This issue focuses on the business and practice of medicine, including: A need to re-engineer the profession of cardiac surgery; a competitive market for medical services online, in retail stores (with some advice for hosiptals), and internationally. Telemedicine is a component of all these growing trends, and is itself growing in acceptance by insurers. A good EMR will be a key component of telemedicine, and this issue has some answers as to why relatively few large EMR projects have succeeded so far.

Thoracic Surgeons Radically Re-assess the Future

The stent-driven, decade-long decline in coronary artery bypass grafting (CABG) procedures, plus new techniques and technologies that will further transform the practice of cardiac surgery, will force cardiac surgeons to compete in an increasingly less-invasive world.[1] At a Society for Thoracic Surgery meeting in January, speakers acknowledged that the trend to percutaneous intervention for coronary disease is unstoppable (despite recent setbacks to the current generation of drug-eluting stents), therefore cardiac surgeons must also adopt minimally invasive techniques.

In short, cardiac surgeons must become “‘cardiologists’ with slightly more intense tools,” just as interventional cardiologists have become “‘surgeons’ with minimally invasive tools,” as one participant put it. However, they cannot simply compete with cardiologists and electrophysiologists but must collaborate with them, in a team-based approach to patient care.

Trend to Market-driven, à la carte Healthcare

Team-based approaches are to be applauded in any aspect of patient care. Unfettered market-based approaches are not, it would seem, given the societal ills we reported in the February Digest. But they continue to gain ground anyway, at least in the US. For instance, a new web site, www.carol.com, lets consumers shop for medical services such as an MRI scan, strep throat test, or annual physical, then compare quality (based on ratings by an independent nonprofit that measures provider performance) and price and make appointments. Healthcare providers who choose to be listed pay a monthly fee plus a fee for each appointment made. At its January launch, Carol.com listed 30 providers offering 350 “care packages” spread over 190 categories. They included HealthPartners, which offered more than 60 packages, and the Mayo Clinic, which offered just one — pregnancy counseling.

There were early signs that Carol was having an effect on prices. Park Nicollet had been charging $231 to treat a sinus infection; then, it saw MinuteClinic’s price on Carol.com of $49. “As a result of Carol, we will restate that payment,” Park Nicollet’s CEO euphemistically told a local newspaper. This is one reason why market-driven care advocates approve of Carol. Those who mistrust the market do not. Some agnostics say there isn’t enough consumer demand for this type of service anyway, and predict the business model will not catch on; others, including the venture capitalists who have bet US$22 million on Carol, say precisely the opposite.

Hospital Involvement in Retail Clinics

The same arguments — on both sides — have been used in the debate over another market-driven trend: retail clinics. On average, one new retail clinic opens in the United States every day. Fifteen percent of the clinics are hospital-affiliated, and the percentage is expected to grow. While convenience, cost transparency, and low costs drive the trend on the demand side, hospitals seeking to retain patients and attract new ones are helping drive it on the supply side.

HealthLeaders magazine suggests that health systems considering the retail clinic business should:

• Limit the scope of services, to ensure convenience, low-cost labor ,and low-cost space; and to limit liability.

• Analyze the target market makeup in terms of underinsured patients who overuse the emergency department for quick care but might go for a convenient, low-cost alternative, and primary-care patients who want quicker access to some types of care.

• If partnering with a retailer, choose one that offers joint marketing and branding opportunities.

• Be wary of the high cost of having physicians oversee the clinic, though in some states it might be required. The presumed higher quality of care and lower liability of on-site physicians can be achieved by good operating protocols and a limit on the types of services provided.

• Determine whether payers will cover visits – this will have a significant impact on a clinic’s success.

• Anticipate physician opposition, and aim not to compete with physicians, but to complement their business.

• Note that nurses comfortable in the hospital setting may not be comfortable in a retail clinic, so be prepared to use innovative recruitment and training methods.

• Budget about US$100,000 to open a clinic, and from $350,000 to $500,000 in annual operating costs.

