The Electronic Pediatrician Returns

Real world medicine vs. the medical dot-coms

By Andrew J. Schuman, MD

Remember me?

Several years ago, when information technology and the Internet were young, I wrote a series of articles that was published in Contemporary Pediatrics under the banner of "The Electronic Pediatrician." These articles sought to introduce pediatricians to office computing, medical software, and the Internet. Although I enjoyed researching and writing these articles, they were not widely read, and the Electronic Pediatrician eventually faded away into oblivion. Through subsequent years I have occasionally written an Internet update, and have included sections on computer technologies and the Internet in my yearly technology update. Now that Contemporary Pediatrics has its own Web site, the editors have graciously allowed me to test the electronic waters once again to see if pediatricians would have an interest in a Web-site-only column geared to the interests of Contemporary Pediatrics' online audience. Future topics might include reviews of electronic medical records software, medical Web sites, or new personal digital assistant (PDA) technology—anything relevant to pediatric computing, medical information technology, or electronic communication.

In this first article I’ll examine the issue of the potential vs. the reality of today's Internet as it relates to the daily practice of pediatric medicine. Next month a related article will present an overview of the some of the best (and worse) medical Web sites available today.

Things have changed!

As we cross the proverbial bridge into the 21st century, pediatric medicine continues to have its joys and its hassles. Caring for children and their families is still the most rewarding part of what we pediatricians do every day, but given the growth and complexity of managed care, we spend too much of our time functioning as medical travel agents, rendering care, prescriptions, and referrals not according to our wishes or those of parents, but according to the limits and restrictions imposed by insurance companies and HMOs. Most pediatricians would agree that we continue to deliver quality care, but it has grown more and more difficult to do so.

The potential of the Internet for improving health care, simply stated, resides not in its ability to present news and information to physicians, but rather in its ability to provide a simpler and more efficient way to navigate the medical care bureaucracy. For many years we've had the technology to link Web sites securely to offline databases, and now when you place an order for a music CD, movie, or book from an online seller, inventory is adjusted, credit card numbers are confirmed and debited securely, the order queued for processing, and a confirmation sent via e-mail. When the product ships, confirmation is sent via e-mail, and your order can be tracked from the shipper’s Web site. Similarly, online banking and stock transactions are now routine, and the majority of Americans are comfortable with these convenient services. All these transactions require reliable, secure, and intelligent electronic processing. It is a relatively simple matter to develop similar Internet-based services that permit a medical office to confirm insurance enrollment, determine formulary medications available to the patient, make and confirm referrals, process specialists’ appointments, order medications from the patient’s preferred pharmacy, and track lab and X-ray results. A few progressive insurance companies have developed Web sites that can be used to confirm patient coverage via the Internet, or to submit referrals for approval, but a comprehensive medical care Web system may not be forthcoming anytime soon. Let's look at the reasons for the delay.

No more hurdles

Technological advances have not delayed this transition. Just a few short years ago there were innumerable hurdles to Internet access. Nowadays computers are inexpensive, hard drives are spacious, and Internet access is cheap and available virtually everywhere. Bandwidth is increasing, and with current technology you don't even need a computer to access the Web as many devices, including PDAs, cell phones, and dedicated Internet appliances, are now fully Internet capable. Connecting to the Internet via computer requires little technical know-how—just a modem, phone line, and the rudimentary computer skills needed to navigate a few computer screens. The point is that there are now few technical or economic barriers for patients and technologically challenged pediatricians who want to get online. The problem is elsewhere.

The wrong focus

Unfortunately, one of the biggest problems with medicine and the Internet today is that the focus of the majority of current e-health Web sites is not on improving health-care delivery, but rather on generating revenue. E-health generates revenue either indirectly, by advertising to physicians and patients, or by providing online health-related "goods and services." The medical industry is no different from any other, and an online approach makes it easy to provide universal access to medicine-related businesses with extremely low up front overhead costs. This is why there are now a number of online pharmacies competing for your prescriptions, and many dozens of patient- and physician-focused Web sites that advertise all manner of medicine-related products.

It is no accident that the infant formula companies that market directly to you and your office staff have now aligned themselves with different medical Web sites, and that these sites now are linked to online medical booksellers, medical supply companies, electronic claims processing companies, and many others. Every medical site hopes to evolve into a physician or patient portal that enables the site to capture a percentage of the revenue generated via "click through" navigation. Even the most naive physician knows that we have a Midas touch that generates huge revenues, not for ourselves, but for the medical industry by our direct and indirect effect on the utilization of medical diagnostics, referrals to specialists and ancillary medical services, and prescriptions for drugs and home-care devices. Many sites hope to change our clinical habits by marketing directly to the physician via the Internet, or hope to generate revenue by simply capturing important data regarding our online preferences. When you register for a physician Web site you provide important data regarding your specialty and your demographics, and the Web pages that catch your attention are monitored and recorded for analysis. All this information is vital to the many companies that depend on physicians directly or indirectly for revenue, and in and of itself is an extremely valuable commodity.

It comes down to this. There is little focus on migrating medical services to the Internet, because existing medical Web sites, pharmaceutical companies, insurance companies, or HMOs need to generate and retain revenues, and the economic future of all these businesses does not depend on improving patient care. Rather they want your online interest and your attention. Physicians are well aware that medical advertising supports much of our medical education, and we do need access to current information to stay informed. Personally I would utilize a medical site that is clinically useful to me and my patients in preference to one that provides information only, and I would be happy to have advertisers support this effort!

Turning things around

Clearly, physicians and patients need to wrest control of our medical care system away from the many organizations responsible for mismanagement of services. Fortunately, enough physicians and patients are so passionately dissatisfied with the existing health-care system that everyone is anticipating sweeping reform either via legislation or through consolidation and re-invention of many failing HMOs, insurance companies and medical management organizations. With appropriate (and delicate) government intervention, and the cooperation and oversight of medical organizations such as the American Medical Association, the American Academy of Pediatrics, and others, online portals will eventually appear that will enable doctor and patient to more efficiently manage patient care, and communicate more efficiently with one another. Insurance companies themselves will eventually realize the tremendous cost savings the Internet could provide, not only by reducing mailing and paperwork costs, but by speeding processing of all inquiries and requests. To achieve this, security and format standards will need to be developed, and once this is accomplished, rather than have dozens of credentialing/procedure request/referral forms, there will be universal simple online versions that should make your life and mine much easier than it is today. One can also expect that electronic medical records will become more affordable or even free, and will utilize a universal data format that will integrate Web/Internet-based patient information seamlessly. When this happens, you and I will have fewer hassles, our patients will receive better care, and we will all have a bit more free time to really enjoy the Internet.

DR. SCHUMAN is Adjunct Professor of Pediatrics at Dartmouth Medical School, Lebanon, NH, and practices pediatrics in Manchester, NH. He is a Contributing Editor for Contemporary Pediatrics.

Andrew Schuman. Real world medicine vs. the medical dot-coms.

Contemporary Pediatrics

2001;6.