Physicians Are Using Technology for Their Patients and Their Practices
Cover Story -- April 2001
By Laurie Stoneham
Until a few years ago, Kenneth Griffith, MD, thought PDA stood for "patent ductus arteriosus." Now he uses his PDA -- that's "personal digital assistant" -- every day to write prescriptions, check drug interactions, and be a hero with his patients for knowing exactly what drugs are on their formularies, saving them a trip to the pharmacy, and making the business of prescribing medicines a high-tech, hassle-free service.
For links to Web sites about technology in the medical workplace, see MedBytes in April 2001 Texas Medicine.
And Dr. Griffith is no maverick. Texas is populated with technologically adventurous physicians. We have Web masters, software developers, electronic security consultants, and computer entrepreneurs within our midst.
Some physicians are using the Internet to offer virtual consults, answer patient questions, and even provide in-depth wellness information. One physician is heralding the use of the Internet to eliminate the hair-pulling hassles of checking plan eligibility and other managed care time zappers. Another talks to her computer to manage her paperwork. Yet another young internist employs optical scanners, infrared printers, and an entire electronic medical record system to take care of patients in a paperless office.
Now, who said that physicians aren't embracing technology? Poppycock!
PDAs and precise prescriptions
Dr. Griffith loves to surf the Internet for new information and ideas to improve his solo family practice in Houston. He had used PDAs and was familiar with the available prescription-writing systems, some of which he'd tested over the last several years. Then, last spring he received an e-mail ad from ePhysician explaining that the service was compatible with a diverse number of practice management systems. And the offer included a free handheld computer.
Dr. Griffith says that because the computer links with his billing software, he was able to begin writing prescriptions for any patient he's ever seen. "It is incredibly easy to use and was obviously designed by a doctor who understands a doctor's work flow."
In practice for 30 years, Dr. Griffith says he literally taps out prescriptions on his handheld computer instead of using a pad and pen. Using the PDA stylus, he taps on the appropriate strength and quantity of the medication and then taps on applicable usage directions. Many of his most popular prescriptions are stored in memory and require only one tap.
He then asks the patient what pharmacy he or she uses. If it has changed from previous visits, he simply taps on the new pharmacy. Addresses and telephone numbers of all the pharmacies close to his office are stored in the PDA database.
Then, he can either print the prescription for the patient to take to the pharmacy or fax it to the pharmacy by putting the PDA in its cradle and pressing the "send" button. "It's a piece of cake," he said.
The service automatically checks for drug interactions. Prescription-writing accuracy is one of the reasons Dr. Griffith decided to incorporate this technology into his practice. He cited the 1999 Institute of Medicine report that estimated preventable medical errors result in up to 98,000 deaths annually, many caused by errors in interpreting handwritten prescriptions. The report goes on to estimate that computerized physician order entry systems could reduce adverse drug events by more than 50 percent.
"It eliminates a whole bunch of calls we used to get from the pharmacies," said Dr. Griffith. Because patient insurance plan formularies are built into the system, no staff time is spent on determining if the medications are covered. "It saves time, it provides a way to have better organized prescription records, and it impresses the patients that we're doing something that saves them time and effort."
A large family practice outside Dallas has been totally computerized for about three years. But David Bragg, MD, says it falls short of being paperless "because the rest of the world isn't paperless." Still one of the two offices of the 21-physician Family Medical Center in Garland relies on an electronic medical charting system to improve the efficiency of care. Nurses enter most the data.
Patients "love it," said Dr. Bragg, who was worried at first about computers in the exam room being impersonal . "If a patient asks a question about something in his chart, I can find it in three seconds."
The information systems officer for Health Texas, a network of 300 physicians, Dr. Bragg adds that converting from paper charts was no easy task. "The start-up and training were intense. It took about three months to get the system in place and then a good six months for everyone to be totally comfortable with it."
The initial investment of about $30,000 per physician was substantial. However, the system eliminates $1,200 in monthly transcription costs and has reduced office staff by one and a half positions.
In practice not yet two years, Jennifer Jordan, MD, of Dallas, is poised to jump into the electronic medical record (EMR) world in the near future. But for now, she's not convinced the technology is where it needs to be, and the cost is prohibitive for her fledgling practice.
