-defined models that specify the types of informationneeded by the system. These models could be specific or generic. An example ofa specific model is a flow sheet. Generic examples include the gateways to Oracleand File Repositories. Information Sharing System (ISS) will have to provide animplementation of these models that function analogous to the mapping. That is,in the case of the Flowsheet model, a C++ or Java implementation of how toinstantiate this flowsheet for a patient who is trying to access it must be provided.

Meeting On the NET (MONET)MONET is a multimedia desktop conferencing system that facilitatescommunication and cooperation among geographically dispersed individuals (thevirtual team) in a networked environment. This desktop conferencing systemutilizes effective communication media, including audio, video and graphics. Inaddition, many application programs, such as x-rays and ultrasound viewers, canbe shared over the network using the Cooperative Multi-user Interface to X-window (COMIX) component of MONET. Using these multicast protocolsenables efficient audio and video data communications.

Future ExtensionsFuture directions for the USHealthNet system include:

� Agent-based technologies for patient tracking;

� Workflow at the application level and at the message-based middleware level;and,

� Advanced User Interface technologies based on enhancements to browsers andsupport-rich VRML.

Value-added Agents for USHealthNetValue-added Agents for USHealthNetValue-added Agents for USHealthNetValue-added Agents for USHealthNetWe are investigating extensions to the USHealthNet environment based on agenttechnologies. The healthcare domain presents a large number of interestingoperations that can be supported by these emerging technologies. Several agentsthat provide value-added services for the USHealthNet environment have beenidentified. They are described in the following section.

Agents are semi-autonomous, goal-directed software objects, components, orapplets. These agents may be modified by the end-user using a business logic layerwhere the user defines business processes, functions and rules. Programs can alsodispatch their own agents when necessary. The primary difference between agentsfor humans and agents for software lies in the nature of the agents’ publicinterface. The key to this is the encapsulation of business objects and rules.

Embedded systems can provide enormous benefits when tightly integrated. Someof the generic agents we have identified include:

� Monitoring and notification agent;

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� Prioritization agent;

� Scheduling agent;

� Filing agent;

� Information access agents (authentication);

� Search and retrieval agents;

� Workflow and process agents;

� Middleware agents (for security and TP monitors); and,

� Clinical data mining and abstract agents.

Monitoring AgentsThese agents generally monitor parameters and goals, as well as notifying someonewhen appropriate. These parameters and goals will vary depending on themonitoring agent. This monitoring is a fundamental aspect of any coordinationmechanism. For extending USHealthNet’s™ capabilities, four monitoring agentshave been identified:

� Referral and order management agents. These agents send referrals and ordersfor tests on patients. They also inform the provider when the results of the orderor summaries of the referral consultations become available. Our currentimplementation of this agent manages orders for ultrasound tests and x-rays.The notification is provided and presented as an HTML document when theprovider logs onto the system.

� Caseworker support agent for prenatal patients. This agent determines if prenatalpatients miss scheduled appointments and notifies a caseworker when follow-upactions are required. Prenatal appointments are currently tracked manually.Missed appointments are followed through with patients since providers arelegally responsible for ensuring that pregnant women follow prenatal care-guidelines. Follow-up of these situations is delegated to a caseworker.

� Home-monitoring agent. Under the authority of the provider, the home-monitoring agent checks with the patient at home (or at a nursing home) usingphysiological parameters such as blood glucose levels, blood pressure, pulse rate,compliance to treatment and the patient’s general well-being. The home-monitoring agent reports back to the provider with this patient information.

� Sign-off monitoring agent. This agent monitors whether providers have signed-off on patient data. All new information (for example, laboratory test results) hasto be reviewed and signed-off by a provider before it can be included in apatient’s record. If providers do not sign-off on new patient information,corrective action is taken.

Prioritization AgentsPrioritization agents are responsible for sorting action items using a priority eventmechanism. Examples of these agents in USHealthNet are:

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� Sign-off prioritization agents. Providers currently get new patient information ina stack on their desks. Not all of this information is of the same priority.Information with a higher priority may include abnormal test results. Thepatient’s clinical status could also affect the priority of new information.

� Contact prioritization agents. Although caseworkers follow-up with all patientson missed appointments, this agent prioritizes the calls to ensure that urgentcases are handled appropriately.

Scheduling AgentsScheduling agents are one of the most studied agents in Distributed ArtificialIntelligence (DAI) literature. In USHealthNet, there are three agents to supportscheduling:

� Provider to provider consultation (or constraint-based) scheduling agent.USHealthNet supports synchronous desktop consultations between providersand specialists. This agent helps in scheduling these consultations and on-linepatient education.

� Patient-visit scheduling agent. This agent--aware of the provider’s schedule-- canpresent itself in the home computer or network computer of a patient to arrangea follow-up office visit, lab work or diagnostic testing with the patient.

� Filing and reporting agent. This agent is a workflow knowledge mechanism,which facilitates the deadlines for filing and reporting authorities.

Filing AgentsNew information is constantly presented to the USHealthNet system frommultiple, geographically distinct locations. In USHealthNet, this is currentlyhandled by browser-based HTML-forms that are designed to input specific typesof information. This information is stored transparently so that it is accessiblethroughout the healthcare community network. Filing agents, however, could betrained to properly route this information.

An extension of this Filing agent could provide automatic data collection frommultiple sources by building a multi-dimensional VRM model for viewing patientcare and provider performance and compliance to policies, procedures andmeasurement guidelines.

Information Access AgentsWhen several autonomous organizations are combined into a single network,information is dispersed throughout the network, possibly in different formats. Adhoc queries become difficult to manage. Information Access Agents can alleviatethis by interacting between users and information in the network. One abstractionof this information is represented by a fully distributed knowledge layer at thenetwork level which provides seamless ease of access for human and non-humansystems.

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Agent ImplementationWe desire an array of agents for the USHealthNet system; this implementationrequires coordinating several different technologies in a distributed environment.Legacy code and local host resources will be accessible through CORBA/IDLinterfaces. Distributed coordination and agents will be implemented in Java. Userinterfaces and other structured information (such as multi-media mail) will bespecified using SGML, HTML, and PDF formats; the display, however, maycontinue to use another technology, such as a browser. The Common ObjectRequest Broker Architecture (CORBA) is an industry standard for providing alocation- and language-independent method for invoking objects. Once an objectis registered with an Object Request Broker (ORB), other objects can access it,even if those objects reside on another node of the network, or if they areimplemented in another language. The Interface Description Language (IDL)provides a language-independent means of describing object interfaces.

� Java is a distributed programming language in which all first-class languageobjects are mobile in the network. A Java application can reconfigure itself orsend new pieces to remote sites on the network. Java can support a variety ofprogramming paradigms, including agents, client/server and peer-to-peer. Inparticular, Java can support applications that seamlessly combine agent and othertypes. For example, an application (such as a multimedia conference call) canembed parts of itself in smart agents that move around the network locatingresources. After locating these resources, the distributed elements of theapplication function on those nodes in a more traditional manner. Mobile Javaobjects in the health-care network can communicate with local resourcesthrough IDL interfaces.

� A primary function of agents is the intelligent analysis of information so that itcan be filtered, manipulated, or reformatted for the end user. Agents need accessto the underlying structure of the information; if this is not provided, the agentmust derive it. The SGML standard can be viewed as a meta-language todescribe markup languages for specific types of information (normally calleddocuments, but SGML can be applied to a much larger variety of structured bitvectors). HTML and HTML+, used by the World Wide Web (WWW), areexamples of SGML-compliant languages.

� "Extensible Markup Language, abbreviated XML, describes a class of dataobjects called XML documents and partially describes the behavior of computerprograms which process them. XML is an application profile or restricted formof SGML, the Standard Generalized Markup Language. By construction, XMLdocuments are conforming SGML documents."

� A key insight from the development of SGML is that no single markup languageis sufficient for all information. Information converted to a single markuplanguage, such as HTML, has lost its original semantic structure. SGMLprovides a standard way both for describing the information that agents need toaccess and manipulating it, even though that information may be transformedinto HTML or Postscript for display. The more the information is structured,the more we can relieve the burden of document analysis from the agent.

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An Example of Agent ImplementationConsider the caseworker support agent that must undertake a complex series ofactions across the network.

A monitor agent sits and waits for a scheduled visit, or event object. As theappointment approaches, the agent may contact the caseworker to schedule areminder telephone call. After the scheduled time passes, the agent examines thesites in the network to determine if the appointment has been kept, and at whichclinic. Sending sub-agents to each of the clinics can do this. If no visit occurred, atelephone call is arranged. The monitoring agent contacts the caseworker'sscheduling agent, as well as dispatching another agent to create a patient dossier.Since the dossier will have a standard structure, the caseworker's scheduler cananalyze and prioritize it. Finally, a user interface agent, customized by thecaseworker, can convert the dossier to a personalized multimedia mail orhypertext document. Part of the scheduler's function is to keep track of thecaseworker and send him or her necessary information at the correct site.

In this scenario, the agents are all programmed in Java; the databases, e-mailsystems and user interfaces are all accessed through CORBA interfaces. Theinformation to be displayed is defined in SGML to facilitate manipulation byagents.

Enhancements to BrowsersImprovements being considered include:

• High-PerformanceDistributed Web Servers

• Better Management of HotDirectories

• Virtual URLs • URL tables

• Groupware Applications • Smarter Servers

• Prefetching Strategies • Logical URLs

High Performance Distributed Web ServersIn the near future, we will have to service large numbers of requests, includinglarge multi-media objects. To meet these anticipated requests, we are investigatingdistributed and multi-threaded web server implementations with I/Ooptimizations.

Logical URLsCurrently the URL is a specific reference to a particular object at a particularserver. This approach has scale-up and fault tolerance problems, particularly fordocuments in great demand.

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Attempts to access a document are routed to the server named in the URL,forcing delays throughout the network. In addition, this may render the links inthe URL inaccessible to anyone who does not have them on their hotlist. Theseproblems will be particularly challenging to commercial ventures, since theytranslate into lost business and inferior service; these problems might sendcustomers elsewhere.

Document replication is necessary to better balance network traffic and providecontinued access in the face of server and network failures, but the current URLprotocol provides no means of supporting this. We are considering twoapproaches-- one short term and one long term--for resolving this problem, URLtables and Virtual URLs.

URL tablesURL tables perform server to server translations. It is simple enough to place thesame document in several locations, but it is more complex to convey thatinformation to a client. Here, the URL designates a primary server that has sentcopies of a particular document to multiple mirror servers. The primary serverretains the list of secondary servers. When a request comes to a server, the serverresponds with the list of mirror servers. The server may also send the document,depending on its current load. If the document is not returned, then the client maycontact one of the mirror servers.

On the client side, a table of mirror servers is kept for frequently used URLs. Ifthe client wishes to access a mirrored URL, then the servers are contacted in arandom fashion until one responds or the request is canceled. Since all serversreturn the list of mirror sites, the table can be updated automatically on eachrequest. Deleting the less frequently accessed URLs can control the size of thistable. An alternative to the table is to include the list of mirror servers in the URL,as contained in other documents. This, however, would be difficult to update.

Virtual URLsA logical URL names a set of servers that contain the desired document, but itdoes not refer to a particular physical server. When a request is sent to a logicalURL, any server in the set may respond. The client is freed from any considerationof the physical server responding to the request, and servers can enter and leavethe set without the client’s involvement. This kind of behavior is required in high-availability transaction processing systems {reference ISIS and TeknekronInformation Bus}. To implement this on the Internet, we will be using theReliable Multicast Protocol (RMP) currently being developed. RMP creates avirtual token ring in the network that allows members to communicate with eachother and it also allows outside processes to send messages to the ring. The set ofservers in the logical URL corresponds to the RMP token ring; the client is anoutside process communicating with it.

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Both Virtual URLs and URL tables require that servers communicate updates toeach other "behind the scenes". This is a standard distributed database problem.RMP provides a technology to support this on the network, although there aremany alternatives. Due to the growing volume of traffic and the initiation ofcommercial ventures on the Web, we suspect that there will be a number ofmethods proposed, not all of which will use the public network.

GroupWare ApplicationsThe Web currently uses strict client/server architecture for object delivery (forexample, hypertext), with a stateless protocol between clients and servers. Thesame approach is being used for current commercial applications. Distributedhypertext and on-line catalogs are just part of the potential applications for theWeb. The Internet already supports a variety of interactive, multi-userapplications, from usenet newsgroups to multi-user dungeons (MUDs) to theMBONE multi-user whiteboard. We are looking at ways of using or expanding thecurrent Web architecture to support GroupWare applications. Although agraphical MUD communicating with browser-based users through a Web serverwill probably be the first significant Web GroupWare application, fields such ashealthcare can also benefit.

Smarter Servers, Smarter ClientsThe development of GroupWare, commercial services, and other applications tobe accessed through the Web represents a fundamental shift in the way the Webwill be traversed. The current hypertext-based traversal paradigm assumes thatusers proceed in a random (or at least unpredictable) walk through the URL graph.The current stateless protocol is perfectly acceptable in this scenario, as there is noreason to retain state that is more likely to be thrown away than kept. With a shiftto applications, this will no longer be true. Traversal, if that is still the right term,in an application is both far more predictable and far more stateful. Complexapplications, such as GroupWare, can be implemented using the currentarchitecture through scripts and forking child processes. This starts to becomeawkward as the applications become more sophisticated. At the same time, thepurely fetch/display architecture of the clients severely limits the complexity thatcan be placed into a single page.

We will attack this problem on the server side by placing intelligence directly in theserver. We will first wrap the server API in a C++ class library, and then to wrapthat in a Java interpreter. Java has mobile objects designed for distributed andmulti-user applications. Linking this with the server provides either an intelligentserver, or applications that use HTML as their GUI. Using a distributed language,such as Java, will also simplify implementing the replicated server strategydescribed above. On the client side we will add the ability to receive sets of formsand pages, as opposed to just a single page at a time. As mentioned above,traversing an application will be significantly more routine than traversinghypertext. We can take advantage of this by downloading working sets of HTML,based on knowledge of the application.

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Prefetching/Caching StrategiesSince a page is the current focus of attention, all the hot-links visible in the currentpage are possible candidates for prefetching. We are investigating other strategiesto reduce the size of this set.

Hot DirectoriesIn the current implementation, management of hotlists may become unwieldy ifthe hotlist becomes too large (since the hotlist is a linear structure). We will beimplementing hierarchical directories that can be organized and managed moreeasily.

Data Warehousing and real-timeAnalytical ProcessingUSHealthNet will use data warehousing to maintain the large amounts ofmultidimensional data used throughout the system and real-time analyticalprocessing to support fast, multidimensional queries.

Understanding Multi-dimensional DataMultidimensional data is accessed in fast, multi-dimensional queries. It is rarely100% populated. That is, of all the theoretical cells in the database, only a smallpercentage is populated. Even though a table could contain a theoretical 32million cells, only 800,000 may actually be populated.

When dimensions are added to the hyper-cube, the sparsity is likely to increase.This means that when we add more dimensions, each number does not breakdown into a possible value for each member of the new dimension. If we add apatient dimension containing 10,000 patients to a medical hyper-cube, we increasethe theoretical volume of the hyper-cube by a factor of 10,000. The actualpopulated volume of the hyper-cube is unlikely to increase by more than a factorof ten, where ten is the average number of patients who visit a medical facility in amonth. A fully calculated hyper-cube is dozens of times, and occasionallythousands of times, larger than the raw input data. Although this would notappear to be a problem since disk space is relatively cheap, a 200 MB source filecould expand to 10 GB.

Real-time Analytical Processing (RAP)Real-time Analytical Processing has two main design objectives: linear access andcalculated results.

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One of the design objectives of the server that handles multi-dimensional data isto provide fast, linear access to the data regardless of the way the data is beingrequested. The simplest request is a two-dimensional slice of data from the n-dimensional hyper-cube. The objective is to retrieve the data equally fast,regardless of the requested dimensions. In practice, simple slices are rare.Generally, the requested data is a compound slice with two or more dimensionsnested in rows or columns. RAP seeks to provide linear response time, regardlessof the data’s retrieval location in the hyper-cube.

A second design objective of the server is to provide calculated results. The mostcommon calculation of RAP is aggregation, but more complex calculations such asratios and allocations are also required. The design goal offers complete algebraicability when any cell in the hype-rcube can be derived from any others, using allstandard business and statistical functions including conditional logic.

Other considerations about RAP:RAP takes the approach that derived values should be calculated on demand. Inorder to calculate and provide fast response, data must be stored in memory. Thisgreatly speeds calculation and results in very fast response to the vast majority ofrequests.

Another refinement of this would be to calculate numbers when they arerequested but to retain the calculations (as long as they are still valid) to supportfuture requests. This has two compelling advantages. First, only the aggregations,which are needed, are performed. In a database with a growth factor of 1,000 ormore, many of the possible aggregations may never be requested. Second, in adynamic, interactive update environment, (budgeting, for example), calculationsare always up to date. There is no waiting for a required pre-calculation after eachincremental data change.

A multi-dimensional application of any size can fit into memory because all multi-dimensional databases store each number very efficiently, generally 10 to 15 bytesper number. As the following chart of real applications shows, a server with 500MB of memory can store about 45 million input numbers.

Since RAP does not pre-calculate, the RAP database is about 10% to 25% the sizeof the data source. This is because the data source requires at least 50 to 100 bytesper record. Generally, the data source stores one number per record that will beinput into the multi-dimensional database. Since RAP stores one number (plusindexes) in approximately 12 bytes, the size ratio between RAP and the datasource is between 12 / 100 = 12% and 12 / 50 = 24%.

Another reason that applications generally fit into memory when using RAParchitecture is due to the very high sparsity previously mentioned. With sparsitytypically 99% or greater in models with 5 or more dimensions, the 45 millionactual values that a .5 GB server can accommodate represents a model with atheoretical volume of more than 4 billion cells. Few financial multi-dimensionalmodels approach these data volumes. A few million populated cells is a largefinancial model.

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R E F E R E N C E S

ASTM E1769-95, "Standard Guide for Properties of Electronic Health Records andRecord Systems," Annual Book of ASTM Standards, Vol. 14.01, February, 1996.

EMRI, Electronic Medical Record Concept Models, Draft Version 1.0. Schaumburg, IL:Computer- based Patient Record Institute, April, 1996.

EMRI, Electronic Medical Record Description of Content. Schaumburg, IL: ElectronicMedical Record Institute, May, 1996.

EMRI, EMR Project Evaluation Criteria, Version 2.1. Schaumburg, IL: ElectronicMedical Record Institute, March, 1996.

EMRI, Description of the Electronic Medical Record and Electronic Medical RecordSystem. Schaumburg, IL: Electronic Medical Record Institute, May, 1995.

EMRI, Framework for Definition and Modeling of the EMR Environment. DraftVersion 1.0. Schaumburg, IL: Electronic Medical Record Institute, May 27, 1996.

EMRI, Glossary of Terms Related to Information Security for Electronic MedicalRecord Systems. Schaumburg, IL: Electronic Medical Record Institute, July, 1996.

EMRI, Guidelines for Establishing Information Security Policies at Organizations UsingComputer- based Patient Records. Schaumburg, IL: Electronic Medical Record Institute,February, 1995.

EMRI, System/Application Functional Requirements Related to Security of Computer-based Patient Records, Draft Version 1.0. Schaumburg, IL: Electronic Medical RecordInstitute, July, 1996.

Dick, R.S. and Steen, E.B. (Eds.). The Computer-based Patient Record: An EssentialTechnology for Health Care. Washington, DC: National Academy Press, 1991.

Dickinson, G.L. EMR/EMR System Qualifying Characteristics. Comment Paper ofHealth Data Sciences Corporation, March 3, 1995.

Schiller, A. and Andrew, W. "The EMR: A Patient Perspective," Healthcare Informatics.pp. 82-84, March, 1996.

Appendix

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G L O S S A R Y

Administrative dataData used in the administration of a medical practice. This includes hospital dischargeabstracts, health insurance claims, and enrollment records.

Administrative simplificationReduction of the cost and complexity of healthcare by standardizing and automating theadministrative activities of healthcare providers and insurers.

ANSIAmerican National Standards Institute.

ASC (Accredited Standards Committee)A committee chartered by ANSI to work on standards in a particular area of commerce.For example, ASC X12 is the committee working on standards for the insuranceindustry, including health insurance.

ASTMAmerican Society for Testing and Materials.

Asymmetric encryptionAn encryption scheme in which information intended for an individual is encoded withhis/her well-known, public encryption key. This data may only be decoded with his/herprivate key (generated from a guarded password).

ATM (Asynchronous Transfer Mode)A fast networking protocol based on small, uniform packets. ATM communications aresuitable for the continuous transfer of large amounts of data, including video streams.

Appendix

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AuthenticatorA device that provides an internally stored or calculated response to verify a user’sidentity when logging onto a computer. Only authorized users are likely to know aunique piece of information (the password) and to be in possession of a unique piece ofequipment (the authenticator).

Automated data collectionDirect transfer of physiological data from monitoring instruments to a bedside displaysystem or a computer-based patient record.

BackboneA high-capacity communications channel that carries data acquired from smallerbranches of a computer or telecommunications network.

BandwidthThe amount of information an electronic connection can carry per unit of time, usuallyexpressed in bits per second.

Biometrics identifierA retinal pattern, fingerprint, or other anatomical feature that can be used by a computerprogram (along with appropriate interface equipment) to positively identify a user.

CapitationA healthcare payment structure based on a set fee per health plan member per unit oftime.

CBA (cost-benefit analysis)A comparison of the net costs of an intervention with the net savings.

CD-ROMCompact disk, read-only memory.

CDSSClinical decision support system.

CEA (cost-effectiveness analysis)A structured, comparative evaluation of two or more healthcare interventions.

CHESS (Comprehensive Health Enhancement Support System)An interactive computer system developed at the University of Wisconsin that providesinformation, social support, and problem-solving tools for people living with AIDS andthe HIV virus.

CHI (Consumer Health Informatics)The study, development, and implementation of computer and telecommunicationsapplications and interfaces which are designed to be used by consumers of healthservices.

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CHIN (Community Health Information Network)Electronic systems that facilitate a community-wide exchange of clinical andadministrative information among providers, payers, banks, pharmacies, public healthagencies, employers, and other participants in the healthcare system.

CHMIS (Community Health Management Information System)An electronic system similar to a CHIN which emphasizes the creation of a datarepository to assess the performance of healthcare providers and insurance plans.

Clinical decision supportAn information tool to help a clinician diagnose and/or treat a patient’s health problem,including relevant diagnostic procedures and treatments.

Clinical information systemA hospital-based information system which collects and organizes clinical, as opposed toadministrative, data related to the care of a patient.

Clinical practice guidelineAn outline of broad parameters for the diagnosis, treatment, prevention, or rehabilitationof a particular health problem.

Coding standardA system for assigning alpha-numeric codes to specific words, concepts, or actions forthe purpose of standardizing messages between computers and organizations.

Computer-based patient recordA compilation of the clinical and administrative information related to the care of asingle individual in digital form.

EMRComputer-based patient record.

CPT-4 (Current Procedural Terminology, Fourth Edition)A classification and coding system for health services maintained by the AMA. CPT-4 isused in billing by clinicians and other non-institutional providers.

CSN (Community Services Network)A project in Washington, DC that uses communication and computer technologies tosupport and coordinate health and human services at the community level.

Data distillationAn informal label for analyzing raw data.

Data repositoryThe component of an information system that accepts, files, and stores data from avariety of sources.

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Decision supportSee Clinical decision support.

EDI (Electronic Data Interchange)The application-to-application interchange of business data between organizations usinga standard data format.

Fault-tolerant computer systemsReliable computer systems which incorporate redundant processors, disk drives, andpower supplies to ensure the full-time operation of a critical information network.

FirewallComputer hardware and software that block unauthorized communications between aninstitution’s computer network and external networks.

Frame relayA fast networking protocol in which data are packaged in variable-length frames forshuttling between computer networks.

HL7 (Health Level 7)An application-level interface specification for transmitting health-related data, usuallywithin a single institution.

HMOHealth maintenance organization.

ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification)

A classification and coding system for health problems and services, maintained byNCHS and HCFA, and used for billing by inpatient hospitals and other institutionalproviders.

IDS (integrated delivery system)An organized system of healthcare providers spanning a range of healthcare services.

IPA (Independent Practice Association)An organization that contracts with a managed care plan to deliver health services at asingle capitation rate.

