Cheaper, too—you can download everything you need for free. But if you build a Web site, will patients come?
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Cheaper, tooyou can download everything you need for free. But if you build a Web site, will patients come?
By Robert Lowes
Cardiologist Kim T. Swanson of Newport Beach, CA, built a Web site for his practice in 1998. It took him 30 minutes. And Swanson didn't have to master arcane computer programming or spend a penny.
For his scant investment of time, Swanson has a Web site as sophisticated as they come. A visiting patient can read about his heart murmur, request a prescription refill, or ask Swanson for advice. Best of all, the doctor doesn't worry about the wrong eyes seeing their online communication, thanks to high-level encryption.
Swanson's experience illustrates how easy it can be to give your practice an address on the World Wide Web. A multitude of organizations will help you erect a site at little or no cost. Someincluding Salu.net, the company Swanson used, and WebMDoffer Web sites as part of a package of services such as online purchasing and electronic claims. So you can kill several birds with one cyberstone.
And vendors have dumbed down the design process with so-called wizards. Maybe you've already used one to create a letterhead or greeting card. Choose a design template and graphics from a menu of offerings, type in your name and information about your practice, type in an e-mail address as well as links to Web sites you'd like to direct patients to, and select some canned patient education material for display. Hit a button, and prestoyou're on the Web.
You have a lot of good reasons to build a virtual office on the Internet. It may attract new patients, and it can certainly help better educate the ones you have. The two-way communication possible with a Web site promises to make life easier for you and your office staff.
However, be aware that while more and more Americans go online for health information, they may not necessarily flock to your site. Swanson receives only five online messages a week from patients seeking advice. "I'm surprised that e-mail contact between doctors and patients has not taken off yet," he says.
And much of the talk about how electronic connectivity can make your office more efficient is just thattalk. Whenever one of Swanson's patients submits an appointment request online, the information must be re-entered into the doctor's practice management system. In an ideal world, the data would automatically flow into that program.
Another cold reality has nothing to do with technology. Somebody in the practice needs to maintain the Web site and respond to e-mail. Just tell that to a doctor whose staff already feels overworked.
But these are only growing pains. There's little doubt that physician Web sites will someday be as much a fixture in medicine as the telephone. Health plans are betting on this. Blue Shield of California, for example, is encouraging Golden State doctors to get a free, interactive Web site from an Alameda, CA-based company called Healinx. So for those physicians who still don't have a Web site, the question's not "Should I build one?" but "How should I build one?" After all, it's a dot-com world.
Approximately 10 percent of physicians in 1999 had Web sites, according to the AMA. While their formats vary, these sites invariably present the same basic information, outlined in a table of contents on the site's home page. Elements typically include:
Doctors' bios and photos.
The address of your office and directions to get there.
Office hours, what services you offer, the insurance plans you participate in, affiliated hospitals, how to make an appointment or request a prescription refill (possibly through online forms).
Patient resources: Articles and lists of frequently asked questions about various medical conditions, as well as hyperlinks to reputable health care Web sites.
Contact us: Many Web sites display an e-mail address here as well as a telephone number. If you invite patients to e-mail you, however, tell them to confine their messages to nonurgent medical matters.1
So who should build your Web site? To simplify the decision, nix the least desirable optionbuilding it yourself from scratch.
"Just because you're a good physician doesn't mean you can create a good site," says New York City pediatric otolaryngologist Michael A. Rothschild, who's writing a book on Web sites for the AMA. While Rothschild has constructed several sites himself, he recommends that the average physician outsource the job.
"You may have the technical ability to write HTML code (programming language for the Web), but design ability is rare, and requires training," says Rothschild. "Four years ago, good design didn't matter as much because Web sites were less common, and the bar was lower. Now, it's like TV advertising. Nobody wants to look at something homemade." Sites with neon-green italic letters on orange brick backgrounds "reflect poorly on your practice," he says. (For more about bad Web design, see below.)