However, she uses voice recognition software for managing her documentation. With a $100 software known as Dragon NaturallySpeaking, Dr. Jordan speaks into a microphone attached to her computer twice a day to take care of her paperwork. It's set up so that she can say a couple of words and the system will type out an entire line. She says the system is "very worthwhile" and simple to operate.
While her exam rooms are already wired for an EMR system, Dr. Jordan says she's waiting for people to have long-term experience using them in the office setting before she takes the plunge. "The people who are marketing these systems are not stupid. They cost big bucks and require lots of training. And until I have assurances that the patient information will be safe and stable, I'm going to hold off on the investment," she explained.
On the other hand, she does have her own Web site ( www.whiterockent.com ) that answers questions about audiology, sinus disease, and allergies, and provides basic surgical information. Not only does this save time and effort in communicating with patients, but also Dr. Jordan says she receives referrals through Web sites that list sinus specialists.
Web referrals and consultations
Without a cell phone, PDA, and pager, Dr. Jordan wouldn't be able to keep up with her physician-partner and husband, William P. Adams Jr., MD, a plastic surgeon who has a clinical practice based at The University of Texas Southwestern Medical Center at Dallas.
Dr. Adams' PDA manages both his personal and professional schedules. His staff creates his surgical, office, and personal schedules on Microsoft Outlook, which is then linked with his PDA through its cradle, "so I know three weeks down the line exactly what I'm doing." With his Palm, he can also transmit information to his nurse or wife.
And while the PDA is helpful in managing his day-to-day responsibilities, Dr. Adams says the Web site he set up himself, www.dr-adams.com , has helped to build his practice. He figures that 30 to 40 percent of his cosmetic patients come directly from the Web. Recently, he has added a "virtual consult" feature to the site, which allows patients to send him a template of photographs and exchange information as though they were visiting in the office.
Getting ready to practice
A general surgery resident at The University of Texas Medical Branch at Galveston, Joseph Naoum, MD, also is honing his skills as a Webmaster. His site, www.healthevolution.com, is dedicated to providing patients with the latest information in a way that is simple and easy to understand. Everything from drug mechanisms to surgery and wellness basics is written at a fifth-grade level and in simple terms, says Dr. Naoum. His goal is to expand the site within the next two years to cover more than 500 different topics.
He sees this part-time effort as a terrific way to attract patients and help them to better understand their health. Dr. Naoum thinks it will also help him build his future practice by attracting more managed care contracts after he completes his training.
Software developer and Web guru
Vince Iannelli, MD, says he grew up with computers. He's been developing PDA software for several years. They're mostly databases, he says, which physicians can download from his Web site, www.keepkidshealthy.com. These programs include everything from immunization schedules, which 10,000 physicians are using for free, to formulas for calculating intravenous fluids and body mass index.
Dr. Iannelli, a pediatrician in Rowlett near Dallas, uses a PDA to take notes on journal articles. His handheld device is also loaded with two reference tools -- The 5-Minute Clinical Consultant and Physician's Desk Reference -- which he relies on occasionally to verify information.
But his first love is the Internet. In addition to his own site, which receives about 4,000 visitors a day, Dr. Iannelli also runs the pediatric site for www.pediatrics.about.com. And despite this fairly heavy traffic load, he receives only five to 10 questions a day, which he says are easy for him to answer on a daily basis.
Cyber security expert
Cyrus Peikari, MD, has an outpatient clinical and hospital internal medicine practice in Dallas. But that's just his day job. During his off hours, this technophile maintains his own Web site, where he delves into the security and privacy issues of health care in the electronic world. He's also developing encrypted messaging software that will allow physicians to communicate securely with patients and colleagues.
Dr. Peikari, a member of Texas Medical Association's Virtual Advisory Committee to the TMA Council on Communication, believes the confidentiality component of the Health Insurance Portability and Accountability Act (HIPAA) is about to turn health care communication on its ear.