ISDN (Integrated Services Digital Network)A digital telephony protocol that represents the next major jump in telecommunicationstechnology. Standard modems restrict speeds to 28,800 bps with the analog phonesystem, but ISDN allows speeds of 64,000 bps and 128,000 bps.

Knowledge-based systemA decision support system based on an automated, systematized application or sets ofrules or heuristics for analysis of raw data.

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LAN (Local Area Network)Communications lines linking a localized group of computers, printers, and servers.

Laser optical cardA plastic device the size of a credit card that can hold large amounts of digital data. Thedata cannot usually be altered once it is written to the card.

Magnetic strip cardA plastic card with a magnetic strip on the back. The card can store about 250 charactersand it is used primarily for personal identification and verifying eligibility for insurancebenefits.

Managed care (or managed health care)The various systems of healthcare delivery that attempt to manage the cost, quality, andaccessibility of health care.

Managed care organizationAn organization, such as an HMO or PPO, that uses one or more techniques of managedcare.

MBoneMBone stands for the IP Multicast Backbone on the Internet. IP Multicast-basedrouting facilitates distributed applications to achieve time-critical "real-time"communications over wide-area IP networks through a lightweight, highly-threadedmodel of communication without congesting server nodes.

NCHSNational Center for Health Statistics.

NCHSRNational Center for Health Services Research.

NIINational Information Infrastructure.

NISTNational Institute for Standards and Technology.

NLMNational Library of Medicine.

NUBCNational Uniform Billing Committee.

OCR (optical character recognition)Automated scanning and conversion of printed characters to computer-based text.

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OLAP (On-Line Analytical Processing)A database architecture that supports querying of complex, multi-dimensional databases.

Patient recordInformation about a patient. Once stored exclusively on paper, this patient information isnow available electronically in some health organizations.

PayerInsurance company, self-insured employer, administrator, or other entity responsible forpaying for an individual’s health care.

PBM (pharmacy benefit management)A method of managing pharmaceutical benefits for insurers and employers. PBM usesdisease management, pharmacy networks, negotiated discounts and rebates, lists ofpreferred drugs, and on-line utilization review. PBM also refers to organizations (such aspharmacy benefit managers) that perform PBM services.

PDQ (Physician Data Query)A system of on-line (Internet) information regarding various cancers, ongoing clinicaltrials, and individuals and organizations involved in cancer care, maintained by NCI.

PPOPreferred provider organization.

Primary dataData collected directly from individuals (e.g., survey, observation) or documents (e.g.,medical record review).

Privacy ActThe Federal Privacy Act of 1974 (5 U.S.C. Section 552a, 1988), which protectsindividuals from non-consensual disclosure of confidential information by governmentagencies.

Provider (or healthcare provider)Any person (physician, nurse, etc.) or institution (hospital, nursing home, etc.) thatprovides healthcare services to patients.

PurchaserAn organization (usually a large employer) that purchases health insurance (usually forits own employees).

Quality assessmentMeasurement and evaluation of the quality of health services delivered to patients,usually focusing on the processes and outcomes of those services.

D R A F T C O N F I D E N T I A L

77777777

RAID (redundant array of independent disks)Multiple computer disks configured as a single disk to provide either data redundancy orenhanced access speed.

Relational databaseA collection of computer-based information that is organized or accessed according torelationships between data items.

ReliabilityThe reproducibility of a measure, or the extent to which the measure yields similarresults each time it is used on similar samples, or the extent to which its componentsyield similar results for the same or similar samples.

Rule-based expert systemA decision support system based on large numbers of heuristics, or rules of thumb, that isderived from the analysis of experts’ actions or from published literature.

Shared decision support systemsA system which provides information to patients and providers regarding the prevention,diagnosis, management, and treatment of medical conditions.

Smart cardA plastic device the size of a credit card with an embedded computer processor andmemory.

SNOMED (Systematized Nomenclature of Medicine)A system for classifying and coding health problems, symptoms, and services.

Speech recognitionThe automated conversion of spoken words into computer-based text. Some speechrecognition systems recognize only one person’s voice; others are speaker-independentbut recognize a limited vocabulary. These devices may recognize continuous speech or,more commonly, require that slight pauses be inserted between words.

Structured data entryA data collection technique that constrains the language and format of clinicaldescriptions for the purpose of ensuring uniform, unambiguous, interchangeablemessages.

TCP/IP (Transmission Control Protocol/Internet Protocol)A communications protocol governing data exchanged on the Internet.

TelemedicineThe use of information technology to deliver medical services and information from onelocation to another.

Proprietary and ConfidentialProperty of Richard Lynes

White Paper –Point-of-Care Knowledge Tools

DiagAssist™An interactive Clinical Diagnostic Decision Support Tool, which considers most of the Internal Medicinedomain, is designed to assist the clinician in determining the patient’s diagnosis or the condition underlyinghis or her complaint. DiagAssist can suggest one or more possible diagnoses based on intelligent mappingof the patient’s chief complaint to our vocabulary (UMLS Metathesaurus), which returns codified medicalconcepts linking over seven thousand HTML pages, providing Care Maps or Clinical Pathways for healthmaintenance and disease management. Another way to navigate DiagAssist is through a series of questionsbased on specialty and topic. These questions encapsulate signs and symptoms, physical findings, testresults, and background information. As the clinician answers each question a Java Inference Enginereturns a differential diagnosis.

DiagAssist’s functionality includes clinical diagnosis, drug interactions, preventive care reminders, andactive (diagnostic or therapeutic) care advice and ICD-9/CPT-4 coding. It is tightly integrated with theUSHealthNet™, our CORBA application server, which provides CORBA services for our Java clientsusing an internet/intranet connection, while allowing easy integration with back-office systems.Constructs such as questions and diagnoses categories are built on top of a more general rules based engine.CORBA and IIOP are used between the client and server.

DiagAssistClient

Client

Rules API

DiagAssistServer

Server

Rules API

MedCo

CORB

Rules

CORBA

questions,diagnoses,

it i

facts,tirules

Proprietary and ConfidentialProperty of Richard Lynes

Preventive Care RemindersDiagAssist is designed to remind the clinician to administer preventive health maintenance services whennecessary; examples include retinal examinations for diabetic patients and routine immunizations.Computer-aided diagnosis and drug-dose determination are usually designed to provide a single report on aspecific set of data on a patient; a preventive care reminder module, however, requires repeated input ofdata on the patient over a period of time, reflecting longitudinal care. This includes not only the patient’sdiagnoses and other clinical characteristics, but also the treatments and tests administered and their dates.Additional examples of preventive care reminders include blood pressure monitoring and cervical cancerscreening. DiagAssist elicits background information and risk factors from patients, then compares thisinformation to detailed preventive care guidelines, identifies potential problems, and recommendsappropriate interventions.

Active-Care AdviceDiagAssist is designed to assist the clinician with preventive diagnostic or therapeutic procedures(including pharmaceutical treatments), particularly for patients suffering from chronic health problems.DiagAssist’s active-care advisory module requires input from an EMR module regarding the patient’shealth problems, tests, and treatments over a period of time. DiagAssist specifies which diagnostic andtherapeutic procedures should be performed at each stage of the health problem presented. DiagAssist’scomputer-based clinical advice can take five basic forms:

1. TREATMENT RECOMMENDATIONS (including pharmaceuticals). DiagAssist canprovide diagnostic and treatment advice. For example, DiagAssist would recommend theappropriate antibiotic for patients with meningitis, based on any known allergies of the patientand the organism’s sensitivity. This information would be derived from an EMR.

2. REMINDERS to perform specific diagnostic or therapeutic procedures for patients withchronic health problems, such as adult respiratory distress syndrome.

3. ALERTS regarding potentially adverse events based on abnormal test results. An examplemight be a deterioration of the patient’s condition.

4. FEEDBACK and PROMPTS regarding testing and treatment options, physician orders, andthe entry of information on the patient’s medical history. Specific Feedback and Promptsinclude:

� Possible injurious effects from drug and dietary supplement interactions

� Possible conflict or redundancy between diagnostic tests ordered for a patient

� Projected test results based on the patient’s history and current clinical condition. If theprobability of an abnormal result is low, the provider can reconsider whether the test isappropriate at that time

� Results of previous tests that are similar to the one being ordered; allowing the provider toreconsider whether the test needs to be repeated at that time

� The cost of a test or treatment; allowing the provider to do a risk-benefit analysis andreconsider whether it is appropriate at that time

� Alternative tests or treatments that would be less expensive than the one ordered

5. PROGNOSES (Future) of intensive-care unit patients. These prognoses are based on theseverity of the illness (using vital signs and other physical measures) and physiologicalreserve (age and general health). DiagAssist is also used to determine the severity of theillness and risk-adjusting outcome measures. An expanded prognostic model is designed topredict survival to 180 days (rather than to discharge); it includes patients who are not acutelyill.

Proprietary and ConfidentialProperty of Richard Lynes

Health Maintenance TrackingThe Health Maintenance module is invaluable for improving patient care. Standard health maintenancetemplates, based on age and gender, comprise a standard data set within the system. These templates maybe customized to more closely track healthcare requirements for groups of patients or individuals. TheHealth Maintenance Tracking system reminds the user about a patient's health maintenance needs at eachvisit. It also generates patient reminder cards for pre- and post-visit follow-up.

Laboratory Data IntegrationThe EMR module stores complete laboratory data including CBC, urinalyses, blood chemistries,microbiology, special studies, and miscellaneous tests. Abnormal results are flagged and are easilydistinguished from results in the normal range. The system also records the results of diagnostic proceduressuch as EKG, pathology, and x-ray reports.

Drug Dose DeterminationThe ScriptPAD™ module can assist the clinician in determining the proper dosage of a specific drug, eitheras an exact quantity or as a recommended range, for a particular diagnosis and patient, cross-referencingdata points in medical records with health plan/payer formularies. The algorithms in the knowledge basethen ascertain the proper dosage of the drug being prescribed. DiagAssist also provides a hyperlink to anon-line Physician’s Desk Reference (PDR) and drug-interactions knowledge base.

Medical Tracking with Drug Interaction DatabaseThis system tracks current and previous medications, presenting collected information chronologically in amulti-date inquiry. Prescriptions are printed quickly and accurately, enhancing patient relations andensuring precise results. Prescriptions are printed on standard prescription forms. They include refilltracking, drug allergies, and contraindication information.

A complete drug interaction database is integrated with the Electronic Medical Record module; this featureallows the provider to maximize accuracy and efficiency when prescribing medications. The systemsupports full Electronic Data Interchange protocol standards for electronic transmission through theInternet Health Care Community’s virtual pharmacy (EDI/XML).

Electronic SignaturesWhether a progress note is entered directly by the physician or dictated and then transcribed, the physicianis required to sign the note electronically. This electronic signature is password-protected, as well asencrypted for complete security. Digital certificates and authentication mechanisms enable additionalsecurity levels to be implemented depending on the organization’s policies.

Summary of Medical ConsultDecision support provides interpretive information processing. It is based on logical conditions or rules,but still displays practicable results for the provider and patient to use when making health care decisions.For example, the medication pricing display could be expanded to include providing alternativemedications based on a patient's profile. This provides the ability to make choices that are both efficaciousand cost effective.

Proprietary and ConfidentialProperty of Richard Lynes

USHealthNet POC ArchitectureDevelopment Team21 November1999

Purpose of this SectionThis document is designed to show the current thinking on different aspects of the USHealthNet project.Specifically it deals with architectural and implementation issues. It follows on from the USHealthNetServer Architecture (Version 1) document (Development Team 24th October 1998) and the subsequentdiscussions within management, particularly the conference call of the 8th November.

USHealthNet Architecture (Revised)

Storage /3rd Party EMR

Concurrency Control

Application /Module Layer

Application / Module API

ContextManager

Script Pad DiagAssist......

SC - API DA - API

Core Services Layer (ObjectM d l)

Patient

PatientEpisode

DaigAssistSession

DaigAssistServer

DiagAssistKnowledge

Base

DiagAssisSession Store

EMREpisodes

EMR CorePatientRecord

ICD9 & CPT4Lookup

ICD9 / CPT4Repository

FDBRepository

DrugInteractions

...

...

UMLSRepository

UMLSServices

UMLS API

...

Figure 1: The original layered architectureFigure 1 shows the original layered diagram for the USHealthNet Architecture. Team USHealthNet hassubsequently elaborated upon this diagram so it now resembles Figure 2 (Note: For clarity purposes, not alllinks between components are shown).

Proprietary and ConfidentialProperty of Richard Lynes

Storage/3rd Party

Application/Module LayerDiagAssistScriptPadCxt Mgr Pat Mgr

Client/Server API (CORBA Layer)

Service API'sFoundation API's EMR API UMLS APIMC APISC API

Core Services Layer (Object Model)

Knowledge ServicesTransaction Services

MCServer

ICD9 &CPT4

Lookup

DrugInteractions

UMLSServices

System API

PatientPatientEpisode

MCSession SP

Session

Security

Ccurrency

TM

Knowledge Bases

MedConsKnowledge

Base

ICD9 / CPT4Repository

FDBRepository

UMLSRepository

......

EMR

MC SessionStore

EMREpisodes

EMR CorePatientRecord

SP SessionStoreSystem Database

User Table

Figure 2: The revised layered architecture

The Application LayerThe application layer now has four definite application/modules, which are in different stages ofdevelopment. As well as these there are other components, which are in research or planning stages andthese may be added to the USHealthNet suite. The components that are in development are DiagAssist,ScriptPad, Patient Manager, and Context Manager. The components which have been researched, plannedor discussed include a UMLS Knowledge Component, a Discharge Summary Writer, and User Manager.

The API LayerThe API layer provides the interface between the client and the server. At this stage it has been decided toimplement the API through CORBA (specifically Orbix 2). This provides us with a level of technologyindependence. There are two types of API within this layer, The Foundation API’s and the Service API’s.The Foundation API’s are so called because they are central to the system. They provide the functionalityaround which the system is built. The Foundation API set currently contains the EMR and the SystemAPI’s.

1.1.1. The EMR APIThe EMR API provides the interface to patient details. It contains calls for interfacing with one or manypatients. The EMR API has different layers of granularity. At the highest level there is the concept ofdealing with several patients. This can then be brought down to the level of a single patient. For singlepatients there is the concept of an episode (or case), which is composed of several sessions. A session is asingle interaction between a patient and a physician. For example there can be DiagAssist Sessions, which

Proprietary and ConfidentialProperty of Richard Lynes

are single question and answer sessions. There can be ScriptPad Sessions, which is essentially a singleprescription. An episode usually spans all sessions relating to a single illness or complaint.

1.1.2. The System APIThe System API has three functions:• Security• Concurrency and multi-user issues• Transaction monitoringAs can be seen the System API is concerned with the interactions between users and USHealthNet. In asenses it can be considered to be parasitic upon the system in that it has nothing to do with medical data,but at the same time the System API is vital for a fully functioning system. The security issues involvedinclude user authentication, logging onto the system and measures to prevent unauthorized access to thesystem. The concurrency and multi-user issues have to be addressed to prevent data inconsistency. Finallytransaction monitoring provides us with two functions. On the one hand it allows us to see how, when andwhere users make use of the system. We can use this to make the system more responsive and also to seewhat services users find most useful. Transaction monitoring also allows us to providing costing to usersfor their use of the system.

1.1.3. Service API’sThe service API’s can be taken on a case by case basis. They provide an interface to services provided byUSHealthNet. Currently two Service API’s exist, the ScriptPad API and the DiagAssist API. Other ServiceAPI’s will be formalized as the services are defined. The existing API’s will also undergo changes. Thecurrent DiagAssist API, for example, provides an interface to EMR functions that are inappropriate for thisAPI. Our understanding of the ScriptPad API is that it provides an interface to a drug database and as suchwill possibly function as a more general API.

The Core Services LayerThis is the server side of USHealthNet. It is divided into two sections, the Transaction Services and theKnowledge Services. The Transaction Services are those which concern users of the system, or patients.These are services such as EMR services, Transaction Monitoring Services, Security Services and so on.The Knowledge Services are those which add value by virtue of the meaningful information they impart tothe user. The Knowledge Services may include ‘smarts’ which more efficiently impart information. Anexample of this is the DiagAssist Service, which has ‘smarts’ that allows it to make best-fit diagnosis basedon criteria.

The Storage LayerThe purpose of the Storage Layer is to provide persistence within the system. This is the layer at which thevarious databases reside. The databases as seen in the diagram may be actual DB’s or may be bridges toexternal DB’s. The connection between the Core Services Layer and the Storage Layer is via ODBC,which gives us some level of independence from the underlying DB technology.

Proprietary and ConfidentialProperty of Richard Lynes

Storage/3rd Party

Application/Module LayerDiagAssistScriptPadCxt Mgr Pat Mgr

Client/Server API (CORBA Layer)

Service API'sFoundation API's EMR API UMLS APIDA-APISC API

Core Services Layer (Object Model)

Knowledge ServicesTransaction Services

DAServer

ICD9 &CPT4

Lookup

DrugInteractions

UMLSServices

System API

PatientPatientEpisode

MCSession SP

Session

Security

Ccurrency

TM

Knowledge Bases

DiagAssistKnowledge

Base

ICD9 / CPT4Repository

FDBRepository

UMLSRepository

......

EMR

DA SessionStore

EMREpisodes

EMR CorePatientRecord

SP SessionStoreSystem Database

User Table

Figure 3: USHealthNet Architecture – Implementation Timeframes

Figure 3 above gives an indication of the dates when different components of USHealthNet come onstream.The diagonal lines represent components that will be installed in Beaumont Hospital in December. Thevertical lines are ScriptPad components, which should be integrated early in the Q1-98. The horizontallines represent the system components of USHealthNet. USHealthNet Version 2 should be ready by end ofQuarter 1 ’99 which would have the system components integrated and possibly other application modules.

Proprietary and ConfidentialProperty of Richard Lynes

USHealthNet Architecture

Purpose of this documentThis document is designed to show the current thinking on different aspects of the USHealthNetproject. Specifically it deals with architectural and implementation issues. It follows on from theUSHealthNet Server Architecture (Version 1) document (October 1998) and the subsequentdiscussions within Team USHealthNet particularly the conference call of the 8th November.

USHealthNet Architecture (Revised)

Storage /3rd Party EMR

Concurrency Control

Application /Module Layer

Application / Module API

ContextManager

Script Pad DiagAssist ......

SC API DA API

Core Services Layer (Object Model)

Patient

PatientEpisode

DiagAssistSession

DiagAssistServer

DiagAssistKnowledge

Base

DiagAssistSession Store

EMREpisodes

EMR CorePatientRecord

ICD9 & CPT4Lookup

ICD9 / CPT4Repository

FDBRepository

DrugInteractions

...

...

UMLSRepository

UMLSServices

UMLS API

...

Figure 1: The original layered architecture

Figure 1 shows the original layered diagram for the USHealthNet Architecture. Team USHealthNethas subsequently elaborated upon this diagram so it now resembles Figure 2 (Note: For claritypurposes, not all links between components are shown).

Proprietary and ConfidentialProperty of Richard Lynes

Storage/3rd Party

Application/Module LayerDiagAssistScriptPadCxt Mgr Pat Mgr

Client/Server API (CORBA Layer)

Service API'sFoundation API's EMR API UMLS APIDA-APISC API

Core Services Layer (Object Model)

Knowledge ServicesTransaction Services

DAServer

ICD9 &CPT4

Lookup

DrugInteractions

UMLSServices

System API

PatientPatientEpisode

MCSession SP

Session

Security

Ccurrency

TM

Knowledge Bases

DiaAssistKnowledge

Base

ICD9 / CPT4Repository

FDBRepository

UMLSRepository

......

EMR

DASessionStore

EMREpisodes

EMR CorePatientRecord

SP SessionStoreSystem Database

User Table

Figure 2: The revised layered architecture

The Application LayerThe application layer now has four definite application/modules, which are in different stages ofdevelopment. As well as other components, which are in research or planning stages and thesemay be added to the USHealthNet suite. The components that are in development areDiagAssist ScriptPad, Patient Manager, and Context Manager. The components which havebeen researched, planned or discussed include a UMLS Knowledge Component, a DischargeSummary Writer, and User Manager.

The API LayerThe API layer provides the interface between the client and the server. At this stage it has beendecided to implement the API through CORBA (specifically Orbix 2). This provides us with alevel of technology independence. There are two types of API within this layer, The FoundationAPI’s and the Service API’s. The Foundation API’s are so called because they are central to thesystem. They provide the functionality around which the system is built. The Foundation APIset currently contains the EMR and the System API’s.

Proprietary and ConfidentialProperty of Richard Lynes

The EMR APIThe EMR API provides the interface to patient details. It contains calls for interfacing with one

or many patients. The EMR API has different layers of granularity. At the highest level there isthe concept of dealing with several patients. This can then be brought down to the level of asingle patient. For single patients there is the concept of an episode (or case), which iscomposed of several sessions. A session is a single interaction between a patient and a physician.We well be implementing the CorbaMed Enterprise Master Patient Index specification and allpatient object requests will be filtered through this Interface. For example there can beDiagAssist Sessions, which are single question and answer sessions. There can be ScriptPadSessions, which is essentially a single prescription. An episode usually spans all sessions relatingto a single illness or complaint.

The System APIThe System API has three functions:

� Security� Concurrency and multi-user issues� Transaction monitoring

As can be seen the System API is concerned with the interactions between users andUSHealthNet. In some senses it can be considered to be parasitic upon the system in that it hasnothing to do with medical data, but at the same time the System API is vital for a fullyfunctioning system. The security issues involved include user authentication, logging onto thesystem and measures to prevent unauthorized access to the system. The concurrency and multi-user issues have to be addressed to prevent data inconsistency. Finally transaction monitoringprovides us with two functions. On the one hand it allows us to see how, when and where usersmake use of the system. We can use this to make the system more responsive and also to seewhat services users find most useful. Transaction monitoring also allows us to providing costingto users for their use of the system.

Service API’sThe service API’s can be taken on a case by case basis. They provide an interface to servicesprovided by USHealthNet. Currently two Service API’s exist, the ScriptPad API and theDiagAssist API. Other Service API’s will be formalised as the services are defined. TheScriptPad API provides an interface to a drug database and as such will possibly function as amore general API.

The Core Services LayerThis is the server side of USHealthNet. It is divided into two sections, the Transaction Servicesand the Knowledge Services. The Transaction Services are those which concern users of thesystem, or patients. These are services such as EMR services, Transaction Monitoring Services,Security Services and so on. The Knowledge Services are those which add value by virtue of themeaningful information they impart to the user. The Knowledge Services may include ‘smarts’which more efficiently impart information. An example of this is the MedConsult Service,which has ‘smarts’ that allows it to make best-fit diagnosis based on criteria.

Proprietary and ConfidentialProperty of Richard Lynes

The Storage LayerThe purpose of the Storage Layer is to provide persistence within the system. This is the layer atwhich the various databases reside. The databases as seen in the diagram may be actual DB’s ormay be bridges to external DB’s. The connection between the Core Services Layer and theStorage Layer is via ODBC, which gives us some level of independence from the underlying DBtechnology.

Wendy Roberts

Vice President of Business Development- AGENCY.COM

Wendy brings over 18 years of marketing experience to her work at

AGENCY.COM. She has focused for the past 8 years on the interactive

medium and electronic commerce, working with many Fortune 500 companies

worldwide, including IBM, NCR/AT&T, Federal Express, and General

Motors.

As vice president of business development, Wendy directly manages the

stimulation of new client opportunities.

Prior to joining AGENCY.COM, Wendy served as the Vice President of

Business Development and Marketing at Tech 2000, the leading developer

of interactive communities of interest in both the Motor Sports and

Energy industries on the Internet.

Wendy pioneered the Electronic Strategies Consulting capability at

Bronner Slosberg Humphrey, which was responsible for consulting both

current and new clients on the impact of interactivity on their

business landscape. Wendy’s role focused on interactive marketing and

database initiatives as well as helping Fortune 1000 clients understand

the impact of interactive supply chain, distribution management,

internal process and re-engineering their business plan as competitive

differentiators.

Additionally, Wendy also served as the co-founder and chief operating

officer of CommSoft Technologies, a company that developed client-

server based electronic catalog applications even before the Internet

was a commercial platform. She developed a custom application for a

software catalog and fulfillment system for NCR’s finance group’s

internal, worldwide network.