However, doctors can't afford to be entirely hands-off. "Once the Webmaster builds the shell, he should teach you how to update the content, like the addition of a new doctor," says Thomas W. Ferguson, an Austin, TX, physician who publishes an electronic newsletter about online patient services called The Ferguson Report.
Another undesirable choice to create your Web site is a company that designs sites for the general business communitya toy store one day, a car dealership the next. It may give you museum-quality graphics, but does it understand the practice of medicine? Or the Health Insurance Portability and Accountability Act of 1996? This federal law requires doctors to safeguard the patient information that will likely stream through their sites. "If a company doesn't know what HIPAA means, pass it up," says information technology consultant Mark Anderson, chief executive of ARC Consulting Group in Houston.
You may have received an offer of a free Web site from a hospital or pharmaceutical company. They're inside the health care industry, but that's the problem. A seemingly generous hospital may refuse to let you post a hyperlink on your site that connects to another hospital's site. On Web sites compliments of pharmaceutical companies, if a patient clicks on an icon promising information on allergy relief, he may be whisked to an ad for the company's allergy medications. Blurring the line between objective medical advice and advertising could alienate patients, warns Michael Rothschild.
You're on safer ground choosing a Web design firm that specializes in health care. Another priority should be a firm that offers patient education resources, but doesn't compromise your reputation. Here are some designers you might investigate:
Medical Web, of Morrisville, NC, charges up to $5,000 for creating customized Web sites and another $100 per month for hosting themin other words, storing Web site files on a server, or central computer, that makes them available to Web surfers. However, Medical Web gives away simpler sites with off-the-shelf designs.
The president, Steve Malik, says his company can afford such freebies because it collects a fee every time the doctor charges a patient for an online consultation. Because Medical Web receives patient payments and cuts the doctor a check, it has the legal rightjust as a billing agency doesto charge a collection fee, according to Malik. The Web site for Medical Web provides links to physician sites it has built, so you can judge the firm's handiwork.
MediSpecialty.com, based in Austin, TX, targets ob/gyns as well as head, neck, and ENT surgeons. It charges between $300 and $600 to create a customized Web site and another $50 per month to host it. Patients who visit ob/gyn sites designed by MediSpecialty can peruse an array of educational material written by doctors. Like Medical Web, the Texas company provides and hosts rudimentary, cookie-cutter sites for free.
Physicians who register with Medscape, a free service, can make a free-of-charge Web site with a wizard. The site will allow visitors to click over not only to Medscape, but also to any other medical site a doctor cares to list. The Web site wizard also lets the doctor include a tool that creates customized directions to his office, a list of frequently asked questions, his e-mail address, and forms such as a patient history. The forms can't be submitted online, but patients can print them out.
Another option is San Francisco-based Medem, a for-profit company spawned by the AMA and six specialty societies (now 12). Medem offers AMA and specialty society members free Web sites through a wizard, stocking them with patient information from the AMA, participating societies, the National Institutes of Health, and other sources. Medem hopes to make money, among other ways, by selling space on physician Web sites for businesses to plop down their corporate logos, which would serve as hyperlinks to the companies' Web sites.
The sites are designed so that visitors won't get lost on the Internet, says Medem's CEO, emergency physician Edward J. Fotsch. If they click on an article about infertility from the American College of Obstetricians and Gynecologists, for example, they won't find themselves on the ACOG Web site. Instead, visitors remain on the physician's site. This cyber-architecture reinforces the notion that the doctor endorses the educational content, according to Fotsch. "It's only natural that you get medical information from your doctor," he says.
Physician Web sites that stress patient education, says consultant Mark Anderson, are a step up from the first generation of sites, which resembled Yellow Pages listings. Even higher on the evolutionary scale are Web sites that allow extensive online communication with patients, typically on a page within the site that only the patient can accessa personal exam room, if you will, in the doctor's cyber office.2 Vendors who offer such sites include Salu.net, Healinx, and San Francisco-based McKessonHBOC, which recently acquired a pioneering Web site maker called MediVation, in Needham, MA.