If you are looking for a retail partner, you can hardly avoid seeing Wal-Mart. As of February this year, Wal-Mart had clinics in 77 stores, including nine operated by local hospitals. Now Wal-Mart has signed a letter of intent to work with local hospital systems and RediClinic to open co-branded walk-in clinics in 200 Wal-Mart stores – half of the 400 co-branded clinics it plans to open by 2010. Wal-Mart has also signed a letter of intent to partner directly with St. Vincent Health System to open four co-branded clinics in Little Rock. (Co-branding means the clinics will jointly bear the names of Wal-Mart and its partners and have an identical look, prices, and record-keeping system.) Having the local hospital system involved will increase the level of trust among shoppers, Wal-Mart believes.

Big as it is, however, Wal-Mart is not the only retail clinic game in town. Other retailers are in it, too. Three physician-staffed Medical Marts opened late last year in Meijer supermarkets in the Chicago area, and more are planned. Each clinic has two full-time primary-care physicians and two full-time medical assistants or licensed practical nurses. As the clinics grow, Medical Marts will add more doctors or nurses or assistants if needed.

The infant industry has its growing pains. Early this year, one recent entrant, CheckUps, had to shut down 23 of its clinics operating in Wal-Mart stores after running out of cash.

Personalized Medicine

Other problems with the market-based approach to patient care were insinuated at a recent conference on personalized medicine (PM). A keynoter said PM’s growth was impeded by a lack of financial incentive to develop treatments for niche markets, and a focus of private research funding on immediate impact “lifestyle” enhancements such as personalized orthopedic implant and tissue regeneration therapies rather than systemic conditions such as liver or heart failure.[2]

Those hurdles may be overcome, but it will take government as well as market action. A Genomics and Personalized Medicine bill recently introduced in the US Senate would provide money to accelerate the introduction of pharmacogenomic innovations, and the likely availability of a fast and affordable individual genome sequencing capability within the next five to 10 years may justify the use of personalized diagnostic and treatment options tailored to a patient’s specific genotype. Until then, personalized medicine will largely consist of tailored patient management schedules and “patient care navigators” who guide patients through individually tailored programs of diagnostics and therapeutics.

PM should and could also consist of giving patients online access to their medical records and doctors, as the Cleveland Clinic is doing through its eClinic system. More than five million [that’s what the Advisory Board article says] enrolled Cleveland patients can access their own medical records, learn about their health conditions, and receive advice on lifestyle and adherence to treatment regimens. They may also solicit a direct consult or second opinion or a customized course of care from an available physician, via the system.

The large set of data accumulating within eClinic lets the Cleveland Clinic further refine care by enabling it to identify common patterns among patient care management schedules and recognize potential downstream effects resulting from changes in patient care.

Medical Tourism

In a globalized world without much in the way of global governance, the global market is pretty much all there is for orchestrating patient care, and the market has begun to flex a muscle — medical tourism. A writer for HealthLeaders magazine offers some cogent reasons for believing that medical tourism is ready to “cross over to the insured population in 2008”:

1. Insurers are under pressure to hold down premiums, managed care is ineffective and unpopular, and many stakeholders are requesting coverage for medical tourism. They include employers, benefits consultants, foreign hospitals and governments, medical tourism facilitators, insured consumers, and, not least, insurers, who “sense an opportunity to increase their negotiating leverage with their existing provider networks by creating viable alternatives overseas.”

The trend has in fact begun: Blue Cross Blue Shield of South Carolina has added Bumrungrad Hospital in Thailand to its hospital network and started Companion Global Healthcare to help other health plans establish overseas networks.

2. In general, though, “mini-med plans and small employers — not big health plans and blue chip companies — will be the early adopters,” because they comprise the biggest segment of the commercial market and the one most likely to benefit. Medical tourism enables them to enhance their plan benefits, not simply control costs.

3. Opposition by US physicians will be modest, in part because medicine is already global, with global conferences, shared training, joint publishing, and a common language — English. Plus, over 25 percent of physicians in the United States are foreign-born, which means that US patients are already accustomed to getting their care from foreigners.

Another reason for muted opposition is that the pie — demand for healthcare — is growing bigger, so US doctors don’t fear loss of business.

4. Despite some inevitable political backlash, mounting fiscal pressures may force at least a few US state and local governments to “begin flirting” with medical tourism soon.