RICHARD LYNESProfessional Resume

3 Acorn Street (781) 545-3938Scituate, MA 02066 cto@mediaone.net

PROFESSIONAL PROFILE:Strategic Planning and Information Technology Solutions Thought-Leader, achieving improvedoperating efficiency through IT and business strategy alignment, and increased shareholder value byleveraging technology as a competitive differentiator.

Professional Competencies:

� Strategic IT and Business planning for e-commerce, e-business and Knowledge Management as acompetitive differentiation in the B2B, B2C and B2ME markets, integrating both buy-side, sell-sideand customer facing processes

� Mentoring companies executives in their migration from traditional mass marketing and operationalpractices to those of 1-2-1 personalization; Customer Relationship Marketing (CRM) utilizinginteractive media, database marketing, and the integration of legacy Line-of-Business applications,including SCM, OLR and ERP solutions

� Guiding executives on the sweeping changes, trends and impacts of technology on competitivestrategies, business objectives and business transformation

� Technical team lead on the design, development and deployment of scaleable Enterprise-wideinformation, software and systems architectures. Supporting Intranet/Extranet applicationinfrastructure components for MRO purchasing and e-catalog procurement, Human Resources,Sale Force Automation, Knowledge Management, and strategies for linking channel partners,suppliers and customers.

Serving as CIO and CTO for several market leaders, my past successes have been achieved by developingvisionary technology strategies and facilitating information flow within the senior management strategicplanning function. By improving knowledge utilization through linking corporate stakeholder processes andobjectives, client business strategies, and facilitating cooperation between cross-functional teams, my insightshave created a more customer centric approach and methodology.

My colleagues have often described me as an approachable team player who has a proven knack offorecasting and keeping them abreast of critical changes in the dynamic, fast paced world of technology. Thistalent does not come from a crystal ball, but from a substantial career of following the movements within boththe Information Technologies and Tele-communications industries.________________________________________________________________________________________

EXPERIENCE:

Jan. 1997- Sequitor Medical Technologies, Inc., Boston, MA.Present Executive Vice President, Chief Information Officer

Developed corporate IT strategy supporting business objectives, positioning Sequitor as a leader in the Point-of-Care Knowledge Acquisition and Delivery tools market. Primary accomplishments have been:

• Established strategic component-based architecture, network centric computing infrastructure, anddevelopment partnerships

• Lead the company in the development of a Community Health Care Information Delivery Network strategy• Developed Internet/Intranet and Extranet based Electronic Medical Records solution, tapping into the

Point-of-Care knowledge Delivery and Acquisition market, based on Java, CORBA, IIOP/HTTP,XML/DHTML, JavaScript and applications integrating AI inference Engines, NLP, Ontology’s, Domainspecific lexicons and semantic network knowledge Services.

• Recently competed a Java client-server three-tiered development project, producing an integratedprescription-writing module coupled with a Diagnostic Decision Support solution.

• Directly oversaw development efforts spread across five out-sourced R & D firms from Boston to Dublin,Ireland.

RICHARD LYNESProfessional Resume

3 Acorn Street (781) 545-3938Scituate, MA 02066 cto@mediaone.net

• Managed multiple parallel projects with increased complexity do to the distributed nature of the remotedevelopment teams, which were completed on schedule and on budget, even when scope was increased.This was a multi-million dollar development effort and one of the first to fully implementing a three tieredclient-server architecture integrating JavaBean components, Corba, IIOP/HTTP, WEB server and SequelServer over the Internet/Intranet topology.

• Playing the additional role of chief architect, designed the overall IT strategy, which lead to the design anddevelopment of a complete Corba API controlling all method invocations between the Java client andCorba applications server and WEB server.

June 1996- Diversified Technologies Group, Hull, MA.Jan. 1997 Managing Partner

As a principal, managed consulting engagements with fortune 500 clients. Projects involved creating corporatevision and strategy leveraging new technologies and service models in support of measurable businessobjectives. Each engagement was awarded as a result of proactively advising the clients of new businessopportunities that could be achieved through the application of technology.

• Defined interactive advertising, marketing and commerce strategies for Internet development companythrough the identification of site tracking, measurement, RAD commerce tools and dynamic contentdevelopment through personalization mechanisms.

• Additional engagements led to the development of a WEB Based Enterprise Asset Management Model.The infrastructure supporting this model is an adaptive framework architecture supporting corporate ITprocurement processes (ERP) and corporate wide asset management. The conceptual design integratesan Intranet based e-catalog coupled with auto discovery agents, which support a Total-Cost-Ownership(TCO) model enabling configuration management, license management, and ESD.

• Other engagements involved the conceptual design of a visionary Network Centric Community Health CareDelivery System. The vision provides for a layered architecture enabling community health care deliveryservices. The design goal is to leverage the Internet/Intranet tools and architecture, and develop acommunity level Extranet (Frame Relay VPN) supporting Practice Management Services integrating othertele-medicine applications.

March 1994 - Bronner Slosberg Humphrey, Boston, MA.June 1996 Chief Technology Officer

Senior executive responsible for research and development, as well as guiding corporate technology strategyand policy for the development of new interactive media capabilities. Consulted with Clients on the impact ofemerging technologies to their existing and new marketing practices. Developed the corporate technologystrategy for several key clients.

Client Projects Executed• Assisted fortune 50 package shipping company in the development of a new business opportunity, which

leveraged key database and electronic cataloging technologies, integrating with their core business ofLogistics and Material Management, to that of digital information and content, leveraging merchant andother supply-chain relationships in a Global Business-Business Internet E-commerce Hub

• Conducted IT assessment and re-designed the software product strategy of a fortune 50 technologycompany, providing them with a greater potential market penetration

• Developed technology plan to support personalized interactive marketing strategy for top ranked direct mailcatalog company

• Greatly enhanced the service offerings of a fortune 50 telecommunications company in the area of onlineservices as a direct result of a technology assessment and requirements development engagement

• Lead a cross functional team in the development of functional specifications and technology strategy whichenabled the virtual integration and consolidation of 175 corporate call centers

• Conducted IT assessments, infrastructure vision development and implementation plans in support ofcorporate business and marketing strategies

RICHARD LYNESProfessional Resume

3 Acorn Street (781) 545-3938Scituate, MA 02066 cto@mediaone.net

Internal Corporate Development• Developed Advanced Technology Group, which identified requirements from all functional areas of the

organization and identified technology standards for the execution of internal and external clientengagements

• Identified new technologies and alliance opportunities• Directed the technology strategy development of three agency capabilities, resulting in three integrated

practice areas:

-Electronic Strategy (E-commerce Consulting)-Tele-services (Call Center Consulting)-Customer Based Management Strategy (1-2-1 Relationship Management Consulting)

April 1992 - CommSoft Technology, Inc., Braintree, MA.March 1994 Co-Founder and Vice President of Research and Development

• Developed ESD product vision and directed development efforts for electronic catalog marketingapplications supporting procurement of IT assets through the Internet

• Responsible for managing a multi-million dollar budget and all technology related development efforts insupport of the organization’s business model

• Actively participated in strategic business planning and execution• Key Clients Served:

- Bell Laboratories -IBM-NCR/AT&T Brussels, Belgium -Boeing (BCAG)-Software Development Company (SDC) -Microcomm-Digital Equipment Corporation -Ungermann Bass

June 1991 - Ronlyn Information Technologies, Augusta, GA.April 1992 Technical Consultant

• Reviewed government bids for small business• Assisted in the RFQ/RFP process, technical specifications and resource analysis

June 1990 - Diversified Technologies Group, Augusta, GA.April 1992 Senior Consultant/Systems Integrator

• Consulted on Electronic Software Distribution (ESD) for the following companies:-IBM -DEC -SDC (Programmers Shop) -Sprint-MCI -NCR -North Point (NPSV) -Corporate Software

• Provided IT architecture design and integration services in the following market segments:

Lite Manufacturing & MRP -Retail (POS)-Wholesale Distribution & JIT -Imaging-Document Management -Health Care

Dec 1988 - Applied Solutions/Systems Integration Group, Augusta, GA.June 1990 Division Manager

• Developed a business plan targeting four primary vertical industry segments:-Medical Practice Management -Integrated Office Automation-Retail Point-of-Sale -Wholesale Distribution

• Managed sales, marketing, systems integration, and support operations• Managed the transition and reorganization of a technology M&A transaction• Established strategic business partnerships with IBM, AT&T, UNISYS

RICHARD LYNESProfessional Resume

3 Acorn Street (781) 545-3938Scituate, MA 02066 cto@mediaone.net

March 1984 - Automated Business Applications, Inc., Augusta, GA.Dec 1988 Managing Principal

• Founding Core Team member of new innovative technology start-up• Directly oversaw Finance, Operations, Sales & Marketing• Directed daily Systems Integration planning & implementation• Developed supply-chain-management consulting infrastructure practice• Designed & development practice methodology, process and tools selection

Nov. 1982 - Technology Import Group, Augusta, GA.March 1984 Senior Consultant

• Provided research for business plan• Developed strategic technology partnership in Pacific Reign• Established vendor selection methodology and process• Conducted in-field product testing and selection

Sept 1981 - Gould Simulated Systems Division, Augusta, GA.Nov 1982 Senior Field Engineer

• Maintained US Army Signal Corps. first interactive computer based training simulator. This was a 7 millionmulti-year project

• Facilitated reorganization of existing support programs and streamlined maintenance processes andprocedures

• Briefed command staff on technical improvements for future simulators• Conducted circuit level diagnostics and troubleshooting• Maintained depot level repairs and local parts stock/inventory

May 1975 - U. S. Army Strategic Communications CommandMay 1981 Lead Communications Engineer

• European and Pacific Theater of Operations, responsible for the engineering and deployment of thestrategic communications backbone. This includes wireless RF Microwave facilities, fixed station DialCentral Office facilities, Satellite and tactical Digital Switching Systems. Managed a team of experts whichwere responsible for site assessment, engineering & network design, and implementation of world widestrategic communications systems

RICHARD LYNESProfessional Resume

3 Acorn Street (781) 545-3938Scituate, MA 02066 cto@mediaone.net

________________________________________________________________________________________

EDUCATION:

Continuing Education Areas:-Object oriented design & analysis -Enterprise applications design & analysis-Network: systems management-Electronic Software & Service Distribution

UNIVERSITY OF GEORGIAGEORGIA INSTITUTE of TECHNOLOGY-BS Computer Science 1982

3 years of advanced communications engineering DOD schools for the United States Armed Services

________________________________________________________________________________________

WHITE PAPERS AUTHORED:

-Re-engineering enterprise work flow processes -Enterprise Messaging-Enterprise Information Systems -Electronic Software Distribution-Electronic Catalogs -Enterprise-Intranet Directions-Virtual Call Centers -Adaptive Infrastructures-E-commerce -Learning Organizations

________________________________________________________________________________________

Professional Associations:

-Institute of Electrical and Electronics Engineers (IEEE )-Re-engineering International Association-Workflow Management Coalition (WfMC)-Object Management Group (CorbaMed)

Concord Associates688 Concord Avenue, Belmont, MA 02478 617-489-3505 FAX 617-484-9354

Professional Biography of Donald Leavitt

Donald > Leavitt is the founder of Concord Associates, a firm devoted to the development and nurturing of seed-stage venture investments. Mr. Leavitt is also President of Dynographics, Inc., an Internet-focused management andmarketing consultancy specializing in the creation of organizationally and strategically aligned:

• Customer acquisition, development, and retention plans,• Internet-compliant strategic marketing plans,• Internet-driven brand-building initiatives,• Interactive marketing and sales scenarios,• Strategic operating plans for new Internet-based e-commerce initiatives, and• Resolution and workout plans for Internet-generated channel conflict widely considered the single most

significant barrier to success for large legacy-driven enterprises transforming from traditional to electroniccommerce channels.

Many of these issues are analyzed in depth in a case Mr. Leavitt co-authored on Bronner Slosberg Humphrey forthe Harvard Business School with David E. Bell, Royal Little Professor of Business Administration at HBS. Mostrecently, Mr. Leavitt collaborated with Professor Bell on an HBS case that focuses on donor acquisition andretention issues confronting the United Way of Massachusetts Bay.

Both before and after the emergence of the Internet as the channel of choice for the new millenium, Mr. Leavitt hasbeen providing strategic product management, M&A analysis, market assessment, and technology evaluationservices to senior management at such marquee clients as Fujitsu, Ltd., Merill Lynch, Lehman Brothers, CanonUSA, Worldwide Volkswagen, CBS, Eastman Kodak, Jones Day Reavis & Pogue, Ziff Davis, and theGovernment of the People's Republic of China.

In 1987, Mr. Leavitt started Spectra Sciences, a designer and manufacturer of high value added, internationallypatented specialty chemicals. During his tenure as founder, CEO and CFO of the company, he raised nearly $3million in seed-stage venture capital financing. Today, Spectra Science is redefining laser technology through itswork with Nanocrystals.

An honors graduate of Brandeis University, Mr. Leavitt began an extensive involvement in the advanced imagingtechnology at NASA's Photographic Research Laboratory in the late 1960's. At NASA, he co-designed theworld's first digital image enhancement system for pictures taken in space and on the lunar surface by Apolloastronauts.

After a number of successful R&D forays covering a variety of rapid access imaging systems, Mr. Leavitt went onto become the Technology Editor of Popular Photography, and the Advanced Technology consultant for TimeMagazine.

Mr. Leavitt has also written and produced major stories for Time, New York Magazine, and The New YorkTimes, where he was one of the first to help chronicle the painstaking restoration of the Leonardo da Vinci's TheLast Supper. In the book publishing field, he was publicity and marketing consultant for Ansel Adams' Yosemittand the Range of Light, one of the best selling big-ticket art books of all time; consulting editor for The NEwAnsel Adams Photography Series; and creative consultant for The Great Ladies of Jazz.

Jeff Heywood - Bio

Over the past 12 years held senior management positions at the following companies:

CFO, StarQuest Software, Inc. 12/98-current-Middleware software company specializing in connectivity software for networks, routers, andeCommerce solutions (web Servers, application servers) for large enterprises in all industry segments.-Privately held, venture funded (Sierra Ventures).

Prior Management positions:V.P. of Finance and Operations, Birmy Graphics Corporation June 98 – Dec 98-Leading manufacturer of software applications for the color inkjet industry-Privately held

Controller, Adobe Systems, Inc. 1990-1998-currently ranked as the third largest application software company in the world-publicly traded on NASDAQ

Director of Finance/Controller, Emerald City Software. 1988-1990-graphic application software company-venture funded-sold to Adobe in 1990

Controller, Mountain View Golf Company 1986-1988-A golf course management and development company-privately held

Prior to the above from 1979-87:

I worked as in various accounting/finance and management roles at various high tech companies such asAcuson, HP, Wiltron, Thomas Industries and I worked for a large metropolitan hospital San Jose HealthCenter (as a lab tech & system administrator after I finished my Bio degree).

The following is my educational background:

BA -Bio SciencesBS -AccountingMBA -Finance & ManagementCalifornia State University, San Jose, CA.

Personnel Statistics:Age – 41Single, with one son (attending USC), live in Los Altos, CA (heart of Silicon Valley)

PATRICK G. MORAND

2529 Kingston Drive Telephone: 847-291-4192Northbrook, Illinois 60062 Fax: 847-291-4193

Email: pgmorand@ameritech.net

CAREER SUMMARY

General management executive. Expertise in: strategic and business planning, public accountability,turnaround, product and market positioning, strategic relationships, management development, headquartersand division operations.

DEMONSTRATED STRENGTHS

• Delivered strong and sustainable revenue growth for national multi-million dollarorganizations within highly competitive environment

• Adept in building, motivating and leading culturally diverse teams with a strongcommitment to customers and focused on the achievement of organizational goals

• Confident and innovative thinker, problem solver and decision maker with anexceptional ability to forge successful business relationships

CENTEON, LLC; King of Prussia, Pennsylvania 12/1/98 - Present$900M international plasma protein manufacturer; division of Aventis Pharmaceuticals

General ManagerAccountable for startup in clinical trials partnerships

• Built a successful network of pharmaceutical/biotech companies, software licenser and the bloodand plasma industry with first-year revenues of $1M

SEQUITOR MEDICAL TECHNOLOGIES, INC.; Chicago, Illinois 6/1/96 - 5/1/98International development-stage, startup company marketing disease management software.

Executive Vice President/InvestorCompany’s first employee, implementing investors’ vision; generating interest among prospectiveusers

LIFESOURCE, INC.; Chicago, Illinois 1992 - 5/30/96$33M high-profile pharmaceutical manufacturer of blood products; 450 employees

President and Chief Executive OfficerFull P/L accountability to the Board of Directors for leadership and direction to competitively positionthe company for growth and acquisition

• Refocused the corporate mission, developed strategic plan and designedcompetency-based critical success factors, resulting in unprecedented year over year 14%growth with lower than CPI price increases

• Quickly turned around financial performance and increased net income 88%• Promptly reversed negative regulatory status from near closure by FDA• Assured company's future by engineering an alliance with ITxM in Pittsburgh• Spearheaded the consolidation, financial negotiations and relocation of 4

separate sites into a new 74,000 sq. ft. headquarters location within 12 months.• By developing a high-performance senior management team and instituting a

continuous improvement culture, transformed the company into an energetic andsophisticated provider of products and services

Patrick G. Morand Page Two

AMERICAN RED CROSS 1974 - 1992

Chief Executive Officer/Division President, Baltimore, Maryland (1987 - 1992)Full P/L accountability for all operations of the system's third largest organization with $50 Mrevenues and 1,000 employees. Developed business and strategic plans; negotiated contracts; designedand implemented corporate initiatives. Headed extensive capital campaign drives.• Designed and secured $13 M in financing for the construction of a 111,000 sq.

ft. facility in less than 18 months• Saved $10 million by consolidating two major regional centers and streamlining

workforce by 42% without service disruption; negotiated two labor contracts• Reduced turnover by 20% and increased minority recruitment by 50% through

diversity initiatives• Founded the National Holocaust and War Victims Tracing and Information

Center; organized the national Board of Advisors; raised $388,000; gainedrecognition for the Center through front-page coverage in New York Times, Washington Postand Wall Street Journal and prime time broadcasts of CBS, NPR and CNN

• Skillfully merged two boards of directors maintaining unwavering support fromkey high-profile members, resulting in high quality governance

Chief Executive Officer/Division President, St. Paul, Minnesota (1982 - 1987)Full P/L accountability for the system’s twelfth largest regional center providing a variety ofcommunity-based services including those to academic medical centers and urban/rural hospitalswithin a five-state area.• Initiated the first organ, bone marrow, bone and tissue transplantation program

affiliated with a major community organization• Under leadership, contributions surged 500% by galvanizing a network of 300

community/civic leaders

Previous experience -- Assistant Executive Director (Dallas), Center Administrator (Toledo), AssistantAdministrator and Account Executive (Columbus).

ACADEMIC CREDENTIALS

B.A., Philosophy ⋅ Athenaeum of Ohio ⋅ Cincinnati, OhioDiplomate, American College of Healthcare Executives

CIVIC AND COMMUNITY LEADERSHIP

Research and Education Foundation of the Michael Reese Medical Staff, DirectorDistrict 30 School Board Selection Caucus, Chair

Northwestern University Associates, MemberRed Cross Holocaust and War Victims Tracing and Information Center, Chair – Nominating Committee

AFFILIATIONS

Executives' Club of Chicago, Chairman of Healthcare Special Interest GroupAmerican College of Healthcare Executives, Regent's Advisory Council Member

Filename: Pat's resumeDirectory: D:\NewCo\HRTemplate: D:\program files\microsoft office\Templates\Normal.dotTitle: PATRICK GSubject:Author: Patrick MorandKeywords:Comments:Creation Date: 06/15/99 12:39 PMChange Number: 2Last Saved On: 06/15/99 12:39 PMLast Saved By: ctoTotal Editing Time: 0 MinutesLast Printed On: 06/22/99 12:51 AMAs of Last Complete Printing

Number of Pages: 2Number of Words: 678Number of Characters: 4,437

Filename: Jeff Heywood BiographyDirectory: D:\NewCo\HRTemplate: D:\program files\microsoft office\Templates\Normal.dotTitle: Jeff Heywood Biography:Subject:Author: Craig FixlerKeywords:Comments:Creation Date: 06/16/99 3:49 PMChange Number: 3Last Saved On: 06/22/99 12:53 AMLast Saved By: ctoTotal Editing Time: 1 MinuteLast Printed On: 06/22/99 12:53 AMAs of Last Complete Printing

Number of Pages: 1Number of Words: 225Number of Characters: 1,349

Ricahrd D Lynes

This demo reflects some of the process and information flows for a typical patient encounter. The screen shots are only here to give you a flavor for what we have developed to-date. The actual applications can be demonstrated in a personal one-on-one meeting. This prototype does not reflect what we image the end product to be, however it did provide a useful understanding of the integration issues faced in the healthcare setting.

ScritpPAD quicklyalerts physicians aboutdrug side-effects &other dangerous druginteractions.

ScritpPAD quicklyallows physicians towrite or refill drugpresciptions, enteringdose, route and othercritical information.

SctiptPad Design Specification Page 1 09/12/97

USHealthNetDesign Specification for ScriptPad ComponentVersion 2.0 – September 11, 1997

SctiptPad Design Specification Page 2 09/12/97

Table Of Contents

I. Purpose of this document................................................................................................................................... 3II. User Requirements ............................................................................................................................................. 4III. Functional Overview........................................................................................................................................... 5

Core Functionality........................................................................................................................................... 5System Features............................................................................................................................................. 5

IV. GUI DesignUser Experience & GUI ................................................................................................................. 6V. System Design: High-Level Object Model And Process Flow.......................................................................... 9VI. System Design: Context Management & EMR Data Access ........................................................................ 10VII. System Design: Formulary/First Data Bank Integration................................................................................ 11

SctiptPad Design Specification Page 3 09/12/97

I. Purpose of this document

This document details the functional/design specification for the ScriptPad component of the "USHealthNetVirtual Physician Desktop". It will define the overall design of the application and its GUI interface, themethods by which the application retrieves necessary data, and an initial specification of the CORBAinterfaces which will be used for the drug-interaction component with the First DataBank knowledge baseand third-party formularies.

Preliminary system requirements have been refined through interviews with practicing physicians, andtheir comments have been integrated into this draft specification.

SctiptPad Design Specification Page 4 09/12/97

II. User Requirements

Our research with physician users and medical IS professionals has encouraged us to refocus ourdevelopment efforts on the prescription writing experience itself. In particular, we consistently heard thefollowing:

1) Physicians typically know which medications they are going to prescribe.2) Drug cost and provider coverage is an important consideration when the physician writes a

prescription.3) Evaluating drug interactions is an “organic” part of the prescription writing process. That is, in

choosing a medication, the physician is already considering what negative interactions must beavoided.

4) Knowing a patient’s drug history will often impact the decision making process.5) Allergy information is critical, but not always provided in a consistent format. Many times,

physicians rely on a patients memory of possible allergies.6) Physicians were skeptical that an expert-system (such as MedConsult) would provide meaningful

advice on medication. All of the physicians we spoke to indicated that “that’s my job.”7) Physicians never want to be limited in their ability to make decisions.8) An interactive prescription system should utilize organizational and interactive metaphors that

correspond to a physician’s daily activities.9) Physicians do not follow a linear decision making process in prescribing medications.

Both the functional and behavioral specifications for the ScriptPad component should integrate the userobservations/requirements above.

SctiptPad Design Specification Page 5 09/12/97

III. Functional Overview

The ScriptPad will be one component within the overall physician desktop currently consisting of theMedConsult diagnosis expert system, and an HTML-based electronic medical record. The purpose of theScriptPad is to allow a physician to manage a patient’s medications.

Based on the user requirements outlined above, We have broken this primary functional requirement intotwo categories: core functionality and system features.

Core Functionality1) Create a new prescription.2) Modify an existing prescription.3) View a patient’s current medication and medication history.

System Features1) Automatic verification and notification of drug allergies.2) Automatic verification and notification of drug interactions.3) Integration with 3rd party formularies.4) Automatic dosage calculation.5) Ability to select drugs from a drug database (i.e., First Data Bank).6) Some ability to enhance prescription writing with supplemental diagnosis information from

MedConsult.