For a good example of the state of the art, visit a site from MediVation at www.martinspoint.org. You'll find yourself at Martin's Point Health Care, a 28-doctor practice based in Portland, ME. Click on the registered user's log in and then go to "Preview." Now you're in the personal Web page of hypothetical patient Jane Doe, who's just received reminders about two upcoming appointments for her breathing problem. There's also a batch of articles on respiratory disease, which MediVation automatically sends to Doe's personal page based on data in her doctor's computerized records.
Jane Doe can keep herself quite busy at the Martin's Point Web site. She can request an appointment or a drug refill, research a medical topic on a database called Healthwise Knowledgebase, or ask her doctor a question. (She can't ask about an emergency, though, according to the instructions.) The question form prompts her to give a phone number or e-mail address where she can be reached.
More than 2,000 real patients at Martin's Point have registered for personal pages on the Web site, and two-thirds have actually logged on. Of the patient messages passing through the site, 50 percent are questions to doctors, 40 percent are appointment requests, and 10 percent are prescription refill requests, says pediatrician and medical director Janice M. Wnek.
This level of interactivity promises to be the norm. Medscape says it eventually will link its physician Web sites with an online patient-record service called AboutMyHealth.net. This service was created by MedicaLogic, a vendor of electronic medical records that merged with Medscape. Integrating Web sites, AboutMyHealth, and MedicaLogic's EMR program will lead to the kind of structured communication offered by rival firms, says Medscape spokesperson Michael O'Donnell. Medem also plans to introduce such capabilities to its Web sites, although a timetable hasn't been announced.
The price tag for this fancy Web technology is all over the map. At one extreme is Salu.net, which charges doctors nothing, but instead relies on fees paid by business partners and underwriting from pharmaceutical companies for its income. In contrast, a 10-doctor practice contracting with MediVation/ McKessonHBOC would pay between $10,000 and $15,000 for the first year, and between $5,000 and $10,000 per year after that, assuming that 1,000 patients log onto the Web site in year one.
Many doctors have harbored reservations about putting an e-mail address on a Web site. For one thing, they've wondered whether communicating online with patients would get them in legal trouble. That fear, ironically, spurred Martin's Point to seek out MediVation several years ago. "Some of our doctors were giving patients their home e-mail addresses, and we worried about that," says Janice Wnek. "Would the messages remain confidential? And what if a patient e-mailed his doctor about chest pains, and the doctor was on vacation? The e-mail would just sit there."
Sophisticated Web site vendors address these security concerns in several ways. To access their personal page, patients must first type in a user ID and password. Unlike ordinary e-mail, patient-doctor messages are encrypted, or transmitted in the form of code. These precautions constitute what e-health companies call "secure messaging." Look for more and more Web site vendors to introduce this protection. And message triaging by medical office staffers lessens the risk that a doctor will fail to respond to a cry of distress.
Cardiologist Kim Swanson, who has a Web site through Salu.net, says secure messaging is secure enough for him. "I bank and trade stocks online, and encryption makes that plenty safe," says Swanson. "The way Salu.net has designed its Web sites is just as effective."
But even if online communication can be made safe, is it efficient? Many doctors fear they'll drown in a flood of e-mail. Web site vendors attempt to avoid this chaos by routing messages to appropriate destinations within a practicejust as if they were phone calls. At Martin's Point, prescription messages go to nurses, appointment requests go to schedulers, and questions to doctors are triaged by nurses.
Instead of viewing online communications with patients as one more hassle, Janice Wnek and others call it a means to avoid the inefficiencies inherent in telephone calls. In cyberspace, nobody plays phone tag, nobody gets put on hold, and nobody gets interrupted. You can answer a patient's message when it suits you.
The Web site for Martin's Point appears to be taking the pressure off phone lines. At one of the practice's offices where telephone volume has been tracked, the number of patient calls fell from 10,000 in November 1999 to 9,000 per month in the first quarter of 2000a period when volume would normally be higher than November's.