5. The direct impact of medical tourism on US healthcare costs will be much smaller than one might think (though it will make a dramatic difference for individual patients who get a US$100,000 procedure done for $10,000-$20,000.) If every US resident who could go abroad for treatment actually went, the savings on total medical costs would be about five percent – still a lot of money, but insignificant relative to the broader benefits that will accrue as the domestic industry re-invents itself to compete or collaborate globally.

Since 2004, over a thousand American patients have gone to Mexico, the Caribbean, Canada, and other sites for just one procedure alone: high-intensity focused ultrasound (HIFU) treatment of prostate cancer. They pay US$25-30,000 for the procedure, which is approved in the European Union but not in the US, where it remains controversial. But failure to compete or collaborate with such overseas initiatives could have a big impact on individual US providers, who are at risk of losing the business not only of domestic patients to medical tourism, but also of wealthy Arabs who are starting to find world-class medical treatment at home, in sophisticated hospitals built and run with the help of US medical institutions. The Cleveland Clinic was hired to develop and operate a new hospital scheduled to open in Abu Dhabi in 2011, and four Cleveland Clinic physicians and administrators moved there last year to run a 700-bed government hospital. Johns Hopkins Medicine International was also hired last year to manage a hospital 60 miles east of Abu Dhabi.

Harvard Medical School, the Cleveland Clinic, and Johns Hopkins have all been hired to plan and run facilities in Dubai Healthcare City, a 500-acre planned community intended for both local residents and medical tourists. The Mayo Clinic opened a small (one lone cardiologist) satellite office there two years ago, but business has been slow.

Aetna and Cigna Cover Telemedicine Office Visits

One way in which US hospitals could compete internationally would be by offering remote consultation and other telemedicine services. But first they have to figure out how to offer telemedicine services at home. The main holdup has been getting reimbursement, and that will remain a problem as long as the jury remains out on the lowest-hanging fruit: online doctor visits. According to a Los Angeles Times article, many patients and doctors remain uncertain whether the technology is right for them, Medicare is sitting on the sidelines, and some smaller insurers that had been reimbursing for online consultations stopped doing so because few members used the service.

But things are looking up. Early this year, two major US health insurers — Aetna and Cigna — agreed to reimburse doctors for online visits, encouraging some doctors to add video so they can see, and be seen by, the patient, rather than merely exchange emails or online forms with them. Companies such as RelayHealth and Medem are ready to help doctors arrange online visits, maintain records, and handle insurance reimbursements, patient co-payments and other payments.

Remote monitoring of EP patients

Fruit hanging somewhat higher up the telemedicine tree is remote disease monitoring. It is not so high as to be unreachable. For heart disease, for example, all three manufacturers of cardiac rhythm management (CRM) devices (Boston Scientific, Medtronic, and St. Jude Medical) sell FDA-approved wireless remote monitoring systems that could reduce capacity constraints in EP programs, free up physician time, and facilitate patient follow-up after device implantation.[3]

These networked devices not only correct abnormalities in the heart’s function but also keep physicians updated without need to bring the patient to the hospital. The doctor can better monitor disease progression via the transmitted telemetry. The reaction from patients has been “extremely positive,” one doctor told the Advisory Board.

In the long run, remote monitoring could help cut health care costs by reducing unnecessary hospitalizations and visits to the ER. Medicare has begun to pay for remote monitoring in most cases. The Cleveland Clinic has achieved “tremendous” efficiency gains since it began remote-monitoring patients, seeing them for one five-minute visit instead of three or four 20-minute visits a year.

Informed Inpatients

Telemedical technology can also benefit hospital inpatients, not just distant outpatients. The University of Pittsburgh Medical Center has been pilot-testing “smart” patient rooms equipped with computer screens that can identify staff who enter the room (via ultrasound devices worn by the staff) and display vital signs, medications, and other information, including reminders to patients to ask for help in getting out of bed if they are at risk for falls. A spotlight focuses on the hand sanitizer dispenser when people enter or leave, reminding them of the need to wash their hands.

Inside the smart room, access to patient information is customized based on a the staff member’s need to know the data. For example, a phlebotomist coming to draw blood would see only current lab orders and allergy information. Staff must ask the patient’s permission before accessing detailed health information stored in UPMC’s electronic medical record (EMR) system.