We propose that the ScriptPad should act primarily as an advisor during the drug selection process. At nopoint should the ScriptPad limit physicians during the selction process. Instead, the ScriptPad should actas an intelligent advisor, highlighting important information, but making it easy for the physician tooverride its suggestions

The system will also have some level of integration with the MedConsult diagnosis application. Upon thesuccessful diagnosis of the patient through MedConsult, the ScriptPad will have access to the diagnosis(ICD9) code (and all other patient information) through a standard set of defined API's. The ScriptPadshould retrieve the diagnosis code and construct a list of recommended drugs for that diagnosis.

After the physician has finished creating a prescription, he/she will digitally sign the order. This data willthen be persisted to the EMR. The actual mechanism for digitally signing has yet to be determined (theFDA has outlined requirements for digital signatures). At some future point, integration with an outsidepharmacy system would be valuable. For the interim, printing out the script may be all that is required.

As mentioned previously, all patient information from outside sources (i.e. the EMR and MedConsult)will be accessible through a standard set of API's. This set of API's will be a superset of the currentlyexisting ones in use by MedConsult. Upon creation, ScriptPad will have access to this object and utilize itfor all patient data needs. The design of the API set should be such that ScriptPad can also use standardmethod calls to update any patient information.

SctiptPad Design Specification Page 6 09/12/97

IV. User Experience & GUI Design

Research completed since the preliminary draft of this design specification has led us to reevaluate thelinear, step-based approach to the prescription writing experience. Our preliminary design supported astructured, multi-stepped prescription writing routine

Our new design presents a user experience that addresses all of the functionality of the previous design,and also meets the following user requirements:

1) Works within an existing, familiar metaphor – writing a prescription. In this case, the script itselfwill encompass dense functionality, allowing the physician to use it as both a data entry tool and theprimary vehicle for user interactions.

2) Recognizes that the physician probably knows which medication he/she wants.3) Presents supplemental information (allergies, etc.) as soon as available, without requiring the

physician to dismiss modal dialog boxes and alerts.4) Supports a “drill down” approach to more detailed information without using multiple data screens

that may disrupt the physician’s natural work flow.5) Complements the physician’s natural, non-linear decision-making process.

Patient InformationThe current patient's name andassociated information isdisplayed for the physiciansreference. This information willbe pulled from the medicalrecord. If the user wants toselect a different patient theycan click on the Patient buttonand a search dialog box willappear allowing the doctor tosearch on the patient's name. Ifmultiple patients match a listwill appear with additionalinformation that helps inselecting the correct patient likeDate of Birth.

Medication IncrementalSearchingAfter a user has typed in apredetermined number ofcharacters, the application willquery the FirstData drugdatabase and return to the dropdown list the drugs that startwith the letters typed. As theuser types more letters, the listwill scroll down to the nextclosest match. The doctor canalso scroll through the list ofdrugs and select the one theywant.

Patient is allergic topenicillin.

Formulary does not cover

Special message here willprovide details to whateveris highlighted on the left.

SctiptPad Design Specification Page 7 09/12/97

Out of Formulary IndicationIf the selected drug is not in the formulary for the patient's insurance company, a red "NF" will appearnext to the selected drug. If a user clicks on the “NF”, a dialog box will appear with all drugs in that sameclass that are in the formulary with their associated costs.

Literature Available IndicationIf there is any literature or other related information available for the selected drug the “i” button will beenabled. If a user wants a list of the literature they click on the “i” button and a dialog box is displayedwith the items listed in alphabetical order. Print and view buttons on this dialog will enable the doctor toprint and/or one or more of the items.

Medication Specific Route/Form/DoseThe Route/Form and Dose will display only the possible values for the currently selected drug. So ifValium is only available for Oral consumption, then Oral will be the only choice and automaticallyselected. Once a route is selected only the Forms for that route will be available. If no drug is selected,these fields will be clear and the controls will be greyed out.

SigSpecific instructions for a given prescription can be entered into the Sig field.

SignatureIf the prescription is going to be sent electronically the doctor enters their electronic signature in theSignature field.

Order ButtonOnce the prescription is complete the doctor can send it electronically or FAX it to the patient's pharmacyof choice or print it out and sign it if their pharamcy does not accept electronic or FAXed prescriptions.

Alerts TabThe Alerts tab displays any information related to the selected drug. The types of alerts available willinclude Allergic Reactions, Drug Interactions, and Not in Formulary. The righthand section of that tabwill display a short description of the currently selected alert.

Allergies TabLists any allergies recorded in the medical record. The allergies that coincide with the current drug willbe highlighted in a different color and detailed information for the selected item will be displayed to theright.

Current Medications TabLists any potential reactions and detailed information for the selected item will be displayed to the right. The other drugs that the patient is currently taking will be highlighted in a different color. If the doctorwants to refill a current medication they can select the refill button next to the drug to populate theScriptPad for a refill. If a doctor wishes to discontinue a drug, he or she selects the “discontinue” buttonnext to th drug listing.

Drug History TabLists any drugs that the patient has taken before highlighting any matches with the current drug.

Status BarDisplays any system messages or the current status of the application. An example would be to displaythe progress of a database search.

SctiptPad Design Specification Page 8 09/12/97

SctiptPad Design Specification Page 9 09/12/97

V. System Design: High-Level Object Model And Process Flow

The diagram below is the object model for the ScriptPad component.

SctiptPad Design Specification Page 10 09/12/97

VI. System Design: Context Management & EMR Data Access

Context Management is the means by which the ScriptPad is notified of changes external to the coreScriptPad classes. These changes might include:

• Selection of a new patient at the desktop level• Modifications and/or additions of diagnoses codes• Any applicable data changes within the Electronic Medical Record application which are used by

the ScriptPad when performing its duties.

The ScriptPad is also responsible for committing any data changes made within the component to thepersistent store.

One elegant mechanism by which these tasks can be accomplished is through the use of theModel/View/Controller Design Pattern upon which the Java Developer's Kit 1.1 Event Handlingmechanism is based. Applying this model to the "Virtual Physician Desktop" is quite simple. Workingtogether with MGH and the other USHealthNet vendors, the ScriptPad will implement this design pattern tomaintain a consistent context with other system components.

A single ChartBean object (implemented as a JavaBean) will be instantiated for any single physiciansession. This bean will serve two functions:1) Present an interface that allows various components to access required patient data (i.e.,

demographics, current medications, etc).2) Provide registration services that will allow different components to “listen” for changes to the

current patient context.

To implement this context management in a heterogeneous operating environment (i.e., HTML & Java),all components must be launched from a single browser instance. Java and JavaScript – in conjunctionwith either BeanConnect or LiveConnect – will be used to pass messages between different components.

SctiptPad Design Specification Page 11 09/12/97

VII. System Design: Formulary/First Data Bank Integration

One of the core requirements of the ScriptPad is integration with 3rd party formularies and the FirstDataBank drug database and knowledge module system. When a physician is in the drug order process,ScriptPad should cross-reference the formulary of the 3rd party payor. It is important to realize that theformulary can be in any number of formats, relational database, hierarchical database, flat files, etc. Amechanism which can be easily adapted to accommodate any of these formats must therefore be adopted.

The other requirement is integration with the set of logic modules contained in the First DataBankproduct called "Drug Toolkit". There are a number of features provided through the toolkit for suchthings as:

1) Drug-Drug interactions 2) Food-Drug interactions 3) Dosage Recommendations 4) and many more...

These are currently available only as a Windows .dll and are therefore severely limited in their uses.

Fortunately, CORBA should provide an ideal encapsulation method for both requirements. A set ofCORBA interfaces will be defined for accessing Formularies in a generic way with the appropriate remoteobjects. Moving between the various types of formularies requires only the creation and implementationof a set of "adapter" classes on the server side for each different type. Each adapter class is responsible forthe formulary specific access methods, they package results up in the standard interface objects, and theclient application only ever has to deal with these standard objects. FirstData Bank integration will occurin the same way. The "Drug Toolkit" dll will be encapsulated within a CORBA interface. Server sideadapter methods will access the dll functions and package the results in the standard CORBA object.These are then passed on for use by the client.

This mechanism will provide an easily extensible architecture which is very open to future changes. Asnew proprietary formularies appear, the simple creation of a new adapter class is all that is required totake advantage of it. It can be imagined that in the future a "wizard" can be created to allow this processto occur in an automated fashion by a non-programmer.

nService(Java)

FDBAPI

ORBApplet(Java)

ORB IIOP interfaces

Fig. 7-1 Interfacing with the First Databank API.

SctiptPad Design Specification Page 12 09/12/97

ScriptPad StartsUp, retrieves areference to the

Orb, and thecreates a

DrugServicesObject.

DBBroker

First Data Bank

Formulary

DBAdaptor

DBAdaptor

DrugServicesstarts up andretrieves a

reference toDBBroker from the

ORB.DrugServices alsoprovides wrapper

methods foraccessing each ofthe Drug Services.

DBBroker starts up. It creates aconfiurable number of DBAdapters for

each database. It then creates aconfigurable number of each of the

DrugServices.

Physician types in thename of a drug he wishesto prescribe and presses

Enter.

Interaction/Use Case diagram detailing theuse and encapsulation of the

FirstDatabank and Formulary Interfacesvia CORBA.

Object RequestBroker

Orb Starts Up andcreates an instance of

DBBroker

System StartUp

DrugQuery

DrugInteraction

DrugEducation

Application StartUpEach Drug Service is invoked

when needed by the client.Each uses one of the pre-

existing DBAdaptor objects forthe actual querying of the

database.

ScriptPad invokes theDrugServices.getAllDrugs

method passing in thename of the drug thephysician entered.

DrugServices asksDBBroker for a reference to

a DrugQuery Object andcalls the getAllDrugs

method on it. In return, itgets a list of all drugs

matching the given drug.

ScriptPadpopulates achoose box

with the drugs,and the doctor

picks theappropriate

one.

Fig. 7-2 Data encapsulation via CORBA

Fact SheetUMLS ® Metathesaurus ®

The UMLS Metathesaurus is one of three knowledge sources developed and distributed by the National Library of Medicineas part of the Unified Medical Language System® (UMLS®) project. The Metathesaurus contains information aboutbiomedical concepts and terms from many controlled vocabularies and classifications used in patient records, administrativehealth data, bibliographic and full-text databases and expert systems. It preserves the names, meanings, hierarchicalcontexts, attributes, and inter-term relationships present in its source vocabularies; adds certain basic information to eachconcept; and establishes new relationships between terms from different source vocabularies.

The Metathesaurus supplies information that computer programs can use to interpret user inquiries, interact with users torefine their questions, identify which databases contain information relevant to particular inquiries, and convert the users'terms into the vocabulary used by relevant information sources. The scope of the Metathesaurus is determined by thecombined scope of its source vocabularies. The Metathesaurus is produced by automated processing of machine-readableversions of its source vocabularies, followed by human review and editing by subject experts. The Metathesaurus is intendedprimarily for use by system developers, but can also be a useful reference tool for database builders, librarians, and otherinformation professionals.

The Metathesaurus is organized by concept or meaning. Alternate names for the same concept (synonyms, lexical variants,and translations) are linked together. Each Metathesaurus concept has attributes that help to define its meaning, e.g., thesemantic type(s) or categories to which it belongs, its position in the hierarchical contexts from various source vocabularies,and, for many concepts, a definition. A number of relationships between different concepts are represented. Some of theserelationships are derived from the source vocabularies; others are created during the construction of the Metathesaurus. Mostinter-concept relationships in the Metathesaurus link concepts that are similar along some dimension. The Metathesaurusalso includes use information, including the names of selected databases in which the concept appears, and, for MeSH®terms, information about the qualifiers that have been applied to the terms in MEDLINE®. Information on theco-occurrence of concepts in MEDLINE and in some other information sources is also included.

Content of the MetathesaurusThe 1999 version of the Metathesaurus contains 626,893 biomedical concepts with 1,358,891 different concept names fromabout 50 source vocabularies. Important additions for 1999 include the Beth Israel Clinical problem list vocabulary; theAlcohol and Other Drug Thesaurus; clinical drug terminology derived from Micromedex; the Pharmacy Practice ActivityClassification; the Patient Care Data Set, which contains detailed nursing terminology; Alternative Billing Concepts, used tobill for procedures by licensed practitioners of alternative therapies; a small initial set of valid values for segments of HL7messages; and terminology used to characterize cancer research projects. Many existing source vocabularies have beenupdated to more current versions, including SNOMED, the Read Codes, LOINC, and MeSH®. A complete list of theUMLS Metathesaurus source vocabularies appears in the Appendix to the License Agreement for the Use of UMLSProducts. Statistics for the number of strings present from each source appear in the UMLS Documentation Appendix B.3.

Metathesaurus ApplicationsThe Metathesaurus is used in a wide range of applications including: information retrieval from databases with humanassigned subject index terms and from free-text information sources; linking patient records to related information inbibliographic, full-text, or factual databases; natural language processing and automated indexing research; and structureddata entry. In many cases, the utility of the Metathesaurus is enhanced when it is used in combination with the SPECIALIST

UMLS Metathesaurus

http://www.nlm.nih.gov/pubs/factsheets/umlsmeta.html (1 of 2) [5/28/1999 10:19:22 PM]

Lexicon, the lexical programs, and the UMLS Semantic Network. To obtain coherent, comparable results in data creationapplications, such as patient data entry, it is necessary to define which Metathesaurus concepts and terms can be included inthe records being created. This may be done by selecting one or more of the many Metathesaurus source vocabularies whichprovide the most appropriate concepts and terms for the specific data being created. Other Metathesaurus concepts and termswill then provide synonyms and related terms which can help to lead users to the vocabularies selected for a particular datacreation application.

The 1999 edition of the UMLS Knowledge Sources includes Metamorphosys, software useful in producing customizedversions of the Metathesaurus.

Obtaining the UMLS MetathesaurusNLM does not charge for the Metathesaurus (or other UMLS products) and it is available to both U.S. and internationalusers. Those who wish to obtain the UMLS Metathesaurus and the other UMLS Knowledge Sources must sign a LicenseAgreement for the Use of UMLS Products and send it to the address at the end of the agreement. Licensees are responsiblefor complying with the restrictions on use of the contents of the UMLS Metathesaurus that are detailed in the agreement.Some uses of some Metathesaurus source vocabularies require separate agreements, which may involve fees, with theindividual vocabulary producers.

The UMLS Metathesaurus is available to licensees via ftp, Web interface, and applications program interface (API) from theUMLS Knowledge Source Server. It is also available on CD-ROM by explicit request. A complete description of theKnowledge Sources and their distribution formats can be found in the UMLS Documentation.

Other Fact Sheets in the UMLS series: Unified Medical Language System, UMLS Semantic Network, SPECIALISTLexicon, and UMLS Knowledge Source Server.

For additional information contact: E-mail: custserv@nlm.nih.gov or 1-888-FINDNLM

U.S. National Library of Medicine (NLM)http://www.nlm.nih.gov/Last updated: 1 March 1999

UMLS Metathesaurus

http://www.nlm.nih.gov/pubs/factsheets/umlsmeta.html (2 of 2) [5/28/1999 10:19:22 PM]

Fact SheetUnified Medical Language System

Background:

In 1986, the National Library of Medicine, (NLM) began a long-term research and development project to build a UnifiedMedical Language System® (UMLS®). The purpose of the UMLS is to aid the development of systems that help healthprofessionals and researchers retrieve and integrate electronic biomedical information from a variety of sources and to makeit easy for users to link disparate information systems, including computer-based patient records, bibliographic databases,factual databases, and expert systems. The UMLS project develops machine-readable "Knowledge Sources" that can be usedby a wide variety of applications programs to overcome retrieval problems caused by differences in terminology and thescattering of relevant information across many databases.

UMLS Development Strategy:

The project is directed by a multi-disciplinary team of NLM staff. NLM encourages broad use of the UMLS products bydistributing annual editions free-of-charge under a license agreement. The Knowledge Sources are iteratively refined andexpanded based on feedback from those applying each successive version.

UMLS Knowledge Sources:

There are three UMLS knowledge sources:

UMLS Metathesaurus●

SPECIALIST Lexicon●

UMLS Semantic Network●

The Metathesaurus provides a uniform, integrated distribution format from about 50 biomedical vocabularies andclassifications and links many different names for the same concepts. The Lexicon contains syntactic information for manyMetathesaurus terms, component words, and English words, including verbs, that do not appear in the Metathesaurus. TheSemantic Network contains information about the types or categories (e.g., "Disease or Syndrome," "Virus") to which allMetathesaurus concepts have been assigned and the permissible relationships among these types (e.g., "Virus" causes"Disease or Syndrome"). NLM also distributes associated lexical programs and software helpful in producing customizedversions of the UMLS Metathesaurus.

NLM has discontinued release of the UMLS Information Sources Map.

UMLS Applications:

NLM and many other institutions are applying the UMLS Knowledge Sources in a wide variety of Applications includingpatient data creation, curriculum analysis, natural language processing, and information retrieval. NLM's own applicationsinclude Internet Grateful Med® , and PubMed.

An issue of NLM's Current Bibliographies in Medicine series, Unified Medical Language System® (UMLS®), covers thestructure and semantics of the UMLS Knowledge Sources, their development and maintenance, and assessments of theircoverage and utility for particular purposes, and the full range of UMLS applications. It contains 280 citations covering theperiod from January 1986 through December 1996. More recent references can be found by searching for Unified Medical

Unified Medical Language System

http://www.nlm.nih.gov/pubs/factsheets/umls.html (1 of 2) [5/28/1999 10:19:31 PM]

Web based EMR or Clinical Information Systems

Project/Product Organization ContactGuardian Angel MIT Peter Szolovitz PhD

W3 EMRS Harvard University/Children's Hospital I. Kohane MD, PhD

Web/Java based ICU monitoring Spacelabs Medical Corporation/Boston University K. Wang PhD

ARTEMIS West Virginia University's Juggy PhD

Web based CIS Columbia University J.J. Cimino MD

Virtual EMR Hewlett-Packard/Virginia Neurological Institutes James Kazmer

Web access project. Massachusetts General Hospital

Web access project University of Missouri in Columbia

Primary Rheumatology Web Munich University Project W. Swobada

The GEODE-CM Harvard Medical School Paul Eric Stoufflet MD

SPIDER Medical College of Wisconsin C. Kahn MD

Java Interface to THE ELECTRONICMEDICAL RECORD Duke University Medical Center D. Pollard MBA

Affinity CompuCare Marina L. Douglas RNMS

ChartMax MedPlus

Web based system Telemachus Inc/TMAC

Benefit Management Healtheon Corporation David Shnell MD

MediVault Service Emergency Medical Systems Inc.

Oacis Healthcare Systems Inc.

Araxys Solution Araxys Inc.

Webpatient System Syracuse University

Intranet product Lawson Software

Webrad Analogic Inc. P. Keezer

ALI Webserver ALI

Freeview (gateway for viewingDICOM-3 images) Passport Technologies division of Elscint Inc.

Webrad Radiology department at Georgetown UniversityHospital

Healthcare Online Daou Systems

Java based CPR Dept. of Family Medicine and Pediatrics,Georgetown University School of Medicine A.E Zuckerman MD

Virtual Medical Manager Secureware Inc./Emory University Charles Watt PhD

Web interface to CIS Regenstrief Institute for Health Care, IndianaUniversity J.M. Overhage MD PhD

Web access to ultrasound Indiana University School of Medicine A.M. Golichowski MD

Other Web-based EMR Projects

http://www.telemedical.com/webemr.htm (1 of 3) [5/28/1999 10:44:49 PM]

Web interface to childhoodimmunizations LCS at MIT E.M. Jordan SM

Webreport Section on Medial Informatics and Dept ofPathology at University of Pittsburg H.J. Lowe MD

TeleMed Los Alamos National Laboratory D.W. Forslund PhD

Web version of the PIS and RxPad PDX Inc.

RxMed

QSINET Quality Systems Inc.

Avicenna Systems Synetic Corporation

EnVenture Health Systems Integration Inc.

Care-Web Institute for Interventional Informatics Dave Warner MD

IDXtendR Outreach IDX Cedric Priebe MD

CareNet Praxis Corporation/Datahouse Inc.

ClinicalWare CompuRad division of LumisysInc.

Wang Inc.

Integrated Healthcare Solutions

Eclipsys Inc.

Internet Prescription Ordering Physician's Online Inc.

Clinical Information System Kaiser Foundation John Maddison MD

Axolotl Inc.

HBOC Inc.

Medicalogic Inc.

Medica Computer Systems/MYSYS LTD

Oceania

Protocol Systems

Health Systems Technologies Inc.

HealthMagic Inc.

Advanced Medical Systems Inc.

UCSD/SAIC Project

Medvision

Healthdesk Inc.

VitalWorks Inc.

Healtheon Inc.

Masterchart

Lucent's HRM system

SMS

Cerner

Object Products Inc.

Other Web-based EMR Projects

http://www.telemedical.com/webemr.htm (2 of 3) [5/28/1999 10:44:49 PM]

Websight Dynamic Healthcare Technologies Inc.

This list is being researched and created by Foster P. Carr MD. and is the 1996-1997 copyright of Digital Med Inc., Allrights are reserved

Other Web-based EMR Projects

http://www.telemedical.com/webemr.htm (3 of 3) [5/28/1999 10:44:49 PM]

Duke Medical Informatics ResearchResearch activities in the Division of Medical Informatics at Duke include:

● computer-based patient record systems

● decision support systems

● hospital information systems

● computer-assisted management protocol systems

● standards development

● security, confidentiality, and privacy

● medical data mining

Much of the current research in the division is centered around The Medical Record(TMR), a comprehensive longitudinal computer-based patient record system(CPRS) developed at Duke University over the last 25 years. TMR provides totaladministrative, financial, and medical management capabilities for the patientencounter.

The TMR record focuses on the patient as an individual. Rather than storinginformation as a series of unrelated accounting transactions, TMR creates anintegrated medical and accounting database which allows detailed reviews of bothhealth and financial history.

TMR - The Medical Record● Introduction

● Appointment Section

● The Patient Encounter: Check-in

● The Patient Encounter: Medical

● The Patient Encounter: Check-out

Duke Medical Informatics Research

http://dmi-www.mc.duke.edu/dukemi/research/research.html (1 of 2) [5/28/1999 10:45:33 PM]

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For your convenience we have provided you with the discrete chapterbreakdown of formal/99-03-01: CORBA Med Specification to make iteasy for you to copy/print the sections you are interested in. The fullCORBA Meds document is also available as a single downloadable filehere, for those who wish to copy/print the book in its entirety.