Martin's Point would run even more smoothly if information that patients submit to the group via the Web site flowed automatically into its practice management system. Instead, Martin's Point staffers must type in the data. That raises the question of whether a vendor's Web site is an integral part of a practice's information system.
Several vendors, in fact, offer physicians Web sites as part of a package of Internet-based applications that cover everything from retrieving lab results to performing billing services.3 And yes, all these applications will eventually talk to each other electronically, vendors promise.
One such vendor is MedWired, which enables doctors to design a Web site with a wizard. The Englewood, CO, company uses a new Web programming language, called XML, that allows it to create a database feeding into all Internet services on the platform, says MedWired's CEO, internist Tom Hazy. When a practice freshens its Web site with information on a new doctor, it can update an electronic billing system as well. Because MedWired is underwritten by third parties such as pharmaceutical companies and insurers, the vendor offers its Web technology to doctors for free.
WebMD provides what may be the most comprehensive electronic nervous system for practices, one that encompasses patient records, patient education, practice management, and billing. It, too, offers free Web sites, which the company intends to connect with other WebMD services without the need for entering data twice, says emergency physician Ricardo Martinez, senior vice president of health affairs.
If you had visited the Web site for The Ob-Gyn Associates in Denver this past August, you would have found 11 doctors listed. At the time, however, the practice had 14 doctors.
Therein lies a common problem for physician Web sites: Nobody's minding the store.
Group CEO Steven Ward admits as much. For a time, he had an assistant assigned to keep the site current. But when she left the practice last spring, Ward couldn't spare anyone to take over her Web duties.
"We're like most practicesreimbursements are declining, and labor costs are rising," says Ward. "It's hard enough for our staff to see the patients that walk through the door, let alone handle ancillary functions like a Web site."
Mark Anderson of ARC Consulting Group has seen scores of other neglected physician Web sites. "It's been a year since some have been updated," says Anderson. "Smaller practices especially get into a bind. They can't afford to hire a Webmaster, and the office staff doesn't know how to make any changes."
At the other end of the spectrum is Esse Health, a 68-member group practice in St. Louis. The group is overhauling its Web site, and each of its 20 offices will have its own version. A member of Esse's information services department will teach office managers how to use a software program to edit their sites.
To be sure, intelligent Web technology minimizes staffing problems. If patient e-mail about everything from medications to copayments goes to a single address at the practice Web site, then somebody must sort through the messages and forward them. But if messages go directly to the appropriate parties in the first place, nobody needs to play mailman.
Still, the staffing requirements of Web sites test a practice's commitment to this new communication tool. Martin's Point Health Care has mulled over adding online chat rooms for patients with various illnesses, says medical director Janice Wnek. However, to keep the discussions from veering onto medically shaky groundsomebody asserting that electrical shocks can cure cancer, for examplethe chat rooms need moderators, such as nurses. Right now, says Wnek, Martin's Point isn't ready to place that demand on anybody.
Doctors might dedicate more staff to physician Web sites if they derived major benefits. However, they've often been frustrated, not only by technological roadblocks such as incompatible software systems, but also by tepid patient response in some instances. Even at Martin's Point, whose Web site is showcased as a success, only a tenth of the patients who've been offered online communication log on.
"The reality is that nobody is crying for this," says Esse Health pediatrician Richard Lazaroff, who heads up his group's Web site committee. "The demand is not there yet."
Surveys would have you be- lieve the exact opposite. According to a New York-based research firm called Cyber Dialogue, 57 percent of people who surf the Web for health information want to e-mail their doctors, and 22 percent are likely to switch doctors for the sake of getting one who's accessible online.
Okay, maybe patient demand for physician Web sites doesn't always live up to the surveys. However, doctors like Lazaroff, who are technological fast-trackers, believe it's necessary to convince patients that on-line communication is a good thing.
"We can wait for patients to want these services, or we can show them the way," says Lazaroff. "It's in our best interest to show them the way, because I'd rather have patients e-mailing me than calling me on the phone."