After unsuccessfully seeking a partner for the project, UPMC developed the smart room concept on its own in about six months. Some physicians have been enthusiastic, while others are “waiting to see.” Patients have generally liked it. The system is still being fine-tuned based in part on patient feedback, and new features — including reminders to patients of when their next medication is due, or to staff that a patient needs to be turned to prevent bedsores — are being added.

Why So Few Successful EMRs?

UPMC, and our own Detroit Medical Center (DMC), are among the fewer than five percent of hospitals that have a full-featured EMR and clinicians who routinely enter orders by computer. Why so few, after a decade and billions of dollars worth of effort? asks a contributor to the American Hospital Association’s Most Wired magazine. The reason, he opines, is because the sellers and buyers of EMRs — vendors and C-suite hospital administrators — have never practiced medicine, and therefore have “no concept of what it is like to take on the daily responsibility of making multiple decisions that affect people’s lives and health, and to be held fully liable for every single action.”

“The solution to clinician adoption of information technology,” he writes, “does not lie in the electronic reproduction of presumed workflows but rather in the support of physician and nursing ‘thoughtflow,’ a true understanding of how clinicians access, assess, prioritize and act upon data coupled with an understanding of the responsibilities and magnitude of consequence that comes with administering care.” And since “only clinicians can determine and describe thoughtflow,” today’s non-physician-designed EMRs “only make clinical care more complicated and cumbersome.”

Therefore, clinicians “must move from a position of occasional consultants to the leaders in clinical information system design,” and C-level administrators, vendors, and developers must “not just seek input from physicians and nurses—they must rely on and be fully led by it.” (I cannot resist remarking, with pride, that this has been and continues to be the case at the DMC, which undoubtedly accounts for the rare but unquestionable success of its EMR implementation.)

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Cleveland Clinic’s 2008 Top Innovations List

Here is the Cleveland Clinic’s second annual (2008) list of innovations predicted to have the biggest impact on healthcare. The list consist of “significant technologies that will help to fight many conditions for which there have been limited or non-existent treatment options.” To qualify for the list, an innovation must:

• Have significant potential for short-term clinical impact (either a major improvement in patient benefit or an improved function that enhances healthcare delivery),
• Have a high probability of success,
• Be on the market or close to being introduced, and
• Have sufficient data available to support its nomination.

And the 2008 winners are:

1. Flexible intralumenal robotics (robot-assisted catheterization)
2. Percutaneous aortic heart valves, delivered via catheter
3. RNA-based therapeutics that target a protein carrying bad cholesterol and triglycerides
4. Genetic testing
5. New anticoagulant drugs
6. Nasal drops that deliver flu vaccine to infants
7. Image fusion (e.g., PET + CT) for diagnostic and therapeutic use
8. Neural implants to restore movement to patients following spinal cord injuries, stroke, ALS and other central nervous system injuries
9. Tissue-engineered cartilage implants for joint repair
10. Dual-source CT

The Clinic’s first list, covering 2007, was:

1. Cancer vaccines (and indeed, Gardasil turned into a huge success)
2. Designer therapeutics to block receptor activation, resulting in: reduced drug side effects such as constipation and nausea; control over the body’s stress response to mediate eating and smoking; and increased good cholesterol levels
3. Neurostimulation for psychiatric disorders, such as deep brain stimulation (DBS) therapy for treatment-resistant depression and treatment-resistant obsessive-compulsive disorder
4. OCT (optical coherence tomography) for the noninvasive diagnosis and treatment of eye disease
5. Bronchial thermoplasty (BT) therapy for asthma
6. Ranibizumab to inhibit uncontrolled blood vessel formation in the eye, which is the primary cause of age-related macular degeneration, the leading cause of new blindness in older Americans
7. Endografting to treat vascular disease, such as thoracic abdominal aneurysms
8. Targeted cancer therapies for advanced cancers such as renal cell carcinoma
9. A left ventricular assist system (LVAS) that senses when to increase or decrease the rate of blood flow
10. Convection-enhanced drug delivery to administer medication directly to the site where it is needed, reducing side effects