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Index

Cover PageTable of Contents PageChapter 1 - OverviewChapter 2 - Person ID specificationChapter 3 - Lexicon QueryIndex

 

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Table 9. Number, percent distribution, and annual rate of injury-related ambulatory care visits, according to intent, mechanism, andambulatory care setting: United States, 1995

Intent and mechanism1

Combined settings

TotalPhysicianoffices

Outpatientdepartments

Emergencydepartments Total

Physicianoffices

Outpatientdepartments

Emergencydepartments

Number ofvisits in

thousandsPercent

distribution

Percent distribution Number of visits per 1,000 persons2

All injury visits . . . . . . . . . . . . . . . . . . . . . 126,129 100.0 100.0 64.7 5.8 29.5 481.6 311.7 27.7 142.1

Unintentional injuries . . . . . . . . . . . . . . . . . 90,639 71.9 100.0 63.1 5.3 31.7 346.1 218.5 18.4 109.6Falls . . . . . . . . . . . . . . . . . . . . . . . . . . 23,245 18.4 100.0 63.1 4.1 32.9 88.8 56.0 3.6 29.2Motor vehicle traffic accidents . . . . . . . . . . 13,118 10.4 100.0 63.5 4.5 32.0 50.1 31.8 2.2 16.0Striking against or struck accidentally byobjects or persons . . . . . . . . . . . . . . . . 8,913 7.1 100.0 54.9 6.8 38.3 34.0 18.7 2.3 13.0Overexertion and strenuous movements . . . . 8,946 7.1 100.0 77.2 5.0 17.8 34.2 26.4 1.7 6.1Cutting or piercing instruments or objects . . . 5,232 4.1 100.0 36.7 5.9 57.4 20.0 7.3 1.2 11.5Natural and environmental factors . . . . . . . 3,767 3.0 100.0 53.6 *5.4 41.1 14.4 7.7 *0.8 5.9Poisoning by drugs, medicinal substances,biologicals, other solid and liquid substances,gases, and vapors . . . . . . . . . . . . . . . . 1,354 1.1 100.0 43.3 *5.8 50.9 5.2 2.2 *0.3 2.6Fire and flames, hot substance or object,caustic or corrosive material, and steam . . . 1,296 1.0 100.0 40.9 *11.8 47.2 4.9 2.0 *0.6 2.3Machinery . . . . . . . . . . . . . . . . . . . . . . 1,129 0.9 100.0 59.5 * 34.5 4.3 2.6 * 1.5Pedal cycle, nontraffic, and other . . . . . . . . 993 0.8 100.0 52.0 *5.9 42.1 3.8 2.0 *0.2 1.6Motor vehicle, nontraffic . . . . . . . . . . . . . . 634 0.5 100.0 * * 34.1 2.4 * * 0.8Other transportation . . . . . . . . . . . . . . . . 449 0.4 100.0 * * 28.8 1.7 * * 0.5Firearm missile . . . . . . . . . . . . . . . . . . . 256 0.2 100.0 * *28.8 * 1.0 * *0.3 *Other and not elsewhere classified . . . . . . . 9,249 7.3 100.0 66.3 6.7 28.1 35.3 23.4 2.4 9.9Mechanism unspecified . . . . . . . . . . . . . . 12,059 9.6 100.0 76.9 5.0 18.0 46.0 35.4 2.3 8.3

Intentional injuries . . . . . . . . . . . . . . . . . . . 3,671 2.9 100.0 25.2 4.9 69.9 14.0 3.5 0.7 9.8Assault . . . . . . . . . . . . . . . . . . . . . . . . 3,320 2.6 100.0 26.8 5.1 68.1 12.7 3.4 0.6 8.6Self-inflicted . . . . . . . . . . . . . . . . . . . . . 299 0.2 100.0 * * 96.0 1.1 * * 1.1Other violence . . . . . . . . . . . . . . . . . . . . * * 100.0 * * * * * * *

Injuries of undetermined intent . . . . . . . . . . . * * 100.0 * * * * * * *Adverse effects . . . . . . . . . . . . . . . . . . . . 5,115 4.1 100.0 69.5 6.3 24.2 19.5 13.6 1.2 4.7Blank cause . . . . . . . . . . . . . . . . . . . . . . 26,651 21.1 100.0 74.7 7.7 17.6 101.8 76.0 7.8 17.9

*Figure does not meet standard of reliability or precision.1Intent and mechanism are based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD–9–CM), Supplementary Classification of External Causes of Injury andPoisoning (5). A detailed description of the ICD–9–CM E-codes used to create the groupings in this table is provided in the Technical Notes.2Based on U.S. Bureau of the Census estimates of the civilian noninstitutionalized population as of July 1, 1995. Figures used are monthly postcensal estimates and are consistent with Census reportsPE-10/PPL-41, Addendum 1 and have been adjusted for net underenumeration using the 1990 National Population Adjustment Matrix.

NOTE: Numbers may not add to totals because of rounding.

Series 13, No. 129 [ Page 17

Introduction,Summary,

andOptions

nformation technologies are transforming the way healthcare is delivered. Innovations such as computer-based pa-tient records, hospital information systems, computer-baseddecision support tools, community health information net-

works, telemedicine, and new ways of distributing health in-formation to consumers are beginning to affect the cost, quality,and accessibility of health care. The technologies that supportthese applications—relational databases, network communica-tions, distributed processing architectures, optical disk storage,and others—are used today by some health care providers andpayers. Yet information technology is often found in isolated“islands of automation” in health care provider and payer institu-tions. Despite the incorporation of high technology into almostevery other aspect of clinical practice, information technologieshave not been fully embraced.

Meanwhile, transformations in the way health care is deliveredare creating new opportunities for innovative applications of in-formation technologies. The health care delivery system is cur-rently undergoing many changes, including the emergence ofmanaged health care and integrated delivery systems that arebreaking down the organizational barriers that have stood be-tween care providers, insurers, medical researchers, and publichealth professionals. These barriers have supported a clear de-marcation between clinical health information and administrativehealth information and reinforced a long-standing distinction be-tween treatment of disease and preservation of health. These dis-tinctions are gradually eroding as new health care deliverypatterns emerge that are supported by, and in some cases relianton, the widespread use of networked computers and telecommu-nications. | 1

2 | Bringing Health Care Online: The Role of Information Technologies

This report discusses the synergy between in-formation technologies and new trends in thehealth care delivery system as health care isbrought online. It identifies some of the opportu-nities to improve health care delivery through in-creased use of information technology, anddiscusses some of the conceptual, organizational,and technical barriers that have made its adoptionso uneven. The report identifies key technologiesand shows how they are being used to communi-cate clinical information, simplify administrationof health care delivery, assess the quality of healthcare, inform the decisionmaking of providers andadministrators, and support delivery of health careat a distance.

CHALLENGES AND OPPORTUNITIES FORINFORMATION TECHNOLOGIESThe technologies used for collecting, distilling,storing, protecting, and communicating data arewidely used throughout American industry. In thehealth care industry, however, their applicationhas been limited to scattered islands of automa-tion, usually limited to discrete departments with-in hospitals. Computers are widely deployed, butnot widely connected. Clinical and administrativehealth information are rarely commingled. Bothtypes of health information are still stored andconveyed primarily in paper form. Health in-formation is rarely converted to digital form andshared among the clinics and primary care officeswhere most health care occurs, the hospitals andcritical care units where most health care dollarsare spent, or the population-based health servicesthat address community-wide health issues. Com-puters are typically used to organize and adminis-ter specific, limited types of health information,but are not linked into an infrastructure that mightallow broader efficiencies or higher quality healthcare.

Figure 1-1 shows the level of adoption of someselected information technology applications asreported by chief information officers (CIOs) of

primarily large health care institutions. As thefigure indicates, almost 70 percent of those re-sponding have introduced electronic systems forsubmitting insurance claims, and more are in theprocess of adopting them. Technologies that allowcommunication between computers at disparatelocations, for example physician-hospital datanetworks or enterprise-wide networks, are beingadopted or planned by a substantial number ofthese institutions as well. Computer-based patientrecord (CPR) systems, which are difficult to im-plement because they require such close integra-tion between many different systems, are at leastin the planning process, according to 50 percent ofresponding CIOs, but so far only about 20 percentconsider that they have CPRs operating at leastat an experimental level. When asked whichtechnologies they were currently evaluating con-ceptually for future implementation, the two mostfrequently mentioned by CIOs were communityhealth information networks and telemedicine.1

The health care delivery system has severalunique characteristics that discourage the spreadof information technologies. Health professionalsperform a wide variety of tasks including rapidlychanging combinations of “hands-on” care, in-ductive and diagnostic thinking, detailed record-keeping, patient education, and communicationwith colleagues. Most of the hardware and soft-ware approaches that address one of these aspectsof medical practice intrude unacceptably on someother aspect: computers are not yet as useful, ubiq-uitous, and handy as the stethoscope and othercommon medical technologies. In addition, medi-cal practice is extraordinarily complex and itchanges rapidly. Systematizing even the processof performing medical procedures, much less ra-tionalizing the language and scientific knowledgeunderlying those procedures, is an almost intrac-table problem. Despite the ongoing efforts of stan-dards-setting bodies, no unified conceptual modelexists that is powerful enough to construct themapping between the information that must be

1 College of Healthcare Information Management, Telecommunications in Health Care Survey, 1994 (Ann Arbor, MI: 1994), pp. 20-21.

Chapter 1 Introduction, Summary, and Options | 3

FIGURE 1-1: Information Technology Applications Currently Being Adopted

������� ���!� � �� � ���!��� �� ���������!� ���� ��!����� ���� ������� ��� �� ���������� �������� ����� ���� �� �� ��� ������

stored in computer databases and medicine as it ispracticed. In a sense, there is not yet a consensusabout what information should be kept in comput-er-based patient records or how it should be de-scribed, organized, and indexed.

Apart from the complexity of clinical knowl-edge and practice, there are structural reasons thatdiscourage implementation of informationtechnologies in health care settings. In addition,many communities have only a few hospitals ormajor insurers. The cooperation necessary to in-terconnect medical information within a horizon-tal layer of the health care system may be seen asanticompetitive and subject to antitrust regula-tion, or it may be hindered by organizations thatregard their internal information systems as com-

petitive advantages and accumulated patient re-cords as corporate assets.

Information technologies tend to flatten orga-nizations and may not mesh well with the rigidlydefined job roles and hierarchical structure of cur-rent medical practice (see box 1-1). Many types oforganizational changes will emerge throughoutthe health care system if information technologiesare widely adopted. In other industries, changesassociated with the introduction of informationtechnologies have included large reductions in thedemand for some types of workers (e.g., mid-levelmanagers and bank tellers), increased responsibi-lities for workers in jobs that traditionally in-volved little decisionmaking (line workers inmanufacturing industries), and an increase in

4 | Bringing Health Care Online: The Role of Information Technologies

BOX 1-1: Effects on the Health Care Workforce

�/$3&"4&%� 64&� 0'� */'03."5*0/� 5&$)/0-0(:� 8*--� $0/5*/6&� 50� "''&$5� 5)&� +0#4� 0'� 5)&� �� .*--*0/� �.&3*$"/4

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5)&� 4536$563&� 0'� )&"-5)� $"3&� %&-*7&3:� "3&� "''&$5*/(� 5)&� $0.104*5*0/� 0'� 5)&� 803,'03$&�� �03� &9".1-&�� )041*=

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4&$503� "5� ��� 1&3$&/5� 1&3� :&"3�� �0.&� )&"-5)� $"3&� )08&7&3�� *4� (308*/(� "5� "#065� �� 1&3$&/5� "//6"--:�

"-5)06()� *5� 45*--� "$$06/54� '03� 0/-:� "� 4."--� 1035*0/� 0'� 5)&� 803,'03$&�

�)*4� 3&1035� %0&4� /05� "/"-:;&� 5)&� $)"/(&4� 5)"5� */'03."5*0/� 5&$)/0-0(:� .*()5� #3*/(� 50� +0#4� */� )&"-5)

$"3&�� 03� 5)&� &''&$54� 5)"5� 5)&4&� $)"/(&4� .*()5� )"7&� 0/� 5)&� 26"-*5:� 0'� 5)&� 803,� &/7*30/.&/5�� �)&4&� 806-%

#&� '36*5'6-� "3&"4� '03� '6563&� 3&4&"3$)�� �/� (&/&3"-�� *5� "11&"34� 5)"5� */'03."5*0/� 5&$)/0-0(:� "11-*$"5*0/4

$06-%� 3&%6$&� 5)&� /&&%� '03� 40.&� 5:1&4� 0'� 803,� "/%� $06-%� 3&%&'*/&� 40.&� +0#� 30-&4�

�03� &9".1-&�� &-&$530/*$� %"5"� */5&3$)"/(&� ������� %&'*/&%� "4� 5)&� �������!���$!�$�������!��� � �#������

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.&"/4� 5)"5� $0.165&3� 130(3".4� "5� %*''&3&/5� '*3.4� &9$)"/(&� */'03."5*0/� "/%� $0.1-&5&� 53"/4"$5*0/4� %*=

3&$5-:�� 8*5)065� )6."/� */5&37&/5*0/�� �):4*$*"/4�� 0''*$&� 45"''4�� '03� &9".1-&�� 0'5&/� /05*$&� "� %&$3&"4&� */� 5)&

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0'� 5)&� &.1-0:&&� 5*.&� 4"7&%� #:� "650."5&%� 1":.&/5� 4:45&.4� 8*--� #&� 41&/5� 0/� 05)&3� 5"4,4�� �&7&35)&-&44�

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competition for local experts from nonlocalsources (discount stockbrokers, for instance).Similar changes are likely to occur for health pro-fessionals, along with a redistribution of status,responsibilities, and remuneration associatedwith the various health disciplines.

Information technologies not only redefinejobs, but they may have more subtle ramificationsas well. The widespread adoption of integrated in-formation systems will challenge the legal sys-tem. Information technologies facilitate alliancesbetween geographically separate parties. Thus,they may challenge the existing structure of statemedical licensing and malpractice laws, as well as“pen and quill” laws that require paper-basedmedical recordkeeping. Consolidations and merg-ers among the many companies offering managed

health care reflect the ability of computer net-works and digital telecommunications to act as anervous system that can connect previously inde-pendent parts of the health care delivery and ad-ministrative systems, forming new bodies knownas integrated delivery systems. These new corpo-rate structures may pose antitrust questions asthey challenge traditional providers of health carein isolated markets.

Information technologies diffuse decisionmak-ing and responsibility because they are developed,maintained, and employed by a variety of people.Physicians—who have held unique positions ofstatus and compensation, as well as legal respon-sibility and risk, under the traditional systems oflicensure and malpractice law—may be put in theuncomfortable position of being solely responsi-

Chapter 1 Introduction, Summary, and Options | 5

BOX 1-1: Effects on the Health Care Workforce (Cont’d.)

�-%.0, 2(.-� 2$"'-.+.&7� +1.� " -� "' -&$� ).!� 0.+$1�� �.0� $6 ,/+$�� 5'$-� /'71("( -1� /+ "$� ,$#(" 2(.-

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ble for implementing complex policies resultingfrom a mix of research findings, technicalconstraints, and business priorities. Networkedinformation technologies may pose new chal-lenges to the traditional legal assumption that con-sumers are adequately protected against poorquality of care through the ability to file lawsuitsagainst their providers, and alternate guarantees ofhigh-quality care may need to be designed to re-place the current legal remedies.

Finally, information technologies are expen-sive to implement and their benefits may be diffi-cult to directly measure, even when all parties arehappy with the results. This may delay their de-

ployment in an industry whose sophisticated tech-nological base is seen by some to be a drivingforce in making health care more expensive.

TRENDS IN THE HEALTH CARE SYSTEM

❚ Aggressive Cost ManagementA major concern for providers, payers, policy-makers, and consumers alike is the rising costs ofdelivering care. Health care expenditures in-creased from 5.9 percent of gross domestic prod-uct in 1965 to 13.9 percent in 1993.2 Totalexpenditures for health care in 1993 were $884.2billion. Government sources pay for about 43 per-

2 Katharine R. Levit et al., “National Health Expenditures, 1993,” Health Care Financing Review, vol. 16, No. 1, fall 1994, pp. 247-294.

6 | Bringing Health Care Online: The Role of Information Technologies

cent of this total; the federal government alonepays nearly 32 percent. Health care is also a majorsegment of the economy, employing approxi-mately 10 million people, about 2.6 million ofwhom do primarily administrative work.3

As the costs of health care have continued torise, there have been concerns in government andin the industry itself about how to contain and re-verse the increase. In the 1990s, particularly in the103d Congress, a number of proposals were madefor far-reaching reforms in the health care indus-try. At the same time, within the health care andinsurance industries, many initiatives to controlcosts are already under way. In fact, perhaps due inpart to these efforts, the growth rate of health carecosts appears to have slowed during the 1990-93period.

One of the major influences in the health careindustry has been the growth of managed healthcare. “Managed care” is a somewhat nebulousterm, but generally refers to a “system of manag-ing and financing health care delivery to ensurethat services provided to managed care plan mem-bers are necessary, efficiently provided, and ap-propriately priced.”4 Managed care organizationsuse a number of techniques to control access toproviders, contain costs, manage utilization of re-sources, and ensure favorable outcomes for pa-tients.

The number of people enrolled in managed careplans has increased dramatically in the past 20years. By 1992, enrollment had grown to over halfof all employees covered by employer grouphealth insurance.5 As shown in box 1-2, the con-cept of managed care has expanded to includemany types of health plans and delivery systems.Many traditional fee-for-service health insuranceplans (those that reimburse members for health

care payments) are also using at least some caremanagement techniques to manage their costs.

❚ Integration of Health ServicesHealth care has historically been a very frag-mented industry. Routine medical care, crisismedical care, medical insurance, medical re-search, and management of public health typicallyhave been handled by entirely separate organiza-tions in business, government, and universities,and a large number of intermediary institutions aswell. There are more than 1.2 million health careproviders—ranging from solo practitioners to1,000-bed hospitals—and they are often isolatedin separate corporate entities from the more than3,000 private insurance payers that distribute pay-ments for health care services. The providers andinsurance companies are further isolated from themedical research community, government healthcare agencies, and public health organizations. Anetwork of private-sector intermediaries hasformed to facilitate the complicated relationshipsbetween the various organizations. It is unlikelythat any of these entities will be willing to collector organize data that save money or effort for someother organization, but deliver the intermediary noimmediate benefit; systemic savings may be irrel-evant in a vertically fractured industry.

Some of this fragmentation may be reducedwith the current trend toward vertical and horizon-tal integration of providers and payers into sys-tems that offer the full “continuum of care” tocovered populations. An integrated delivery sys-tem is one that brings together hospitals, primarycare providers, nursing homes, home health careproviders, pharmacies, and other services into asingle system through purchase, merger, jointventure, contract, or other means. As hospital ad-

3 U.S. Congress, Office of Technology Assessment, International Comparisons of Administrative Costs in Health Care, OTA-BP-H-135

(Washington, DC: U.S. Government Printing Office), September 1994.

4 Marrianne F. Fazen, Managed Care Desk Reference (Dallas, TX: HCS Publications, 1994), p. 149.5 U.S. Congress, General Accounting Office, Managed Health Care: Effect on Employers’ Costs Difficult To Measure, GAO/HRD-94-3

(Washington, DC: U.S. Government Printing Office), October 1993.

Chapter 1 Introduction, Summary, and Options | 7

BOX 1-2: Managed Care

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8 | Bringing Health Care Online: The Role of Information Technologies

missions and inpatient days have declined be-cause of cost control efforts begun in the 1980s,many hospitals have entered these other lines ofbusiness. Some integrated delivery systems arebeing organized by insurers or managed care orga-nizations.

❚ Increasing Value of Digital InformationNew patterns in health care delivery are enhancingthe value of clinical health data and creating in-centives for collecting and disseminating healthinformation electronically within and between or-ganizations. As managed care organizations growand fee-for-service care wanes, doctors and otherpractitioners have both a financial interest in de-livering low-cost care and incentives for docu-menting and analyzing their care practices.Administrators in Health Maintenance Organiza-tions (HMOs) and integrated delivery systemshave long sought to reduce transaction costs (afteran initial investment in equipment and software)by computerizing internal communications andautomating communications with suppliers andother business partners. In addition, they have avested interest in understanding the clinical de-tails of how care is delivered in order to efficientlymanage resources.

For example, it is possible to use administrativerecords alone to limit overuse of optometry ser-vices by approving eye examinations purely onthe basis of elapsed time since the last exam. How-ever, care can be more prudently and perhaps com-passionately managed by considering not only thetime of the last billing, but also the clinical recordof that visit and other health information about thepatient. Were the previous results normal, or didthey indicate a problem? Does the patient haveany other conditions that might warrant frequenteye examinations? Could the current complaint bedue to an adverse reaction to a prescribed medica-tion and, hence, warrant a visit to the prescribingphysician rather than an optometrist? This fine-grained analysis of clinical records is contingenton standardization and digitization of clinical re-cords because paper records are generally inade-quate for these purposes.

Finally, the government has a stake in helpingto develop inexpensive, standardized approachesto information exchange so it can effectively fundmedical research, manage widespread publichealth problems, reduce its administrative costs,and reduce the cost of the health care it purchasesand provides through Medicare, Medicaid, veter-ans’ care, and employee insurance programs. Anindication of the magnitude of this interest is thedesignation of health care applications as a keycomponent of the National Information Infra-structure (NII) by the Administration’s Informa-tion Infrastructure Task Force (IITF). Appointedby the President, the IITF is comprised of high-level representatives of the federal agencies thatplay a role in developing and applying informa-tion and telecommunications technologies. TheIITF’s Committee on Applications and Technolo-gy coordinates efforts to develop, demonstrate,and promote applications of the NII and developsand recommends technology strategy and policyto accelerate its implementation. One part of thiscommittee is the Health Information and Applica-tions Working Group. This group is again dividedinto subgroups in the categories of telemedicine,consumer health information, standards, andemergency medicine.

These private and governmental interests indigitizing health information in order to managecosts and integrate delivery of health services aremanifest in a slow but perceptible trend towardstandardization of health care information and op-timization of care delivery. These processes areoccurring on many levels. The medical and com-puting communities are slowly developing: a)lexicons for consistently describing medical care,b) consensus standards for exchanging medicaldata between computers, and c) models for how tocollect and organize medical information digital-ly. Protocols for standardizing delivery of care andmetrics for measuring the quality of health careservices are being developed, as well as decisionsupport systems that may increase the efficacy ofmedical decisions. And throughout the health caredelivery system, innovative applications of in-

Chapter 1 Introduction, Summary, and Options | 9

formation technologies are being studied, tested,and implemented.

CONGRESSIONAL INTERESTRecognizing the changes occurring in both healthcare and telecommunication technology and theirrelevance to the congressional agenda, the Chair-man of the Senate Committee on Labor and Hu-man Resources asked the Office of TechnologyAssessment (OTA) to conduct a study on the im-pacts of information technology on the health caresystem. The request was supported by the Chair-man of the House Committee on Energy andCommerce.6

Recently, there have been numerous legislativeinitiatives addressing aspects of incorporating in-formation technologies into the delivery of healthcare. In the 103d Congress, several comprehen-sive health care reform bills were introduced,7 andthis pattern has continued in the 104th Congress.These bills seek to restructure various aspects ofthe payment and insurance framework of thehealth care industry, but, in addition, they oftenspecify procedures for simplifying administrationof health care delivery through the use of informa-tion technologies. For example, several recentbills direct the Secretary of the Department ofHealth and Human Services (DHHS) to adopt uni-form standards for various medical data, based onthe work of standards committees accredited bythe American National Standards Institute and onthe advice of groups such as the Workgroup forElectronic Data Interchange and the Computer-Based Patient Records Institute.8

The bills call for standards for:

1. defining common sets of data elements to bestored electronically in patient records,

2. performing administrative transactions,3. assigning uniform patient and provider identi-

fication numbers,4. assigning codes to medical procedures and de-

scriptions,5. applying electronic signatures, and6. ensuring patient privacy and data security.

Most bills specify the adoption of the standardsby DHHS within two years or less, and, followingthe adoption, provide various measures designedto encourage rapid adoption of the standards bynearly all health care providers. These measuresmay include direct incentives, such as require-ments that all health plans implement the stan-dards for all transactions, or indirect incentives,such as requirements that all transactions regard-ing Medicare patients be filed electronically. Theincentives may also be provisional: they may di-rect the Secretary to assess whether sufficientnumbers of health plans are utilizing the standardsand to require full participation, should it prove tobe cost-effective. Most bills include exceptionsfor small hospitals and those that can show theyare in the process of installing an adequate in-formation system. Some of the bills override statelaws requiring the maintenance of paper-based pa-tient records.

Several bills seek to establish national or statedatabases of health information for quality assess-ment purposes, control of fraud, or tracking dis-ease patterns.9 Other bills would authorize grants

6 This committee is now known as the House Committee on Commerce.7 Two examples are U.S. Congress, Senate, S. 1757, Health Security Act, and S. 1494, Health Care Information Modernization and Security

Act of 1994 (Washington, DC: U.S. Government Printing Office, 1994).

8 U.S. Congress, House of Representatives, H.R. 1200, American Health Security Act of 1995 and H.R. 1234, Basic Health Care Reform Actof 1995 (Washington, DC: U.S. Government Printing Office, 1995); and U.S. Congress, Senate, S. 7, Family Health Insurance Protection Act(Washington, DC: U.S. Government Printing Office, 1995).

9 U.S. Congress, House of Representatives, H.R. 798, Veterans’ Benefits, Title 38 U.S.C., Amendment (Washington, DC: U.S. Government

Printing Office, 1995), and H.R. 1200 and S. 7, ibid.