For every Richard Lazaroff, though, there are five doctors who are taking their sweet time incorporating Web sites into their practices, a fact noted by e-health executives.
"Medical practices aren't ready for the vision we're proposing," says MedWired's Tom Hazy. "That's why a lot of them don't include e-mail addresses on their Web sites. Our goal is to let doctors adopt the technology at their own pace."
There's nothing wrong in going slow. Want to make a first, sure-footed step? Simply ask your patients what they expect healthwise from the Internet, and what they'd like you to do, says Tom Ferguson. "They'll help you figure out a strategy."
However, don't go so slowly that you succumb to inertia.
"There isn't any downside to having a Web site," says Kim Swanson. "The only mistake you can make is not having oneunless you want to stay in the Dark Ages."
1For more on e-mail and other nonvisit care, see "Re-engineering your practice: Do more for your patients by seeing some of them less," Oct. 23, 2000.
2For more on personal Web pages, see "Who'd have thought it? Patients are putting their records online," April 10, 2000 .
3For more on physician connectivity, see "Will the Internet finally put an end to paperwork?" July 10, 2000 .
No physician sites are profiled in Web Pages That Suck (Sybex, 1998), a crudely titled book that offers pointers on how to avoid bad design. But that's only because co-author Vincent Flanders didn't look hard enough. If you point Flanders to what some physicians are building on the Web, he makes snorting sounds.
For starters, he takes offense at the purple background on the site for the Watson Clinic in Florida. "That's garish," says Flanders, who also publishes a Web site echoing his book's titlewww.webpagesthatsuck.com. He's bothered even more by a big navigational button called "Section" that sits in a row with other buttons marked "Next," "Previous", and "Home." After you've done some trial-and-error exploration, clicking on "Section" usuallybut not alwaystakes you back to the beginning of one of four subdivisions of the Web site. ("For Patients" is one such subdivision.) However, Flanders had to figure that out for himself.
"If somebody's sick, he doesn't want to think about something like this," complains Flanders. "Navigational tools should be self-explanatory."
Flanders is a little more impressed with the Web site for Esse Health, a group practice in St. Louis. "But I don't like all that white space at the bottom of the home page," he says. "It's wasted. And look at the 'Whats New' button. It should be 'What's New.'"
Flanders reserves his fiercest thumbs-down for a Web site created by two entrepreneurial doctors in Illinois. Log in here, and a window pops up advertising a free e-mail service called MiracleMail. It turns out that people who promote MiracleMail this way receive a share of advertising revenue that the service pulls in. Even after you close the MiracleMail window, it reappears every time you hit the Web site's "home" button. It's the window that won't die.
"This reeks of unprofessionalism," says Flanders. "If my doctor did that, I'd be unhappy."
Sounds like Flanders has plenty of new material for a second edition of his book.
Internet addresses for vendors and medical practices mentioned in the accompanying article:
MediVation: www.medivation.com(now part of McKessonHBOC)
Esse Health: www.essehealth.com
Martin's Point Health Care: www.martinspoint.org
The Ob-Gyn Associates: www.obgynassoc.com
Kim T. Swanson, MD: www.salu.net/ktswanson
Watson Clinic: www.watsonclinic.com
This is the last installment in our series looking at how doctors are using the Internet. Below is a complete list of all articles to date. You can also find them on our Web site at www.memag.com, under "Information Technology" in the Medical Economics Library.
"The good newsand badabout Web-based EMRs," Sept. 4, 2000
"Build your own information highway," Aug. 7, 2000
"Will the Internet finally put an end to paperwork?" July 10, 2000
"How connectivity is changing practice," July 10, 2000
"Are online pharmacies good for your patientsand for you?" June 5, 2000
"Save thousands a year on medical supplies," May 8, 2000
"Who'd have thought it? Patients are putting their records online," April 10, 2000
"Help your patients surf the Net safely," March 6, 2000
Robert Lowes. Putting your practice online is easier than ever. Medical Economics 2000;23:45.