Digital Doctor
If the medical team had done the usual thing, said Dr. David Jarvis, "the patient would have been dead within minutes." As he examined the hemorrhaging stroke patient who had just been wheeled into an intensive-care unit in Appleton, Wis., last spring, Dr. Jarvis recalled a warning from his medical studies. There would be lethal results
when two commonly used drugs, Dilantin and dopamine, collide. The patient had already received Dilantin in high doses to control seizures caused by pressure on the brain, and an intensive care nurse was preparing to administer dopamine, which is routinely given to patients with severely lowered blood pressure.
To make certain, "I looked it up in my Palm, right at the
patient's bedside," Dr. Jarvis said. "Then we used a different drug and kept him alive."
In the first wave of a technology innovation that many doctors predict will save lives and money, thousands of physicians like Dr. Jarvis are getting professional assistance from hand-held computers popularized by
Palm and other makers.
Proponents say hand-held computers can vastly improve patient safety by reducing mistakes that are blamed for thousands of deaths each year. So far doctors are using the devices primarily for reference, writing prescriptions and keeping track of billing data. But enthusiasts predict that eventually incorporating hand-held computers into wired or wireless networks could someday yield enormous cost savings for doctors, health plans and insurers
by reducing paperwork and expensive delays in approvals and payments. (More than 3 in 10 of the three billion prescriptions each year have to be rechecked, by some estimates, because of confusion over a doctor's handwriting or insurance rules.)
Consumers, meanwhile, might be able to avoid exasperating delays at the pharmacy if their doctors knew which drugs were covered by a patient's insurance before writing the prescription.
As with most technologies, there are possible drawbacks,
including the potential to further blur the ethics and privacy boundaries between physicians and companies that hope to cash in on the doctor-patient relationship. But despite such issues, a new industry is emerging. At least 50 companies, mostly start-ups, are responding to the trend toward the digital doctor.
Doctors as a group are a potentially receptive audience:
Industry data indicates that a full 20 percent of American physicians already carry hand-held devices, if only to keep track of schedules and stock holdings.
Some start-up companies, like ePocrates, which offers quick data on drug doses and interaction, and Parkstone Medical Information Systems, which has developed prescription-writing software, are getting help from
established companies like Palm or Microsoft — which themselves are fiercely competing to provide the basic software operating systems for hand-held computers.
Other big companies with a piece of the action include
technology players like I.B.M., Siemens and WebMD; drug makers like Johnson & Johnson, Eli Lilly, Glaxo Wellcome and Bristol-Myers Squibb, and so- called pharmaceutical benefit managers — or P.B.M.'s — like Merck-Medco, AdvancePCS and Express Scripts.
Already, 90,000 doctors have downloaded a free early version of ePocrates, the drug- reference software program for hand-held devices that Dr. Jarvis, a resident
physician at a University of Wisconsin clinic, consults to check drug interactions, appropriate doses and side effects. Several companies are introducing advanced
programs that, while a patient looks on, can let a doctor
prepare a prescription to be printed, submitted by fax or, in the future, transmitted by wireless Internet links.
Other companies are testing programs that provide patient
charts, incorporate the doctor's notes and keep track of the doctor's time with patients for billing purposes. And with an ear toward the many physicians who are put off by
keyboards and tiny screens, some hand-held units even record and take voice dictation.
"Physicians have grown up since medical school dictating or writing and not typing, said Donna Whiteford, a vice president of Merck-Medco.
Ease of use is no small consideration. Computer-challenged
physicians have raised serious problems for companies like WebMD and Medscape, which had based their businesses on the concept of using Web sites to assemble audiences
of doctors for drug advertisers. But the drug companies
discovered that their sales pitches were often seen only by computer savvy underlings in the doctor's office
who had little or no influence on the choice of drugs ordered by the physician.
The new industry based on hand-held devices may be more attuned to the way that doctors actually spend their workdays. Doctors are often festooned with beepers, cell phones and mini-tape recorders and hand- held computers, said Dr. Lloyd A. Hey.
"All those devices will eventually be consolidated into a single hand-held device," predicted Dr. Hey, a Duke University surgeon and a founder of MDeverywhere, a
start-up that offers software to help doctors keep track of billable hours.
Younger physicians in postgraduate residency programs, like Dr. Jarvis, who is 36, tend to be enthusiasts of hand-held devices — an inclination their instructors
typically encourage. One in four programs for family practice residents, including those at the Universities of Washington, Idaho, Montana and Alaska provide hand-held units for family practice residents, according to the
American Academy of Family Physicians.