10 | Bringing Health Care Online: The Role of Information Technologies

for rural telemedicine efforts10 or establish a tele-medicine commission to formulate plans forwidespread implementation of telemedicine.11

Finally, there have been efforts in both the 103dand 104th Congresses to reform and deregulatetelecommunications.12 Such reforms may affectthe price of telecommunications services and,therefore, help determine the feasibility of incor-porating telecommunications into health care de-livery on a large scale. In addition, current billshave certain direct influences on health care, in-cluding a requirement that prices for telecommu-nications service to rural health care providers becomparable to those for urban providers.13

REPORT SUMMARY

❚ Scope of the AnalysisIn chapters 2 through 5, this report discusses someof the challenges and opportunities for using in-formation technology to improve the health caresystem. First, it addresses the potential impact ofinformation technologies on health care deliveryand introduces a variety of technologies that arebeing used to collect, organize, and share clinicalinformation needed for providing patient care.The report then explores the exchange of healthinformation for administrative purposes amongthe many stakeholders including providers, payers,employers, consumers, and government agencies.It discusses how the quality of health care mightbe improved by providing health care profession-als with high-quality information and decisionsupport tools at the point of care. Finally, the re-port explores the potential for addressing the

needs of those in rural or other underserved areasthrough telemedicine.

Advanced information technologies offer anarray of other possibilities for influencing deliv-ery of health care services. It was impossible to ad-dress all applications in this report. Those selectedwere viewed as having the most potential for de-creasing costs and improving quality and access inhealth care. Particular emphasis is placed on ad-ministrative simplification, quality assessment,and telemedicine, as specified by the congression-al committee requesting the report. The report alsobriefly mentions the potential for telecommunica-tions to assist consumers in becoming better in-formed and more involved in decisions affectingtheir health care, and points to the need for addi-tional study. Emerging applications of informa-tion technology, including remote surgery andvirtual reality applications, were not considered,nor were issues related to the reform of medicaleducation to include greater use of informationtechnology. These are, however, fertile areas forfuture research.

Before computers were introduced into thehealth care delivery system, clinical and adminis-trative records were kept separately in paper form,patient utilization of services was rarely scruti-nized systematically, and clinical information wasseldom exchanged between business organiza-tions (or even among the various clinicians an in-dividual might see). Thus, paper-based technolo-gies and common organizational policies workedalong with various state laws to provide an ad hoclevel of protection for individual privacy that isclearly inadequate in the emerging world of com-

10 U.S. Congress, House of Representatives, H.R. 851, Rural Telemedicine Act of 1995 (Washington, DC: U.S. Government Printing Office,

1995), and U.S. Congress, Senate, S. 7, op. cit., footnote 8.

11 U.S. Congress, House of Representatives, H.R. 426, National Committee on Telemedicine Act (Washington, DC: U.S. Government Print-

ing Office, 1995).

12 U.S. Congress, House of Representatives, H.R. 3626, Antitrust and Communications Reform Act of 1994; Antitrust Reform Act of 1994(Washington, DC: U.S. Government Printing Office, 1994), and U.S. Congress, Senate, S. 1822, Communications Act of 1994; Telecommunica-tions Equipment Research and Manufacturing Competition Act of 1994, and S. 2111, Telecommunications Services Enhancement Act of 1994(Washington, DC: U.S. Government Printing Office, 1994).

13 U.S. Congress, Senate, S. 652, Telecommunications Competition and Deregulation Act of 1995 (Washington, DC: U.S. Government

Printing Office, 1995).

Chapter 1 Introduction, Summary, and Options | 11

puterized patient records, integrated delivery ser-vices that operate on a nationwide basis, andinstant electronic messaging. New combinationsof legislative protections and technical safeguardswill be necessary to protect individual privacy ashealth care information is computerized and stan-dardized. These issues are discussed brieflythroughout this report, but were discussed in de-tail in the OTA report Protecting Privacy in Com-puterized Medical Information.14

The issues and policy options that emerge fromeach chapter of this report are briefly summarizedin the sections that follow. First, however, two keythemes are introduced that echo throughout thechapters. These are cost containment and stan-dards development, and they reflect congressionalconcerns about containing health care costs andenabling administrative simplification that aremanifest in the bills of the 103d and 104th Con-gresses.

❚ Cost ContainmentReducing the cost of delivering health care is per-haps the prime motivation for congressional inter-est in exploring the use of information technology.Anticipated cost savings are based on analogousreductions in transaction costs for industries suchas banking—which built information infrastruc-tures supporting automated teller machines andpoint-of-purchase credit card verification—andon the increase in productivity and product qualityin domestic manufacturing industries associatedwith just-in-time inventory control, continuousquality improvement, and other techniques thatare highly dependent on information technolo-gies. Although similar efficiencies and improve-ments may be possible within the health care

system, the magnitude of the savings is very diffi-cult to predict for several reasons.

Most cost containment predictions maintainthe traditional fault line between administrativeinformation and clinical information. Administra-tive processes include activities such as transmit-ting and processing claims, utilization review,purchasing supplies and tracking inventory, pay-ing bills, managing internal finances, negotiatingcontracts, complying with regulations, and con-trolling quality. Administrative costs of providinghealth care have been estimated at between $108billion and $135.1 billion per year in 1991,15 orbetween 12 and 15 percent of the health care bill.Estimates of annual savings that could be realizedthrough increased use of information technologyin administrative functions have ranged from $5billion to $36 billion,16 or enough to reduce ad-ministrative costs between 0.5 and 3.6 percent.

These estimates, discussed in more detail inchapter 3, may be somewhat optimistic becausethey assume rapid adoption of electronic data in-terchange and high rates of market penetrationthat do not appear to be materializing. The deeperproblem with such predictions is that they areoften based on merely converting all transactionswithin the existing system of fee-for-servicehealth care to electronic form. However, the shift-ing landscape of health care delivery patterns can-not be treated as a perturbation within a more rapidprocess of digitizing health information. Suchdigitization did not happen over the past two de-cades despite the availability of increasingly capa-ble computer and telecommunication systems;indeed, several organizational and technologicalimpediments (discussed in chapter 2) make it like-ly that widespread digitization will happen only in

14 U.S. Congress, Office of Technology Assessment, Protecting Privacy in Computerized Medical Information, OTA-TCT-576 (Washing-

ton, DC: U.S. Government Printing Office, September 1993).

15 Allen Doubloon and Matthew Bergheiser, “Reducing Administrative Costs in a Pluralistic Delivery System Through Automation,” pre-

pared by Lewin-VHI for the Healthcare Financial Management Association, Apr. 30, 1993.

16 Project HOPE, Center for Health Affairs, “Estimating the Cost-Effectiveness of Selected Information Technology Applications,” unpub-

lished contractor report prepared for the Office of Technology Assessment, March 1995.

12 | Bringing Health Care Online: The Role of Information Technologies

synergy with the progressive adoption of man-aged health care practices and development of in-tegrated service delivery systems.

A second class of economic considerationsconcerns the effectiveness of encouraging specificinformation technology implementations. Theseare of concern to Congress for purposes of guidingprocurement decisions and research priorities. Inrecent years, the field of economic evaluation ofmedical technologies has expanded rapidly. Ris-ing spending on health care has stimulated the useof formal techniques such as cost-effectivenessanalysis and cost-benefit analysis to assess thecost and health effects of using particular medicaltechnologies.

Cost-effectiveness analysis (CEA) has emergedas the most popular technique for economic evalu-ations. CEA involves a structured, comparativeevaluation of two or more health care interven-tions. Analyses are designed to show the relation-ship between resources used (costs) and healthbenefits achieved (effects) for given technologiesor programs. In CEA, the cost per specified healtheffect, such as lives saved or quality-adjusted life-years saved, is calculated for particular technolo-gies or programs. If the ratio is measured similarlyfor different technologies or programs, the costper effect can be compared. Formal CEA involvesa number of explicit steps, including:

1. identifying the perspective of the study,2. identifying the competing interventions,3. defining costs,4. defining effects,5. discounting future costs and effects to their

present value,6. adjusting for quality-of-life factors,7. analyzing the incremental costs and conse-

quences of one option over another, and8. examining uncertainties underlying

the analysis.

In cost-benefit analysis (CBA), the net costs ofan intervention are compared with the net savings:the benefits of a program or technology are ex-pressed entirely in monetary terms. Because thebenefit of medical technology generally involveshealth effects such as life-years saved, CBA re-

quires that these effects be valued in monetaryterms. One of two techniques—the human capitalapproach or the willingness-to-pay approach—isgenerally used to measure benefits. The humancapital approach considers the value of a humanlife by estimating an individual’s projected futureearnings. The willingness-to-pay approach con-siders how much individuals are willing to pay fora reduction in the risk of death or illness.

Applying the formal techniques of CEA andCBA to information technology applications inhealth care is difficult for a number of reasons.Some of the difficulties are general to all medicaltechnologies: the competing alternatives for atechnology are not always known; a technologymay be cost-effective in some patient groups andnot in others; technologies constantly undergochange; there are no standards on how to definecosts (e.g., whether and how to consider indirectcosts such as productivity losses, or intangiblecosts such as pain and suffering); there are no stan-dards regarding the length of patient followuptime to consider; analysts differ in their use ofmethodologies by which to adjust health effectsfor quality-of-life factors; and there are many un-certainties underlying such analyses. A generalproblem with CBA involves trying to place amonetary value on reductions in mortality or mor-bidity.

Beyond these general difficulties, evaluatinginformation technologies presents some uniqueproblems. It is difficult to conduct comparativestudies because system features and levels of ser-vice vary widely across institutions and users. Inaddition, many applications have been in exis-tence only a short time. Information technologiesand applications change frequently, making anal-yses difficult—and making even some well-con-ducted analyses quickly obsolete. In general, it isdifficult to identify and quantify appropriatecosts, savings, and health effects. For most evalu-ations of information technology, direct costswould include equipment and operating costs, thevalue of the technician’s time, and the cost ofmaintaining equipment. However, it is hard to ac-curately identify and quantify indirect costs such

Chapter 1 Introduction, Summary, and Options | 13

as productivity gains or losses. In general, it isvery difficult to tie the use of information technol-ogies to health consequences.

As a result of these limitations, most existingeconomic evaluations do not constitute formalcost-effectiveness or cost-benefit analyses. Instead,most have attempted to estimate savings in termsof productivity gains to the system. Some havealso speculated about how various applicationswill ultimately influence patient care. The designand scope of such analyses vary widely acrossstudies, as does the level of rigor.

Congressional OptionsRecognizing that implementation of informationtechnologies will be an incremental process, Con-gress may wish to attempt to evaluate the possiblesystemic savings associated with implementationof information technologies in a way that recog-nizes the shifting patterns of health care delivery.Alternatively, Congress could evaluate, for ad-ministrative purposes, the costs and benefits ofimplementing various specific technologies orsets of technologies. These are difficult chal-lenges. However, should Congress wish to pursuesuch analyses, it could direct agencies or congres-sional support services to implement one or moreof the following options:

OPTION 1: �������� �������� ����� �� ����� �� ��

��� ��������� ����� ��������������� ��� �����������

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���� �������� ���� � ��������� ���������� ���� ���� ���� ��� ���

�������������

OPTION 2: ������ ��� ���� �������� ��� ��������

���� ����� ��� ������������� ��� ��������� �����������

������� ����� ���� ��� ����������� ��������� ������� ����

������� ��� ��������� �������� �� ��� ����� ��� ����

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OPTION 3: ��������� ���� ���������� ���� ����� ���� ���

������ ������������ ������� ���� ��� ����� � �������� ��

���� ��������������� ��� ��������� ������������� �������

������ ��� ����� ��� ������� ����������

OPTION 4: ���������� ��������� ���� ���� ���� ����� ��

������� ������������ ���������� ��� ���� ������� ���� �������

������� ��� ����� ������� ���������������� ��� ��� �����

������� ���������

Given these possibilities for cost-benefit analy-ses and systemic cost analyses, it should be notedthat some stakeholders who contributed to this as-sessment indicated that rigorous cost-benefit orcost-effectiveness analyses would not play a ma-jor role in their decisions to implement informa-tion technologies. Rather, these technologies andsystems of technologies were considered by manystakeholders to be as fundamental and as immuneto cost-benefit analysis as the telephone: adoptionof the technologies would be necessary to remaincompetitive in the health care industry.

❚ Standards DevelopmentThe second major theme that recurs throughoutthis report is the central role of standards develop-ment for systematizing the compilation and ex-change of health care information. One value ofdigitized health information is that it can be ma-nipulated quickly and accurately by computerswithout human intervention. The accuracy, speed,and cost of machine-processing are adversely af-fected by novelty, diversity, and frequent changesin the rules. Until standards are in place and com-pliance is widespread, costly activities—such asmaintaining multiple formats for health care in-formation, dealing with exceptions, and develop-ing new interface software as new proprietaryapproaches to managing health information be-come fashionable—will continue to offset somepotential savings of processing health care recordsand transactions electronically.

Standards development is an ongoing process.A number of organizations are working on stan-dards for the content and format of electronichealth information. Standards for the format ofbilling and core insurance transactions are welldeveloped, and the Health Care Financing Ad-ministration (HCFA) has adopted some of them.Another area of standardization that could facili-tate electronic transactions is a system of unique

14 | Bringing Health Care Online: The Role of Information Technologies

identifiers for individuals, providers, and sites ofcare. At present, each provider uses its own num-bering system, which can create confusion whenhealth information is exchanged between differ-ent institutions.

The development of technical standards is pri-marily a private-sector activity. However, it couldbe accelerated through federal participation in de-veloping standards that would encourage in-formation exchange and protect the privacy ofparticipants in the health care system, and throughexpeditious implementation of such standards inall federal health care matters as a catalyst fortheir adoption by the private sector. This shouldnot be construed as a call for federal agencies toindependently establish standards for implement-ing information technologies—such efforts wouldalmost certainly fail to meet the needs of variousstakeholders. Rather, federal agency participationin existing standards activities would preempt du-plicative development of federal regulations andrequirements. Further discussion of standards ap-pears in individual chapters of this report.

❚ Information Technologies forTransforming Health Care

The potential for new computing and telecommu-nications technologies to reduce the cost of deliv-ering health care, while facilitating broad structur-al changes in the health care industry, may presagea rapid expansion in the application of informa-tion technologies to the health care system. Chap-ter 2 charts the technological and organizationalfactors that will help guide the path of that expan-sion should it occur.

Policy IssuesMany of the practical frustrations encountered byparticipants in the health care system can be tracedto the inability of current information systems toprovide accurate, timely information where it isneeded in the health care process. Poor informa-tion mobility has become an impediment to effi-cient delivery of high-quality health care. Thisimpediment becomes more prominent, expen-sive, and problematic for health care delivery or-

ganizations as they grow larger and morecomplex. One approach to solving this problem isto liberate health information from its traditionalpaper medium by creating, transmitting, and proc-essing it through more flexible electronic means.Electronic information can be used again andagain, in different forms for different purposes. Itcan be reformatted easily and transmitted cheaplyonce the infrastructure to do so is in place.

Chapter 2 identifies the broad currents of in-formation flowing within the health care system,and then describes various approaches to comput-erizing clinical information within hospital andambulatory care units. One portion of this clinicalinformation is the patient’s medical record, whichhas conventionally been kept as a thick folder ofpaper forms and films. The chapter describes thedesign of paper recordkeeping systems and thereasons they are inadequate for documenting carein an integrated health care delivery organization.It discusses ways that this information might bedigitized and then disseminated (with appropriatesecurity measures) through standardized commu-nications protocols.

A diverse suite of key computer and commu-nication technologies supports the digitizationand dissemination of clinical records. The chapterdescribes technologies for: a) capturing data asit is generated by caregivers and the machinesthey use to monitor and treat the patient; b) com-pressing, storing, securing, and retrieving data;c) networking and telecommunications technolo-gies sharing information; and d) refining data andcomparing data streams so computers can supportmedical decisionmaking. Insight and wisdommust somehow be culled from an overwhelmingflood of bits and bytes.

This suite of advanced information technolo-gies is also the context for discussions in subse-quent chapters of the report that addressadministrative health data management, qualityassessment and decision support, and deliveringhealth care services and information at a distance.

Congressional OptionsMany of these core technologies have been devel-oped by the private sector for nonmedical pur-

Chapter 1 Introduction, Summary, and Options | 15

poses and will be adopted within the health caresystem as needed. Nonetheless, Congress maywish to consider certain policy options that couldencourage harmony in how that adoption pro-ceeds.

OPTION 1: �������� ��������������� ����������

Congress could direct relevant agencies to sup-ply personnel to actively participate in standards-setting meetings. This would proactively obviateany federal regulatory activity that might be atodds with consensus standards by making surethat government interests are represented withinthe standards-setting process. Congress couldalso provide financial support for the process, in-cluding funding research support to help resolveany technological roadblocks that impede stan-dards development. Congress could also directfederal agencies to set aggressive schedules forimplementation of consensus standards in theirown health care delivery and administrative acti-vities as a catalyst for similar private-sector ac-tion.

OPTION 2: ���� ��� ��������� ����� � ������� ��

������� �������� �� ���������� ��������

These efforts could include research into hu-man-computer interface technologies for use inhealth care settings and research into large-scale,open architecture implementations of informationtechnologies in health care settings.

OPTION 3: ��������� ����� ������� ��� �������

��� � ���� ������������ �� ��������

The agencies or committees charged with thiscoordination could:

1. establish procedures for expediting approvaland distribution of medical software;

2. establish mechanisms (or support similar pri-vate-sector efforts) for reviewing and dissemi-nating clinical protocols;

3. advise Congress on specific needs of the medi-cal, technical, and consumer communities withrespect to legislation establishing regulationsand policies pertinent to information technolo-gies; and

4. set national standards for patient and institu-tional identification numbers and security pro-cedures to be used with patient records.

❚ Networks for Health AdministrationChapter 3 explores the exchange of healthinformation among the many stakeholders—pro-viders, payers, employers, consumers, and govern-ment agencies—particularly for administrativepurposes.

Policy IssuesAs part of a larger effort to reduce costs, improvequality of care, and improve access to health care,efforts to effect administrative efficiency throughgreater use of electronic commerce in health careare an important component. Today, about 75 per-cent of hospital claims are submitted electronical-ly, the vast majority of these being Medicareclaims submitted to HCFA. Physicians submitsome 47 percent of their Medicare claims elec-tronically, but only about 16 percent of totalclaims.17 Between some payers and providers, theprocess of billing and being paid has been totallyautomated, with the organizations exchangingelectronic claims, remittance advice (documentsthat explain how much of the claim is paid), andelectronic funds transfers. However, such levelsof automation are still unusual. Electronic claimservices help providers deal with the multitude ofdifferent formats and requirements of payers.They offer software and services for translatingand reformatting claims and other electronictransactions among the 400 or so different sys-tems in use.

Compared with a paper-based system, it ap-pears that electronic information reduces costs forsome users. Most of the estimates for savings re-

17 “Automated Medical Payments Statistical Overview,” Automated Medical Payments News, Feb. 8, 1993, p. 3.

16 | Bringing Health Care Online: The Role of Information Technologies

sulting from the use of information technology arebased on cost reductions in payer-provider trans-actions resulting from automation in a fee-for-ser-vice environment. Managed care organizationscan have equivalent transactions that presumablywill cost less using information technology. How-ever, the major savings that are expected to accruefrom managed care come from better managementof both resources and patient and clinician behav-ior—for example, reduction of unnecessary ser-vices. Information technology should assist in thisas well. For example, having up-to-date patient re-cords available at the point of service should re-duce duplicate testing or the provision ofnonallowed treatments. While it has been arguedthat information technology fosters better man-agement, actual evidence of its contributions tocost reduction in this area is difficult to find.

Community health information networks(CHINs) facilitate exchanges of clinical or admin-istrative data among providers and payers in a par-ticular community or region. CHINs can helpoffset the lack of standardization by providingtranslations and interfaces between incompatiblecomputer systems used by different network sub-scribers. Some networks, often called CHMISs(Community Health Management InformationSystems), may also maintain a repository of ad-ministrative information for use in performingoutcome research and quality assessments of pro-viders and insurance plans in the community. Atthis point it is not clear whether community net-works, which offer service to competing providersin the community, will survive as more verticallyintegrated health care organizations build propri-etary information networks.

While exchanging health information electron-ically offers advantages, it also raises fears thatprivacy and confidentiality of health informationmay not be protected. Many consumers alreadyfear that too many people have access to theirhealth information. Most information needed forhealth care administrative transactions comesultimately from the patient record. Clinical in-formation in coded, abstracted form becomes ad-ministrative information. The provider attemptsto capture, either through manual or automated

means, everything that is done for the patient dur-ing a stay or visit, and to document informationabout resource utilization and costs in order toprepare an appropriate bill. Electronic patient re-cords are under development in many locationsthroughout the country. In addition to technologi-cal and organizational barriers, there are a numberof regulatory and legal barriers to complete imple-mentation of electronic patient records, includingconflicting state laws and regulations about howpatient records must be maintained and the wayprivacy and confidentiality of records should beprotected.

Health information is not limited to the patientrecord. Rights of patient access and procedures forprotection of privacy and confidentiality are notclearly defined for secondary and tertiary users ofhealth information (e.g., payers, researchers, andorganizations maintaining health data reposito-ries) under federal or most state laws. While mosthealth care is local, in that people usually see care-givers in their own communities, health informa-tion often needs to cross state lines because thepayer, provider, patient, and/or employer may bein different states.

Congressional OptionsSavings may be available to the health care systemas a whole as a result of universal implementationof electronic medical payments. However, at cur-rent implementation rates, universal compliancemay not be achieved for some time, if ever. Get-ting started with electronic commerce requires asolid organizational commitment and a signifi-cant investment in equipment, software, processredesign, and education, but some organizationshave weak financial incentives to make the invest-ments needed to institute electronic payments.Others are forging ahead, unwilling to wait forstandards. The health care industry in the UnitedStates is not organized as a “system” with a centralfocus or consensus on how to deal with system-wide problems. The different parts of the frag-mented system have diverse incentives, andefforts by participants to control costs in their ownarea can tend to increase costs elsewhere. How-ever, these shifted costs are so subtle and spread

Chapter 1 Introduction, Summary, and Options | 17

over so many participants in a complex systemthat they are difficult to quantify.

The federal government has provided someleadership in helping the health care industrymove toward greater use of electronic informa-tion, and may wish to continue this leadershiprole. There are three major areas in which govern-ment action might be considered: 1) providingleadership in the adoption of standards for elec-tronic medical payments and other transactionsand exchanges of health information; 2) establish-ing a system of unique identifiers for people, pro-viders, and payers; and 3) establishing a moreconsistent regulatory environment for interstateexchanges of health information.

OPTION 1: ������� � ��� ����� �� � �� � �������"#

����� ��� � ���� �� � ����������� �������!� �������� �� � � �#

��� ��� ��� ����� ��� � �� � ����� ����� ��

The Health Care Financing Administration’s(HCFA’s) adoption of claims submission stan-dards, along with incentives such as faster pay-ment of electronic claims, has already beeninstrumental in encouraging some payers and pro-viders to begin use of electronic payment systems.

OPTION 2: � ���� � �� � �������� ��� �������!#� � �#

�� �� �������� ���� ��� � � �������� ������������ ��#

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��� �� �� ���� �� ��� ���� � �������

If it is believed that HCFA’s influence alonewill not ensure high enough levels of participationin a standardized electronic health payment sys-tem, then a more active federal role may be con-sidered. A corollary to this option may be:

OPTION 3: ���� � � ��� ��� ��� � ��!� ����� � #

����������!� ��� �������!� ��� � �� �������� ��� ��� � �#

��������� ���� ����������� � ����������� ��� �����������

����� �������!� �������� ��� ��� ��� � ���� �� ��� ���#

����� �� �� ��� �� �� ����� �!�� �� � � �� � ��!� ��� ���#

�������� ���� ����� ������ �

OPTION 4: �������� � �!�� �� ��� ����� � �� ����� ��

���� ��� ����� ������ ���� ��� ��� �� ��� �� �

A national system of electronic commerce forhealth information will operate more smoothly ifthere is a better system for uniquely identifyingparticipants in that system, both to prevent du-plication and loss of information and to facilitatecoordination of benefits when multiple providersand payers are involved in a patient’s care. Be-cause of its national reach, the federal governmentmay be in the best position to establish systems ofidentifiers.