While the proposed regulations issued in December have not been finalized and are still under review, Dr. Peikari says the outlook is dire and far more serious than most physicians realize. "HIPAA is every doctor's worst nightmare and they don't even know it," he said, adding that the 1,535-page privacy regulations "will be the biggest fiasco health care has seen . " Dr. Peikari suggests that complying with the regulations is far more complex than physicians currently understand and will require a complete overhaul of how all records are kept, including paper charts.
While the government estimates that getting the entire health care system compliant by Feb. 26, 2003, will cost $3.5 to $4 billion, Dr. Peikari notes that the American Hospital Association thinks that figure is ridiculously low. He estimates the final tab will range in the neighborhood of $30 billion because of system changes, software needed, and implementation of new procedures regarding the exchange of information.
The American Medical Association says the administrative costs and burden haven't been calculated adequately. "The cost estimate of $4,000 for small physician offices seems absurdly low," the AMA said in its January 2001 Preliminary Assessment of Final Privacy Rules .
The intent of the law is to protect patient privacy and confidentiality. As currently modeled, internal policing of these procedures must be implemented by assigning a staff person to monitor adherence, and noncompliance could result in steep fines or even land a physician in jail. Dr. Peikari says that's the piece that's most disturbing. "You can't argue with the regulations when there's a jail sentence waiting for you if you don't comply."
Because of the snarled nature of these regulations, Dr. Peikari and VirusMD are offering consulting services to help physicians and other organizations become HIPAA compliant. Dr. Peikari can be reached at email@example.com or at (214) 807-7306.
One of the most practical applications of the Internet for physician practices is using the medium to verify insurance information. Stan Pomarantz, MD, is showing physicians in the Dallas-Fort Worth area how to take advantage of the technology to reduce administrative hassles. WebMD, a major consumer health care Web site, now offers physicians a way to verify eligibility, make referrals, and check claims status. The participating plans that are currently offering some or all of these administrative services are Aetna, Humana, CIGNA, PacifiCare, UnitedHealthcare, and Prudential.
Working as a consultant with Humana's e-commerce team, Dr. Pomarantz says Dallas is a pilot market for Humana and WebMD to jointly market these services. Physicians can sign up and use the service at no cost for participating plans. "What typically took 15 minutes to do by phone is now being done online in about 30 seconds," Dr. Pomarantz explained. Through the end of January, more than 2,600 of the 7,800 physicians in the area were using the service, which the plans are underwriting because it's more efficient for them also.
"It's a cultural shift from paper, fax, and phone to Internet connectivity," said Dr. Pomarantz.
Doctors and technology: an uneasy courtship
Health care is one of the last frontiers for technology to conquer. There are many philosophies as to why this is so. Most physicians say they're unsure of the technology, both its operation and long-term viability, not to mention the cost. Scott Yates, MD, MBA, who has a fully electronic office (see "The Paperless Office") in The Colony near Dallas, suggests "the biggest fear physicians have is writing the check."
Dr. Peikari, who has a degree in electrical engineering, thinks his fellow physicians typically lack a technological mindset. "Even getting them to double-click is a challenge."
Physicians, like everyone else, have trouble deciphering trends, learning what's available, and determining whether the expense and effort are worth the investment. TMA is helping members wade through the maze.
"We're looking at the rate of technology absorption, what it means, where it's useful, and where it's not useful," said Louis J. Goodman, PhD, executive vice president of TMA. "We're looking at what makes sense for the doctor and the patient." The organization is bombarded by everything from Internet portals wanting links from the TMA Web site to endorsement-seeking product manufacturers. Dr. Goodman says that distinguishing the toys from the viable technology is not an easy task.
"It's exciting on one hand and frustrating on the other because the promise of the technology is certainly there and it's moving very rapidly," Dr. Goodman emphasized. "But the litmus test we have to apply to every one of these new technologies is determining whether it's better than the way it's being done now, if it's truly cost effective, and whether it will save time or provide better information."
Dr. Bragg says there's not going to be a perfect time to find the perfect product in an evolving marketplace. "You've just got to dive in and go for it," he said, "and find out how to put it to use for you and your practice."
TMA Advantage: Tools and answers on the TMA Web site
The paperless office
April 2001 Texas Medicine Contents
Texas Medicine Main Page