That is good news for the specialized managed care companies that administer the drug-payment plans for most Americans. Merck-Medco, a managed care unit of Merck & Company, plans to connect its computers to hand-held
units and desktop PC's in 40,000 physician's offices by the end of this year, said Stephen Cohan, a senior vice president of Medco, which administers drug plans for 65
million Americans.
Merck-Medco's system is intended to let a doctor check a
patient's insurance and preferred drug prices in "real time" and send the prescription to a retail or mail-order pharmacy, Mr. Cohan said. "The faster this market takes hold, the better off we all are as part of the health care system," he said.
Dr. Elizabeth Beautyman, a Manhattan internist, has been using an earlier, less sophisticated system from ParkStone Medical Information Systems in a Casio hand-held device for about a year. ParkStone provides the insurance information for all her patients. She adds notes about prescriptions and renewals as she writes them. Then she aims an infrared beam at a nearby printer, which makes a copy that the patient can take to the pharmacist.
"I like it because it produces a legible prescription," Dr. Beautyman said. "My handwriting has deteriorated, even though I try really hard." ParkStone, which is based in Fort Lauderdale, Fla., has hired I.B.M.'s health-care
consulting unit to drum up business. I.B.M. representatives visit doctors and offer free installations of ParkStone systems.
None of the start-ups are profitable, although Allscripts, which is based in Libertyville, Ill., and collects transaction fees from doctors, said it would pass the
break-even milestone early next year.
Companies that sell hand-held units are exploring potential income sources, said Jeff Tangney, a vice president of ePocrates. They include sending advertising
messages to specific doctors from drug makers, pharmaceutical managed care companies and medical journals and deriving transaction payments from drug plans and pharmacy chains.
"Doctors are not going to pay a lot of money for technology," said Newt Crenshaw, vice president of e-Lilly, a technology venture capital unit of Eli Lilly.
"It had better be useful, it better be fast, and it better be free," he said, exaggerating only slightly .
Lilly has paid for information from doctors who participate in surveys on their hand-held units about drugs and has promoted tests of hand-held prescription
systems from ePocrates, based in San Carlos, Calif., and
Pocketscript, a start-up company based in Mason, Ohio, outside Cincinnati.
Johnson & Johnson is also helping ParkStone, which is now
available in 14 states, offer its system nationwide. It also has a marketing deal with iScribe, based in San
Mateo, Calif., to develop hand-held wireless and electronic prescription services.
But there are plenty of obstacles on the road to acceptance of hand-held devices. Jeff Jackson, a vice president of AdvancePCS, a managed care pharmacy company
that covers 80 million Americans, lists several challenges:
¶Patients covered. Physicians will want the records, insurance and prescription information for at least 6 of every 10 patients to be handled by a single device. But
pharmacy management company covers 60 percent, raising the
prospect of a doctor's having to juggle several different vendors' hardware and software. To prevent such incompatibilities, Mr. Jackson said, the industry
will need to develop unified technical standards.
¶Integration with existing systems. Systems based of hand-held devices will need to be linked to older office computer systems and be made available to staff
members who write prescriptions and keep the books.
¶Industry consolidation. "The marketplace cannot sustain 50 separate companies," Mr. Jackson said. "They will have to boil down to a few companies and more of a standard solution across the industry."
¶Cost. To reach 400,000 doctors at an installation cost of a few thousand dollars each could require $1 billion in the first 24 to 36 months, and then $250 million
annually, Mr. Jackson estimates.
But Barret Toan, chief executive of Express Scripts, another big managed care drug supplier, said it would not be necessary to put hand-held units in the pockets of
every one of the nation's 500,000 physicians in active practice. "Just 3,000 physicians who each write 4,500 prescriptions annually for Express Scripts would come to over $500 million of prescriptions," Mr. Toan said.
He said Express Scripts, which is paying transaction fees to Allscripts and Pocketscripts, had identified 35,000 high-prescribing physicians, which the company sees as an initial target audience.
There are other potential problems. Under new federal privacy rules, each patient must give consent before medical information is transmitted by any electronic means, including hand-held units. Medco, for example, says it was already checking to make sure its prescribers comply.
On another front, questions have been raised about the legality of valuable gifts, like hand-held devices and software, to physicians by cash-rich drug companies.
Pocketscripts avoids that issue by loaning hand- held units to doctors, who agree to watch a brief drug commercial twice a month.
"We don't sell any data," said Steve Burns, chief executive of Pocketscripts. "We're afraid at this point. We're dancing with the pharmaceutical companies, the
P.B.M.'s and the pharmacies," he added, and being careful not to offend any of them. |