In order to create a consistent legal and regula-tory environment for electronic health informa-tion, Congress may wish to consider the followingoptions:

OPTION 5: ������� � �� � ���� � ��� �������

��� � � ��������� ����� � ���� ��� �����!� ��� ������ ����#

��!�� ����� � ����� � � ���� ��� �������� ���� � ���

�����������

A number of industry groups have been work-ing with state governments to encourage adoptionof uniform legislation, and the Department ofHealth and Human Services has been assigned thelead role in designing model state privacy laws.An alternative or supplement to this option maybe:

OPTION 6: �������� � � ��� � ��������� ��� � ���#

����� � ������� �����!� ��� ������ ������!� ��� � ����� ��#

���������� ����� � � ��� ���� ��� ��� � ������� ��

�������� ���� ����� � ��� ������������ ��� � ����� ��#

���������

Additional federal legislation may be neces-sary as a framework for state legislation, or to re-place state laws, if the process of revisinglegislation on a state-by-state basis is seen as inef-fective or too time-consuming.

OPTION 7: ���� � � ��� ��� ��� � ��!� ����� � #

����������!� ��� �� �� � �� � ���� ������ ��� � ���� ��

���� ������ � �������� � �� �� ��� �����!� ���� ��� � �

� ��� ��� � � ���� ���� ��� � �������!�� � �����!� � #

��� ��� ��� ����������� ������ ��� ���� � ����� ��

���� �����!� ��� ��� ��� �� � � � ��� � ���� �� � ������#

�����

18 | Bringing Health Care Online: The Role of Information Technologies

Because of the importance of privacy and con-fidentiality to the public, the continually changinguses for health information, and the constantlychanging nature of threats to privacy and confi-dentiality, it may be necessary to establish one or-ganization as an ongoing locus of responsibility.

❚ Improving the Quality of Health CareChapter 4 finds that advanced informationtechnologies—computer-based patient records,structured data entry, advanced human-computerinterface technologies, portable computers, auto-mated data capture, online query, knowledge-based information systems, and computernetworks—can potentially improve the quality ofhealth care by enhancing clinical decision sup-port, and by improving data for assessing both theeffectiveness of health services and the perfor-mance of health care providers and insuranceplans.

Information technologies could facilitate fasterand easier collection of information about the pa-tient and the health problem at hand. Portions ofthat information could be entered by clinicians ator near the point of care, captured directly fromdiagnostic and monitoring equipment, or enteredby the patient prior to care. Technologies such asrelational databases with online query could sup-port faster and easier search and retrieval of pre-viously collected information about the patient, aswell as information from local or remote knowl-edge bases. Development of computer-based clin-ical protocols and other forms of clinical decisionsupport systems (CDSSs) that apply decisionrules and other knowledge-based approaches toinformation about the patient and health problemat hand could recommend diagnoses, tests, treat-ments, and preventive care. They could also leadto more rigorous construction and analysis ofmeasures of service effectiveness and perfor-mance of providers and plans. Computer net-works, high capacity telecommunications,advanced human-computer interface technolo-gies, and improved graphics software could leadto more flexible organization and display of thisinformation as appropriate for individual clini-

cians, and more rapid and widespread dissemina-tion of the results of performance measures tovarious parties.

Empirical evidence demonstrating the abilityof these technologies to achieve these goals is lim-ited, mixed, or incomplete. Moreover, concernshave been raised about possible adverse effects onthe quality of health care arising from thesetechnologies, including:

1. incorrect parameters or criteria, or omitted oraltered steps, in CDSSs that could lead to inap-propriate care;

2. excessive reliance on monitoring equipmentand CDSSs, which could undermine the abilityof clinicians to exercise professional judgmentin nonroutine cases and reduce the interperson-al aspects of patient care (the “quality of car-ing”); and

3. the temptation to use readily available adminis-trative data for assessing the effectiveness ofspecific health services or the performance ofproviders or insurance plans.

If the data are incomplete or inaccurate, the re-sults could be misleading.

Policy IssuesThe private sector has been largely responsible forthe development and application of informationtechnologies in clinical decision support and per-formance assessment of health care providers andinsurance plans. The federal government’s rolehas mainly involved:

1. developing information systems and perfor-mance measures for its own health insuranceand health care delivery programs, most nota-bly Medicare;

2. funding of intramural and extramural researchand demonstration projects; and

3. participating in voluntary standards-setting ac-tivities with private-sector organizations.

All of these activities in both the private andpublic sectors are likely to continue, with some in-creasing and others decreasing. In an era of bud-getary and regulatory restraints, however, majornew government initiatives, such as funding for

Chapter 1 Introduction, Summary, and Options | 19

technology development or mandated regulationof clinical information systems, are unlikely. Itcan be argued that this is appropriate—in otherwords, that the federal government should not in-terfere in private market decisions regarding theselection of new technologies or their applica-tions.

On the other hand, the federal government—specifically HCFA—is responsible for ensuringtight the quality of health care rendered to Medi-care and Medicaid beneficiaries.18 Recent effortsto move more beneficiaries into managed carehave underscored quality concerns, given the ex-pectation that capitation creates an incentive forunderservice.19 Several policy issues regardingthe potential impact of information technology onthe quality of care delivered to Medicare and Med-icaid beneficiaries deserve the attention of federalpolicymakers.

The foremost issue is the extent to which clini-cal information systems actually change clinicalpractice patterns and patient outcomes, and wheth-er those changes are beneficial to providers andpatients. Empirical research on this issue remainslimited, mixed, or incomplete, and more solid evi-dence regarding these impacts needs to be ob-tained. To pursue such research, Congress couldconsider the following options.

Congressional Options

OPTION 1a: �������� ��� �� ������ �������� ���� �����$

������ ������ �� ���� �!��������� ������� ���� ����� ��� ��

�������$�� ���� ������#������� ���� ������ �� ���� �����$

��������� ����� ��� ��������� ���

� develop and test the reliability and validity ofvarious methods of measuring and assessing(with risk adjustment) the performance of pro-viders and health plans;

� develop, implement, and evaluate specific sys-tems of risk-adjusted performance indicators;

� evaluate the effectiveness and safety of clinicalinformation systems, including CDSSs.

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OPTION 1c: ������� ���� ����� ��� ������������ ���� ��$

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Until more solid evidence is available regard-ing the effectiveness and safety of existing clinicalinformation systems and the reliability and validi-ty of performance assessment systems, more dras-tic action—such as mandating the testing andcertification of all such systems—is probably notjustified. Legal questions regarding who shouldbe held liable in situations in which such systemslead clinicians to make decisions that harm pa-tients are probably best left to the courts to re-solve.

Assuming that clinical information systems arefound to be effective and safe in terms of their im-pacts on practice patterns and patient outcomes,the next set of issues focuses on the most efficientmeans of developing and implementing those sys-tems.

One issue regarding government involvementin the development of standards and technologyconcerns the classification and coding of healthservices. Many major payers currently employ

18 The state governments share responsibility for the Medicaid Program with the federal government.19 Given a fixed payment per plan member, providers may be tempted to minimize the volume and/or intensity of services rendered for each

patient.

20 | Bringing Health Care Online: The Role of Information Technologies

two separate systems for coding health services:ICD-9-CM20 for billing by inpatient hospitals andother institutional providers, and CPT-421 for“professional” billing by clinicians and other non-institutional providers and suppliers.

For payment and other purposes, services ren-dered by a clinician in an inpatient setting must becoded using both of these systems, creating addi-tional costs for providers. For many services,however, the codes in ICD-9-CM cannot beequated (“crosswalked”) with those in CPT-4 be-cause of substantial structural differences betweenthe two coding systems. Moreover, bothICD-9-CM (Vol. 3) and CPT-4 have serious tech-nical limitations, such as overlapping and duplica-tive codes and inconsistent and noncurrent use ofterminology. Most importantly, neither has ade-quate room for expansion, so both are running outof codes as new services are created or differentuses of existing services are distinguished. In ad-dition, neither system provides sufficient clinicaldetail to support the creation of the kinds of data-bases required to accurately assess patient out-comes using advanced information technologies.

Citing these and other problems, the NationalCommittee on Vital and Health Statistics, an advi-sory body to the Secretary of Health and HumanServices, has recommended developing a unifiedclassification and coding system for health careservices.22 However, in 1994, even HCFA reaf-firmed its intention to continue this dual codingsystem policy in its Medicare and Medicaid pro-grams, despite the substantial barriers this posesto efficient information processing and analysis.

OPTION 2a: ������� ��������� ����� � ���� ��������

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❚ Telemedicine: Remote Access to HealthServices and Information

Telemedicine can be broadly defined as the use ofinformation technology to deliver medical ser-vices and information from one location to anoth-er. The use of telecommunications to deliverhealth care services and exchange information isnot new. Chapter 5 discusses how recent techno-logical advances—such as fiber optics, integratedservices digital networks, and compressed video—have eliminated or minimized some of theproblems (e.g., poor quality images and slowtransmission speeds) that limited earlier applica-tions.

Currently, there is much interest in the potentialof telemedicine to lower costs, improve quality,and increase access to health care, especially forthose who live in remote or underserved areas. Pi-lot tests are also under way to test the feasibility ofdelivering a variety of services directly to con-sumers in their homes.

20 Practice Management Information Corp., International Classification of Diseases, 9th Revision, Clinical Modification, Fourth Edition,

1993 (Los Angeles, CA: 1993).

21 American Medical Association, Physicians’ Current Procedural Terminology, 1994 (Chicago, IL: September 1993).

22 U.S. Department of Health and Human Services, Public Health Service, National Committee on Vital and Health Statistics, The National

Committee on Vital and Health Statistics, 1993 (Washington, DC: May 1994), pp. 8-10, 54-75.

Chapter 1 Introduction, Summary, and Options | 21

Although there are no studies that prove thecost-effectiveness of telemedicine, in some casesit would seem to have the potential to reduce costsfor some participants. For example, telemedicinecan eliminate the time and wages lost at work andtraveling expenses incurred when specialists and/or patients have to travel for consultations. In ad-dition, keeping patients in their own communitiescan increase revenues for local hospitals and de-crease the cost to patients. The cost of a bed in acommunity hospital is considerably less than in alarge medical center. Costs might also be reducedby staffing hospitals and clinics with allied healthprofessionals, such as nurse practitioners and phy-sician assistants, who would deliver serviceswhere there is no resident physician. Overall costsalso could be lower using telemedicine if it allowspatients to be seen earlier, thus preventing theneed for later, more costly care. Using telecom-munications to deliver services directly to thehome would also reduce the costs of travel, as wellas the pressures on clinics, emergency rooms, anddoctors’ offices.

In the short term, however, costs could in-crease. Telemedicine could add an extra step to theprocess if the patient still requires referral to alarger medical center. If it improves access to care,there may be increased use of health services asmore people take advantage of their availability. Ifreimbursement for telemedicine services becomeswidespread, the system may be vulnerable toabuse through overuse or fraudulent claims. Costis not the only criterion, however. It is important toconsider the “value” of delivering services tothose who might otherwise not get them at all be-cause of their physical location.

Telemedicine can increase access to health carefor populations in rural or inner city areas. It cando so by making these areas more attractive tohealth care providers by giving them immediateelectronic access to up-to-date information and re-sources, specialists for consultative purposes,continuing medical education, and other col-leagues. Enabling local hospitals to remain eco-nomically viable by keeping patients in their owncommunities is another benefit for access, as wellas for the economic stability of the community.

Telemedicine appears to have the potential toimprove the quality of care, but this has not yetbeen proven. It can provide faster, more conve-nient treatment and minimize the disruption of thepatient’s life. By reducing the need for referrals,the continuity of patient care is ensured. The qual-ity of care may be better for a patient who has thebenefit of family support in the local area. For pro-viders, ready access to information to help themmake more informed decisions will improve thequality of the care they deliver. Electronic accesswill help them stay up to date and enable them toreceive continuing medical education creditswithout leaving their communities. Some believethat the establishment of clinical practice guide-lines for telemedicine could help to provide amore consistent level of care.

While telemedicine has been practiced for 30years, its current iteration is still in the early stagesof development. It will take a number of years be-fore it is used widely enough and evaluated suffi-ciently in terms of its effectiveness and efficiencyfor definitive statements to be made about itsoverall value and recommended uses. Like all newtechnologies, there will be impacts that cannot beanticipated in advance. Rigorous evaluation stud-ies are needed to determine telemedicine’s poten-tial benefits, and such research is currently beingsupported by a number of federal agencies. The re-sults should provide policymakers with the datathey need to make decisions about the efficacy oftelemedicine. Proposed federal budget cuts, how-ever, are likely to have a negative impact on tele-medicine research efforts.

Policy IssuesWhile the use of telecommunications in deliver-ing health services has great potential, it alsoraises a number of issues that need to be resolvedif telemedicine is to thrive. In general, patient con-sultations using telemedicine are not reimburs-able (except for teleradiology and telepathology).This will have a negative effect on its diffusion un-til HCFA promulgates a national policy. One ofthe reasons for HCFA’s reluctance is the fact thatthere is a lack of research available to support the

22 | Bringing Health Care Online: The Role of Information Technologies

safety, efficacy, clinical utility, and cost-effective-ness of telemedicine.

Another issue is the cost of the telecommunica-tions links required for telemedicine. In many ru-ral areas, the communication infrastructure isunable to support the bandwidth necessary tocarry the signals for telemedicine using two-wayinteractive video. In addition, the costs of connec-tions between local and long-distance telecom-munication carriers can pose a significant barrierto telemedicine projects. Under the existing tariffstructures, telephone calls placed to locations in-side the local access transport area boundaries areoften more expensive than those placed outsidethe same service area.

Telemedicine raises some difficult legal andregulatory issues as well. Remote diagnosis andtreatment across state lines could bring differentlaws and regulations into play. A previous OTAreport found that the present legal scheme does notprovide consistent, comprehensive protection ofprivacy in health care information, whether it ex-ists in a paper or computerized environment.Clearly the privacy implications for telemedicinewill continue to receive careful scrutiny. Physi-cian licensing becomes an issue because telemedi-cine facilitates consultations without respect tostate borders and could conceivably require con-sultants to be licensed in a number of states. Thiswould be impractical and is likely to constrain thediffusion of telemedicine projects. Telemedicinemay, in fact, decrease the threat of malpracticesuits through improved recordkeeping and data-bases, and the fact that taping the consultationswill automatically provide proof of the encounter.However, it may also raise other liability issues,such as the lack of a “hands-on” examination bythe consultant.

Congressional OptionsResponsibility for telemedicine policy is sharedamong federal, state, and local lawmakers, andmany of the decisions affecting the diffusion oftelemedicine are influenced largely by the privatesector. Federal efforts to reform both the healthcare and telecommunications systems, each trav-

eling its separate path, will have an effect on tele-medicine’s progress.

Implementation of telemedicine is likely toproceed with or without federal support as provid-ers recognize its benefits to their practices. How-ever, federal government support will be requiredif it is to benefit those who need it the most—people living in rural and inner-city areas wheremarket forces are unlikely to provide the servicesneeded. In a time of tight fiscal constraints andshrinking research budgets, federal funding pro-vided will need to be carefully monitored to en-sure it is being used wisely. If Congress wishes toencourage the diffusion of telemedicine to helpsolve the disparities in health care availability, itcan have the most impact in the areas of researchfunding and reimbursement for telemedicine con-sultations. The two are closely connected, in thatformulating a standard reimbursement policy isdependent on obtaining satisfactory answers tomany of the questions raised about telemedicine’sefficacy and cost-effectiveness. Congress maywish to:

OPTION 1: � ������� � � ���� ��� ��� ������� �� ���

������� �� �� �����

The research currently under way is crucial toanswering many of the questions about the bene-fits of telemedicine. To ensure that projects aresustainable when funding ends, agencies need tobuild in certain requirements. This is currentlyachieved by requiring that grantees make a finan-cial investment in the project, often throughmatching funds. Many of the current funding op-portunities for telemedicine projects focus on ru-ral areas. Telemedicine also offers potential forsolving some of the problems of inner-city healthfacilities. After assessing these needs, Congresscould target support for depressed areas where theneeds are great and a limited investment might behighly leveraged.

Because the data that would support a uniformreimbursement policy for telemedicine consulta-tions are not yet available, HCFA is moving slow-ly and deliberately in accumulating the necessaryinformation on which to base a sound decision.

Chapter 1 Introduction, Summary, and Options | 23

This seems a prudent strategy. Experimentingwith reimbursement in a small number of demon-stration sites will provide valuable insights thatwill eventually enable the agency to craft a carefulpolicy based on actual results. Congress may wishto ensure that adequate funding is provided tosupport those experiments. As the results becomeavailable, Congress may wish to provide oversightand conduct hearings to determine what furtheraction may be warranted.

Until recently, there was a lack of coordinationof federal efforts in research, policymaking, andimplementation of distance care. This has been re-medied considerably by the creation of the teleme-dicine working group of the Administration’sInformation Infrastructure Task Force.

The costs of implementing telemedicine can bea barrier to its diffusion, especially for small com-munities and facilities. To address this barrier,Congress may wish to:

OPTION 2: ����� ��������� ��� ���������� ����

���� ����������

In many small communities, it makes econom-ic sense for groups to share the costs of imple-menting, operating, and maintaining atelecommunications network. For example,schools, medical clinics, libraries, social services,and others who would benefit from improved in-formation services may need to join forces to getstarted. The Department of Defense and the Na-tional Aeronautics and Space Administration(NASA) have been leaders in research related totelemedicine applications, and the military hashealth facilities in a number of locations. In somesites the military has cooperated with civilianhealth care personnel to deliver services usingtelecommunications. Where possible, the exper-tise that exists in the military and NASA should beshared with the civilian sector. Agencies such asthe Department of Veterans Affairs could also beinvolved in cooperative efforts with the civiliansector.

OPTION 3: ������ ����� ����������� ������ � ����

���� ��� ��� �� �����������

In many cases, those who might benefit mostfrom telemedicine applications know very littleabout them. While information dissemination isincreasing in a variety of formats, there is a needfor a centralized, online database of telemedicineinformation. Such coordination might includecreating an electronic clearinghouse that wouldprovide a range of information about telemedicineprojects, including funding opportunities, currentprojects, and people to contact for assistance andadvice. Congress might wish to ensure that mech-anisms exist, either in the public or private sectors,to widely disseminate research results and otherinformation about telemedicine.

One of the goals of the IITF telemedicine work-ing group is to investigate the feasibility of settingup an online database of telemedicine activities,and work is continuing to determine the best wayto achieve this. Such a clearinghouse could be es-tablished in a designated federal agency withinDHHS, such as the National Library of Medicineor the Office of Rural Health Policy. Alternatively,Congress could provide support for a private-sec-tor group, such as the Telemedicine InformationExchange network at the Telemedicine ResearchCenter, Oregon Health Sciences University. Thisoption would avoid duplication of effort and pro-vide a single site where telemedicine informationcould be maintained and obtained. However, itwould also require careful consideration concern-ing the content of the database and how informa-tion would be structured and formatted. Anytelemedicine clearinghouse would only be usefulif kept up to date, and support for qualified staffwould needed to be assured.

OTHER APPLICATIONSThe applications of information technology de-tailed in chapters 2 through 5 and summarizedabove were selected because of their potential toimprove access to health care, improve the qualityof care, and reduce the costs of delivering care.These were of particular interest to the study’s re-questers. OTA was unable to undertake an in-depth analysis of a number of other applicationsof information technology that also have potential

24 | Bringing Health Care Online: The Role of Information Technologies

for improving health care. Two are mentionedhere—consumer health informatics and commu-nity networking.

❚ Consumer Health InformaticsConsumer health informatics has been defined as“the study, development, and implementation ofcomputer and telecommunications applicationsand interfaces designed to be used by health con-sumers.”23 The basic principle is that of empower-ing people to play a greater role in their own healthcare and to be active participants in decisions af-fecting their health.24 Information technology canbe used to provide more health-related informa-tion to consumers, “the largest untapped resourcefor health care.”25 Taking measures to prevent ill-ness and disease, by adjusting lifestyles or takingsafety precautions, for example, could have a pos-itive impact on the health care delivery system andallow people to lead healthier lives.

Shared decision support systems are designedto inform patient/provider decisions regardingprevention, diagnosis, management, and treat-ment, and ultimately to improve the quality ofcare and reduce costs. Choices are made collabo-ratively by patients and their caregivers. An exam-ple is the interactive video disk system developedat Dartmouth Medical School that allows menwith benign prostatic hyperplasia and early stageprostatic cancer to share in decisions on theircourse of treatment.26 Some regard these comput-

er-based systems as transforming the culture ofthe health care system to one in which patients,physicians, and other providers play equal roles indecisionmaking. 27

Information technology also could play an im-portant role in reducing a consumer’s need forhealth care services. Demand management can bedefined as the “the support of individuals so thatthey can make rational health and medical deci-sions based on a consideration of the benefits andrisks of the options available.”28 Current exam-ples include health risk appraisals, written and au-diovisual media, telephone counseling services,and community resources. Although a compre-hensive demand management system does not yetexist, information technologies can make inter-ventions more available and effective, and pro-vide a sophisticated, multipurpose informationsystem based on a new concept of the individualhealth record. When developed, these comprehen-sive services will allow consumers to understand,choose, and evaluate health services in new ways,and could have a positive impact on health carecosts and quality.29

Information technology also fosters commu-nication among people who can provide supportand encouragement to those dealing with chronicillnesses or a medical crisis. There is a large andgrowing community of people using computers toprovide help and support to one another to addressa variety of concerns. For example, as of early

23 Tom Ferguson (ed.), “Consumer Health Informatics: Bringing the Patient Into the Loop,” Proceedings of the First National Conferenceon Consumer Health Informatics, July 1993, p. 2. The Administration’s Information Infrastructure Task Force, Consumer Information Sub-group, defines consumer health informatics as “any information that enables individuals to understand their health and make health-relateddecisions for themselves or their families.”

24 John Wennberg, “Shared Decision Making and Multimedia,” Health and the New Media: Technologies Transforming Personal and Pub-

lic Health, Linda M. Harris (ed.) (Hillsdale, NJ: Lawrence Erlbaum Associates, Inc., 1995).

25 Vergil Slee and Deborah Deatrick, “Reengineering Health Care Decision Making,” Health Commons Update, vol. 2, winter 1995, p. 6.26 Wennberg, op. cit., footnote 24.27 Deborah Deatrick, Executive Director, Health Commons Institute, personal communication, June 9, 1995. See also Slee and Deatrick, op.

cit., footnote 25, p. 1.

28 D.M. Vickery, “Demand Management, Self-Care, and the New Media,” Linda M. Harris (ed.), op. cit., footnote 24.29 Ibid.

Chapter 1 Introduction, Summary, and Options | 25

May 1995, America Online reported it had 148scheduled self-help groups.30 Some of thesegroups address health-related concerns, such asdiabetes, stroke, AIDS, cancer, or disabilities.Others support the caregivers of people sufferingfrom Alzheimer’s disease or other debilitating ill-nesses. Nonprofit groups, such as the AmericanSelf-Help Clearinghouse, provide assistance andinformation to those wishing to set up an electron-ic support group or find out about such groups.31

Information on a variety of online health resourcescan be obtained from the National Health In-formation Center.32

The CHESS system is an example of one thatallows consumers to access information abouttheir illnesses and to support one another usinghome terminals.33 Another is the Connect Sys-tem, a computer and voice-mail system used tomonitor inner city drug-using pregnant women inCleveland, Ohio. At Case Western Reserve Uni-versity, ComputerLink was a demonstration proj-ect that supported the caregivers of persons withAlzheimer’s disease and AIDS by delivering in-formation, communication, and decision support,accessed through home terminals.34 (See ch. 5 formore complete discussion of these systems.) Fu-ture systems geared to the needs of consumers arelikely to include interactive video to the home.

Participants in an OTA workshop in July 1994had a number of suggestions regarding what ac-

tions are needed to foster greater electronic healthresources for consumers. These included:

1. support research and development;2. support wide access to the NII as it develops;3. insist on good needs assessment for consumer

applications;4. incorporate medical informatics into the med-

ical education curriculum;5. support clinical trials of different ways of shar-

ing health data;6. reduce the cost of telephone links to electronic

bulletin boards;7. subsidize premarket development of tools that

private corporations can use and resell;8. facilitate the use of technology by managed

care organizations;9. educate, support, and train users; and

10. provide grassroots technology “set-asides.”

The Administration’s Information Infrastruc-ture Task Force has a subgroup of representativesfrom federal agencies who are addressing con-sumer health information and the NII. This com-mittee has coordinated the development of a draftwhite paper outlining key policy issues for thefederal government to consider as the public in-creasingly relies on electronic means of informa-tion access and exchange.35 This paper wasreleased for public comment at a federally spon-sored national conference on networked consum-

30 Todd Woodward, Self-Help Information Center, America Online, personal communication, May 8, 1995.31 Barbara J. White and Edward J. Madara (eds.), The Self-Help Sourcebook: Finding and Forming Mutual Aid Self-Help Groups, 4th ed.

