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The Internet and Disease Management - Vince Kuraitis
The Internet and Disease Management - Vince Kuraitis
Vince Kuraitis JD, MBA is Principal of Better Health Technologies. Vince has 19 years diverse experience in health care business development, operations, management consulting, and marketing. His experience spans over 80 different health care organizations, including disease/care management companies, hospitals, health plans, internet health companies, and physician groups. Vince's education includes MBA and JD degrees from UCLA, and a BS degree in business administration from USC.

Better Health Technologies (www.bhtinfo.com), a consulting/business development company, focuses on disease management and Internet health. BHT’s expertise relates to business strategy, design of business models, and partnership development. BHT publishes an e-newsletter with 2,500 subscribers in 27 countries. A free subscription is available by sending an e-mail to subscribe@bhtinfo.com.

Recent client projects have been with established health care organizations and pre-IPO companies. Established organizations include: PCS Health Systems, Varian Medical Systems, Disease Management Association of America, VRI, Washoe Health System, S2 Systems, CorpHealth and Centocor. Pre-IPO companies include Life Navigator, DiabetesManager.com, CogniMed, Caresoft, Benchmark Oncology, SOS Wireless, Click4Care, and Adaptive Learning.

Vince Kuraitis, Principal
BETTER HEALTH TECHNOLOGIES, LLC
Disease Management and Internet Health
Consulting and Business Development
(208) 395-1197 (208) 361-0039 fax
www.bhtinfo.com vincek@bhtinfo.com
To receive our free e-newsletter: subscribe@bhtinfo.com


Question 1 - Everyone talks of the internet as the great equalizer in dissemination of healthcare information and in treatment.

How can the internet be effectively used for disease management in rural areas? I'm thinking of the issues involved where the telecommunications infrastructure is simply not there (or it is very limited) and the costs of access are astronomical.

What steps should states take to ensure the integrity and quality of information transmitted over the internet, particularly when it is dealing with treatment or diagnosis? by hanson on October 16, 2000

Answer 1 - Good morning Ardis. While I'll try to tackle your question, I'll certainly note that it's pushing the boundaries of my expertise.

You're right about POTENTIAL value of the Internet in rural areas. The lack of Internet infrastructure is very similar to the lack of infrastructure and reimbursement for telemedicine in rural areas.

There are some important differences, however. First, DM benefits in that programs are constructed NOT to cross the boundaries of "practicing medicine". Second, many Internet DM programs don't require much bandwidth.

My personal opinion is that the states should stay away from integrity and quality of information issues. More State regulation is likely to be a deal killer for DM...there is much federal legislation (e.g. HIPAA) to deal with already. DM programs need uniformity across state lines if the Internet is to be used as a means of making DM more effective. by Vince Kuraitis on October 16, 2000
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Question 2 - Good Morning Vince. As we get this forum started would you talk for a couple minutes about Disease Management. This really became a "buzz word" in the 90's, however, it has not realized all the expectations once touted. Will you give a brief history of Disease Management and where we are now? by HBInterview on October 16, 2000

Answer 2 - Good morning all, and greetings from Boise, Idaho. Apologies...I've been on the road 8 days the past two weeks and am fighting a head cold.

I'll try to share some nuggets of useful information during this week. First, when speaking of disease management, it's important to distinguish between 1) DM as a process, and 2) DM as a business model.

1) As a process, DM works! The simplest way to think about DM as a process is to think of it as proactively extending total quality approaches to the highest cost/highest risk patients in the health care system (more later here).

2) As a business model, DM has floundered. The Disease Management Purchasing Consortium tracks over 150 companies in this space. Most were funded in the mid to late 1990s, when capital was plentiful for health services companies. There are 10-15 companies emerging from this field (more later), and a distinguishing characteristic among them is their use of the Internet. by Vince Kuraitis on October 16, 2000
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Question 3 - Let's jump right into your topic, Disease Management and the Internet. How has the internet affected disease management programs? by HBInterview on October 16, 2000

Answer 3 - In a very broad sense, the Internet affects DM in two ways.

1) Efficiency. A services based approach can be made far more efficient through the use of the Internet. Patient information can be moved around more efficiently, some patient transactions can be done over the Internet, etc.

2) Effectiveness. Some (not all) DM programs can be done more effectively over the Internet. To date, DM programs have focused on only a few specific diseases -- CHF, asthma, diabetes, COPD....the list isn't long. What's in common among existing DM programs?