(Denville, NJ: St. Clares-Riverside Medical Center, 1992).

32 NHIC’s home page on the World Wide Web is located at <URL: http://hic-nt.health.org/ >. NHIC is a service of the Office of DiseasePrevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, and the George Washington Univer-sity Himmelfarb Medical Library.

33 F.M. McTavish et al., “CHESS: An Interactive Computer System for Women with Breast Cancer Piloted with an Under-Served Popula-tion,” n.d.

34 Patricia F. Brennan, “Differential Use of Computer Network Services,” American Medical Informatics Association, Proceedings,

Seventh Annual Symposium on Computer Applications in Medicine, Oct. 30-Nov. 3, 1993, Washington, DC, p. 27.

35 Kevin Patrick and Shannah Koss, “Consumer Information ‘White Paper,’” Consumer Health Information Subgroup, Health Informationand Application Working Group, Committee on Applications and Technology, Information Infrastructure Task Force, working draft, May 15,1995.

26 | Bringing Health Care Online: The Role of Information Technologies

er health information in May 1995. It will serve asthe cornerstone for Administration policy in ap-plications technology development and use.

Key policy issues for the federal governmentidentified in the paper include:

� the need to coordinate federal consumer healthinformation dissemination efforts both withinthe government (federal, state, and local) andwith private providers;

� assurance of privacy and confidentiality;� assurance of the availability of information

critical for public health;� the need for research and evaluation of the im-

pact of consumer health information;� the role of standards in vocabularies and data

transmission;� information validity and integrity;� assurance of telecommunications infrastruc-

ture for adequate information delivery; and� education and training.

❚ Community NetworkingHuman services, including health care, are oftendelivered in a fragmented fashion, leading to du-plication of effort on the part of providers and con-sumers. Telecommunications could be used tocoordinate and streamline these services throughcommunity networking,36 enabling the providersof a wide variety of social services to share in-

formation and communicate with one another. Anearlier OTA report discussed the role of the localcommunity infrastructure—schools, libraries, se-nior centers, and town halls—in delivering federalservices to citizens electronically, especially thosein rural areas, small towns, inner cities, and peoplewith special needs37 (see box 1-3). The difficultiesof building an infrastructure can be a barrier, how-ever. One group of researchers commented:

Although there is widespread endorsement ofsuch proposed efforts as managed care and one-stop shop service delivery, the more difficulttask in most communities is to build an infra-structure that supports such coordination with aholistic approach to service and care.38

One example of a project using telecommu-nication and computer technologies to supportand coordinate health and human services at thecommunity level is the Community Services Net-work (CSN) in Washington, DC. This is a joint ef-fort of the U.S. Public Health Service, HowardUniversity School of Social Work, Rice Universi-ty and Baylor College of Medicine, MacroInternational, Inc., United Seniors Health Cooperative, and Bell Atlantic Corp. Several communitiesacross the country are currently exploring the de-velopment of CSNs. The Lawrence LivermoreLab in California is helping Macro and other part-ners develop test-beds to move CSNs from pilot toearly operational status.39

36 For a discussion of the role of information technology in strengthening community action, see Nancy Milio, Engines of Empowerment

(Ann Arbor, MI: Health Administration Press, 1995).

37 U.S. Congress, Office of Technology Assessment, Making Government Work: Electronic Delivery of Federal Services, OTA-TCT-578(Washington, DC: Government Printing Office, September 1993), ch. 5. See also U.S. Congress, Office of Technology Assessment, Telecom-munications Technology and Native Americans: Opportunities and Challenges, OTA-ITC-621 (Washington, DC: U.S. Government PrintingOffice, August 1995).

38 G.A. Gorry et al., “Health Care as Teamwork: The Internet Collaboratory,” in Health and the New Media, op. cit., footnote 24, p. 97.39 Kevin Patrick, Department of Health and Human Services, personal communication, May 10, 1995.

Chapter 1 Introduction, Summary, and Options | 27

BOX 1-3: Grassroots Computer Networking: Lessons Learned

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The ASP MarketASP.

Unheard of even a year ago, the term 'ASP' is now used all over the industry. But what is an ASP?

ASP is an acronym for Application Service Provider. As outsourcers of enterprise applications, at the bareminimum ASPs take on the hosting and application service needs of companies whose core competenciesare not in information technology (IT). A large draw for middle market customers is that ASPs canessentially work with their IT departments to host complex applications for e-commerce, human resources,and financial management solutions. ASPs offer them access to Fortune 500 applications to which theywere previously denied.

USi: A Superior ASP

But not every company using the term ASP can deliver the same service. Some outsourcers only offerco-location or hosting, yet claim the ASP title. Any company considering an ASP to outsource theirenterprise solutions would do well to ask the ASP the following key questions.

How many software partners do they have? What are the capabilities of their network? How quickly canthey get your solution up and running? What kind of capital outlay will you have to provide up-front?

How large is their technical staff? How much expertise do they possess to implement and manage yourapplication, and respond to any emergency? Is their network secure? Is it redundant, failsafe, andgeographically mirrored? How fast is their connectivity?

Are regular software and network upgrades included in the service? Do they offer contracts with servicelevel agreements and project timeframes that include financial penalties when these promises are not met?

A top of the line ASP can offer all of this so its clients don't have to — and USi aspires to over-reach thesebenchmarks. USi has partnerships with a number of best-of-breed software vendors, Cisco-PoweredGlobal Network, and a partnership with telco U S WEST. This ensures that our clients have multipleoutsourcing options, can leverage a world-class network, and have high-speed Internet access andperformance.

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  Return to Table of Contents

Pharmaceutical Expenditures in Perspective●

Cost-effectiveness of Pharmaceuticals●

From the Manufacturer to the Patient●

Compliance with Medication Regimens●

Prescription drugs not only prolong life and improve the quality of life, they alsofrequently reduce or replace more expensive forms of medical treatment such ashospitalization, nursing care, and surgery. With the great potential for continuedpharmaceutical breakthroughs, prescription drugs will continue to play an importantrole in containing costs, even as overall health-care expenditures increase.

PHARMACEUTICAL EXPENDITURESIN PERSPECTIVE

Rising health-care costs can be attributed to several factors, notably demographicshifts in the population and the explosion of life-prolonging innovation. In 1997, totalnational health expenditures (NHE) in the United States amounted to 1.1 trilliondollars—13.5 percent of gross domestic product (GDP)—according to the HealthCare Financing Administration. The share of GDP allocated to health has nearlydoubled since 1970, when it was just 7.4 percent.

Beyond 2010, the aging of the population will have a significant impact onhealth-care spending. Those 65 and older are about 13 percent of the populationtoday and account for roughly 34 percent of health expenditures. As baby boomersenter their 70s and 80s, the share of the population 65 and over will exceed 20percent. Because the frequency and intensity of health-care utilization increasesharply with age, this demographic shift will raise health expenditures.

The U.S. currently devotes a higher percentage of GDP to health expenditures than

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any other major industrialized country [Figure 4-1]. Since 1980, the gap has widenedbetween the U.S. and other industrialized countries in the share of GDP allocated tohealth. In contrast, the share of GDP devoted to pharmaceuticals in the U.S. is aboutaverage for an industrialized country [Figure 4-2]. Since 1980, the share of GDPallocated to pharmaceuticals also has increased in the U.S., although this has been ata much slower rate than with other health-care components and is in line withincreases elsewhere. These data suggest that pharmaceutical expenditures do notcontribute to higher than average health expenditures in the U.S.

Overall, the proportion of health expenditures allocated to outpatient prescriptiondrugs in this country has declined from past levels, but has risen somewhat in recentyears [Figure 4-3]. In 1965, 9.0 percent of health expenditures was allocated toprescription drugs. In 1997, the percentage was 7.2.

In relation to consumer spending on other items, expenditures on prescription drugsare relatively small. According to the Department of Commerce, per capita personalconsumption expenditures on pharmaceuticals averaged 64 cents a day in 1997. Thiscompares to consumer expenditures of $8.45 a day on housing, $7.94 on food, $2.84on clothing, and $1.07 on telephone services [Figure 4-4].

 

COST-EFFECTIVENESS OFPHARMACEUTICALS

Prescription-drug therapy is highly cost-effective. Other interventions—such assurgery, hospitalization, physician visits, and nursing care—are typicallytime-consuming and expensive. Prescription-drug therapy often eliminates the needfor these costly interventions. Until cures are discovered, incremental advances indrug therapies often reduce treatment costs by controlling symptoms and alleviatingpain.

Ulcer therapy illustrates the progression of drug innovation and its ability to lowermedical costs. Prior to the advent of H2 antagonist drug therapy in 1977, 97,000operations were performed for ulcers each year.1 By 1987, the number of surgerieshad dropped to 18,926. In the early 1990s, the annual cost of drug therapy per personamounted to about $900, compared to $28,000 for surgery.2 The discovery that the H.pylori bacterium is the principal cause of ulcers has led to the use of antibiotics incombination with H2 antagonists to treat duodenal ulcers. At a cost of about $140 perpatient, combination therapies now eradicate the bacterial cause of most ulcers. Morerecent examples of the cost-effectiveness of prescription drugs include:

For asthma patients, increased drug spending keeps patients out of the hospital.Results from the Virginia Health Outcomes Partnership program for Medicaidasthma patients demonstrated an average 42 percent decline in the rate ofemergency room and hospital urgent care visits. In a little more than one yearafter the program was implemented, it saved Medicaid about $285,000. Hadthe program been in effect throughout the state—rather than in just seven

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counties—it is estimated that the savings could have topped $2 million.

In a year-long disease-management program for about 1100 patients withcongestive heart failure run by Humana Hospitals, pharmacy costs increased by60 percent, while hospital costs declined 78 percent. The net savings were $9.3million.3

●

Researchers at the National Bureau of Economic Research recently examinedthe overall costs of treating heart attacks and depression, two conditions forwhich drugs play an important role. They found that the total cost of restoringhealth for heart attack patients has fallen by about 1 percent annually from1984 through 1991.4 Similarly, researchers found that the aggregate price oftreating acute major depression fell by 25 percent during 1991–1995.5 Thesetrends highlight the cost-effectiveness of prescription drugs and the need forhealth-care plans to examine prescription drug costs comprehensively in thecontext of the overall costs of treating patients.

●

A recent study sponsored by NIH found that treating stroke patients promptlywith a clot-busting drug not only reduces disability—it also saves health-carecosts. The study showed that while it initially costs more to treat patients withthe drug, the expense is more than offset by reduced rehabilitation and nursinghome costs.6 Treatment with the clot-buster costs an additional $1.7 million per1,000 patients. But reduced rehabilitation and nursing-home costs result in netsavings of more than $4 million for every 1,000 patients [Figure 4-5].According to NIH, use of the clot-busting drug in the tens of thousands ofeligible stroke patients could amount to savings to the health-care system inexcess of $100 million per year.7

●

A study published in the American Journal of Managed Care shows that a newdrug for migraine headaches is lowering the total cost of caring for patientswith this disease. Although drug expenditures for patients in the studyincreased, the total costs of treating these patients for migraine headachesdeclined 41 percent as a result of treatment with the new drug.8 Another studyshowed that the drug lowered lost-labor costs and reduced employees’ lostproductivity due to migraines. The benefit to employers of this reduction inlost productivity was valued at $435 per month per employee [Figure 4-6]. Incontrast, the cost of the drug was $43.78 per month. The benefit-to-cost ratiowas 10 to 1.9

●

A study released by the Agency for Health Care Policy and Research inSeptember 1995 concluded that increased use of a blood-thinning drug wouldprevent 40,000 strokes a year, saving $600 million. In economic terms, thelifetime cost of a stroke exceeds $100,000, while the average annual cost ofdrug therapy and monitoring is $1,025.10

●

In a 1993 study, cancer patients whose immune systems were weakened byhigh-dose chemotherapy were helped by a new pharmaceutical known as acolony-stimulating factor. The treatment saves $30,000 per patient in

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hospitalization costs for bone-marrow transplants [Figure 4-7].

A study published in the New England Journal of Medicine showed thatpatients on ACE inhibitors for congestive heart failure avoided nearly $9,000each in hospitalization costs over a three-year period—and that the drugreduced deaths by 16 percent. The potential savings for Americans with heartfailure amounts to $2 billion a year.11

●

A drug for schizophrenia has enabled many patients to be treated outside thehospital, in less costly settings, according to a 1990 study. The annual cost ofthe drug therapy was $4,500, compared to more than $73,000 a year fortreatment in a state mental institution. Between 133,000 and 189,000schizophrenia patients could potentially be helped by schizophrenia therapy.12

●

Patients with kidney disease who suffer anemia may be treated with drugtherapy at an annual cost of $3,600 to $4,000 a patient. Drug therapy saves$6,540 a patient in the cost of medical care plus costs associated with reducedproductivity, such as lost wages.13

●

Immunosuppressive drugs have dramatically improved the success rate oforgan-transplant surgery by preventing patients’ immune systems fromdestroying the new tissue. One of these drugs was found to shorten averagehospital stays by as much as 10 days and reduce rehospitalization after kidneytransplants. The cost of postoperative hospitalization may be nearly $10,000less for patients treated with the drug.14

●

Combination drug therapy of three medicines—including a proteaseinhibitor— can reduce the AIDS virus in many patients to undetectable levels,enabling them to return to work and reducing the need for hospitalization. Theannual cost of the three-medicine therapy ranges from $10,000 to $16,000. Incontrast, the cost of treating advanced AIDS in a hospital is estimated at$100,000 a year [Figure 4-8; also see box on HIV/AIDS in Chapter 1].

●

A 1994 study published in the Journal of the American Medical Associationestimated that a routine chicken pox vaccination program in the U.S. wouldsave $391 million annually in work-loss costs [Figure 4-9]. Work-loss costsinclude the value of work missed by adults with chicken pox and the value ofwork parents miss when their children are sick.

●

Use of a cholesterol-lowering drug in patients with angina or who have had aheart attack increases life expectancy in men and women of various ages andvarying cholesterol levels, according to a Scandinavian study. TheScandinavian researchers analyzed the direct costs saved by this therapy forpeople of different ages and cholesterol levels and found that savings rangedfrom $3,800 per year of life for 70-year-old men with cholesterol levels over300, to $27,400 per year of life for 35-year-old women with cholesterol levelsin the lower 200s.15

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The 6,595-patient "West of Scotland Coronary Prevention Study" found that acholesterol-lowering drug reduced the risk of heart attack by 31 percent and therisk of death from all cardiovascular causes by 32 percent in individuals whohave elevated cholesterol levels, but have never had a heart attack. Thesefindings showed for the first time that cholesterol-lowering drugs could preventheart disease and reduce the risk of death.16

●

The Centers for Disease Control estimates that every $1 spent on the vaccinefor measles-mumps-rubella (MMR) saves the health system $21, every $1spent on the oral polio vaccine saves $6, and every $1 spent on thediphtheria-tetanus-pertussis vaccine saves $30.17 The introduction of the oralpolio vaccine eliminated the need to build the national iron-lung centersenvisioned by the government in the 1950s, saving billions of dollars.18

●

Cases of bacterial meningitis among young children dropped nearly 80 percentover 11 years after the introduction of a vaccine, saving $135 million a year inavoided hospital costs.19

●

Bronchial-mucolytic therapy for cystic fibrosis, when used in conjunction withstandard therapies, was proven in clinical trials to reduce the risk ofrespiratory-tract infections requiring IV antibiotic therapy by 27 percent,reducing costly hospitalizations and other related medical costs.20

●

Estrogen-replacement therapy can help aging women avoid osteoporosis andcrippling hip fractures, a major cause of nursing-home admissions.Estrogen-replacement therapy costs approximately $3,000 for 15 years oftreatment, while a hip fracture costs an estimated $41,000.21

●

 

FROM THE MANUFACTURERTO THE PATIENT

The cost-effectiveness of prescription drugs—combined with a steady stream ofnew-product introductions—has contributed to healthy industry growth since 1970,when sales amounted to $6.6 billion [Figure 4-10]. Sales by research-basedpharmaceutical companies are projected to reach $134.1 billion in 1999, a 7.6 percentincrease from $124.6 billion in 1998. Sales within the United States by bothU.S.-owned and foreign-owned research-based companies account for $91.8 billionof the 1998 total. Sales abroad by U.S.-owned companies account for the remaining$42.3 billion.

According to data published by the health- care information company IMS Health,the main drivers of growth in the late 1990s have been non-price factors, includingincreased volume of prescriptions, record sales of new products and new productformulations, and the changing mix of available products being used.22 In 1998, 80percent of industry growth was due to non-price factors [Figure 4-11]. IMS datadiffer from the sales figures quoted above because they include all products on the

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market as well as added costs from drug wholesalers.

In 1997, manufacturers’ net U.S. sales of human-use prescription pharmaceuticalsamounted to $71.8 billion and was dominated by five major product classes. In 1997,the largest class was pharmaceuticals acting on the central nervous system, with$14.4 billion or 21.9 percent of manufacturers’ U.S. sales [Figure 4-12]. Over thesame period, products acting on the digestive or genito-urinary system generated $9.0billion or 13.6 percent of sales. Cardiovasculars accounted for $11.5 billion or 17.5percent. Anti-infectives sales totaled $9.6 billion or 14.6 percent. Sales ofpharmaceuticals affecting neoplasms (cancers), the endocrine system, and metabolicdiseases amounted to $12.1 billion or 18.4 percent of U.S. sales. Smaller classesincluded respiratory products with 10.9 percent of the market, dermatologicalproducts with 2.1 percent, and vitamins and nutrients with less than 1 percent.

Pharmaceutical manufacturers’ sales are mainly to large drug wholesalers.Wholesalers, in turn, distribute the products to retail pharmacies, hospitals, HMOs,clinics, mail-order companies, and other organizations that fill prescriptions. In 1998,78.4 percent of sales of human-use ethical pharmaceuticals flowed throughwholesalers, up from 71.8 percent in 1990, and 57.3 percent in 1980 [Figure 4-13].

In 1998, the retail sector—including independent, chain, food store, and mass-merchandise pharmacies—dispensed more than 2.1 billion prescriptions, according toIMS Health. In terms of dollar sales, retail channels account for over 64 percent ofdispensed prescription sales in the U.S. [Figure 4-14]. Sales by hospital pharmaciesaccount for 12.8 percent of the market, mail-order pharmacies comprise 10.8 percent,clinics 6.1 percent, long-term care pharmacies 3.1 percent, and staff-model HMOs1.5 percent. More than 90 percent of HMOs contract with retail pharmacies to fillprescriptions.23

 

COMPLIANCE WITHMEDICATION REGIMENS

Unless patients take their medicines according to physicians’ instructions andsystems are in place to guard against adverse drug interactions, prescription drugsmay not be used cost-effectively. It is estimated that only about half of prescribedmedicines are taken correctly.

Noncompliance is a costly problem—for employers, insurers, the health-care systemand, of course, patients. The National Pharmaceutical Council (NPC), an industryresearch organization, estimates that noncompliance costs more than $100 billion ayear, due to increased hospital admissions, nursing-home admissions, lostproductivity, and premature deaths.24 Noncompliance results in more hospitaladmissions, emergency-room care, physician visits, and, occasionally, surgeries.There are also serious personal consequences. For example, failure to takecontraceptives can lead to unwanted pregnancies, failure to takeestrogen-replacement medication can cause osteoporosis, and failure to take

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hypertension medicine can result in heart attack or stroke.

Compliance rates vary with the disease and setting of the patient group. According todata reported in the Journal of Clinical Pharmacy and Therapeutics, patients in homesfor the aged had relatively high rates of compliance, as did patients in the first year ofantihypertensive treatment. In contrast, patients taking penicillin for rheumatic feverhad relatively low rates of compliance.

The National Council on Patient Information & Education (NCPIE) dividesnoncompliance into two categories: acts of omission and acts of commission. Acts ofomission include never filling a prescription; taking less than a prescribed dosage;taking a medicine less frequently than prescribed; taking medicine "holidays"; andstopping a regime too soon. Acts of commission include overuse; sharing medicines:and consuming food, drink, or other medicines that can interact with a prescribeddrug.

One way to improve compliance is to provide patients with easy-to-understandinformation about their medicines. As a result of voluntary, private-sector programs,more than 60 percent of patients now receive written information about theirmedicines with their prescriptions. This percentage increases every year.

ENDNOTES

Boston Consulting Group, The Contribution of Pharmaceutical Companies:What’s at Stake for America, September 1993.

1.

PhRMA, based on data supplied by the Health Care Financing Administration,1993.

2.

"Provide Education about Congestive Heart Failure and Pump Up YourSavings," Managed Healthcare, April 1998, Vol. 8, No. 4, pp. 42–44.

3.

Cutler, D., et al., "The Costs and Benefits of Intensive Treatment forCardiovascular Disease," American Enterprise Institute/Brookings Institution,December 1997.

4.

Frank, R.G., et al., "Price Indexes for the Treatment of Depression," AmericanEnterprise Institute/Brookings Institution, December 1997.

5.

Fagan, S.C., et al., "Cost-effectiveness of Tissue Plasminogen Activator forAcute Ischemic Stroke," Neurology, Vol. 50, pp. 883–889, 1998.

6.

National Institutes of Health, National Institute of Neurological Disorders andStroke, "New Stroke Treatment Likely to Decrease Health Care Costs andIncrease Quality of Life," news release, April 22, 1998.

7.

Legg, R.F., et al., "Cost-effectiveness of Sumatriptan in a Managed CarePopulation," The Journal of Managed Care, Vol. 3, No. 1, January 1997.

8.

Legg, R.F., et al., "Cost Benefit of Sumatriptan to an Employer," Journal of9.

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Occupational and Environmental Medicine, Vol. 39, No. 7, July 1997.

Secondary and Tertiary Prevention of Stroke Patient Outcome Research Team:9th Progress Report, March 1996.

10.

"The SOLVD Investigators," New England Journal of Medicine, Vol. 325, No.5, pp. 293-302, 1991; Walsh America/PDS.

11.

Hospital and Community Psychiatry, Vol. 41, No. 8, 1990.12.

Levy, R.A., "What to Tell Patients About the Cost-Benefit of Medications,"Wellcome Trends in Pharmacy, January 1993.

13.

Showstack, J., et al., "The Effect of Cyclosporine on the Use of HospitalResources for Kidney Transplantation," The New England Journal ofMedicine, Vol. 321, No.16, 1989.

14.

Johannesson, M., Jonnson, B., et al., "Cost Effectiveness of SimvastationTreatment to Lower Cholesterol Levels in Patients with Coronary HeartDisease," New England Journal of Medicine, Vol. 336, pp. 332–336, 1997.

15.

Shepherd, J., et al., "Prevention of Coronary Heart Disease with Pravastatin inMen with Hypercholesterolemia," The New England Journal of Medicine,November 16, 1995.

16.

Medicine and Health, "Vaccines for Children Program: Bad Policy or Start-upGlitches?" August 15, 1994.

17.

Boston Consulting Group, The Contribution of Pharmaceutical Companies:What’s at Stake for America, September 1993.

18.

Adams, W.G., et al., "Decline of Childhood Haemophilus Influenzae Type b(Hib) Disease in the Hib Vaccine Era," Journal of the American MedicalAssociation, January 13, 1993, pp. 221–226.

19.

Cystic Fibrosis Foundation, "Rationale for the Use of HumanDeoxyribonuclease 1 (rhDNase-Pulmozyme) in Patients with Cystic Fibrosis,"Consensus Conferences, Volume IV, Section 1, September 22, 1993.

20.

Clark, A.J., and Schuttinga, J.A., "Targeted Estrogen/ProgestogenReplacement Therapy for Osteoporosis: Calculation of Health Care CostSavings," Osteoporosis International, Vol. 1922, pp. 195–200.

21.

IMS, IMS Retail and Provider Perspective, 1998.22.

Hoechst Marion Roussel Managed Care Digest Series: HMO-PPO/MedicaidDigest, 1998.

23.

National Pharmaceutical Council, Noncompliance with Medication Regimens:An Economic Tragedy, June 1992.

24.

Phrma: Publications: Industry Profile 1998, Chapter 4

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Chapter Five: The Changing Pharmaceutical Marketplace

 

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