** Short term clinical effectiveness (with the possible exception of diabetes, which we can discuss). The goal has been to keep people out of the ER and away from hospital beds.
** Short term return on investment on behalf of the at-risk payor (NOT necessarily the patient)
** DM program programs to date have been done more "TO" patients, rather than "FOR" patients.

The Internet changes all this.
** DM programs are being built for a very wide range of conditions. For example, one company, DiseasesRx, has licensed domain names for 141 diseases/conditions.
** DM programs will be able to focus on longer term benefits. My health plan might not be very interested in a DM program that keeps my foot from being amputated 15 years down the road -- but I AM (if I'm diabetic).
** The patient is put in charge. Internet DM will be done primarily by patients and for their own benefit.

I could write for hours. by Vince Kuraitis on October 16, 2000
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Question 4 - It's no secret that healthcare has been "dragging their feet" in taking advantage the internet and that consumers are pushing healthcare in that direction. Is this same dynamic true for disease management? If so, what is being done to overcome this and if not, why? by HBInterview on October 16, 2000

Answer 4 - The Internet offers significant opportunities for patients to manage their own chronic conditions. Patients are becoming empowered with tools, technology and information to manage their own conditions.

What's new about Internet DM?

** Anytime, anywhere availability -- for patients and for their health care providers
** Information capture. Information entered by patients themselves or through monitoring devices can be stored in a data warehouse for future reference
** Longitudinal data....not just a snapshot in time, but a continuous moving picture of a patient's condition and factors that contribute to that condition
** Automating the DM process. There are many reasons that patients don't adhere to treatment guidelines. Among these is complexity and inconvenience. For example,if you are a diabetic, you have to remember to measure your blood sugar, go through the pain of a needle stick, and then remember to write down the results. What a hassle!

We are just a few years away from having this entire process automated. Eventually patients will have chips implanted under their skin that will monitor their blood sugar levels. Readings will be transmitted wirelessly. Medication adjustments will be sent back to another implantable device that will inject medication based on the latest blood sugar readings. Pretty amazing. by Vince Kuraitis on October 16, 2000
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Question 5 - You mentioned there are 10-15 companies emerging from the Disease Management field, what other characteristics besides the internet set them apart from others? by HBInterview on October 16, 2000

Answer 5 - The Disease Management Purchasing Consortium found a number of factors in common among the companies most successful at winning DM contracts from health plans:

** Direct provider interactions with patients (not just mail or other indirect interventions)
** Home education visits when needed
** Unscheduled inbound phone calls from patients are taken live
** Takes 100% fee risk or risk on a total population
by Vince Kuraitis on October 17, 2000
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Question 6 - You mentioned that health plans may not be interested in disease management programs because often the benefits are long term but the patient is interested. This significantly changes the revenue model. How do these programs survive without the help of insurance? by HBInterview on October 16, 2000

Answer 6 - DM programs of the future will be funded in at least 3 different ways:

1) By the health plan (or other financially at-risk group)
2) By patients themselves (particularly if and when defined contribution benefits take root)
3) By organizations that want to have a "relationship" with patients. This means your healthplan, hospital, pharma companies....even non-healthcare companies. From an ecommerce perspective, DM is one of the stickiest applications that can be developed...many people will visit websites every day to keep up with a DM regimen.
by Vince Kuraitis on October 17, 2000
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Question 7 - The internet is enabling us to have alot of data at our fingertips. Is there a movement to centralize the data captured with disease management programs in a way meaningful to the healthcare team and patient? by HBInterview on October 16, 2000

Answer 7 - There are 2 differing approaches to centralizing patient information:

First, there's the provider centric Electronic Medical Record (EMR) model. Some of the vendors include Cerner, McKessonHBOC, Eclipsys, SMS, etc.

Second, there over are 30 companies developing personal online medical records (see www.informatics-review.com/records.html). Leading contenders include Wellmed and Medscape. These companies are betting that patients themselves will want to maintain control and/or access to their personal medical information.

These approaches of managing patient information are parallel to the 2 evolving models of DM:
1) DM Services provided to the most at risk patients by a health plan
2) Internet DM tools used by a wide range of people and supported by an equally wide range of organizations that are trying to develop ongoing relationships with patients (e.g., hospitals, PBMs, health plans, doctors, etc).
by Vince Kuraitis on October 17, 2000
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Question 8 - How will HIPPA regulations affect DM programs? Are DM programs any more prepared for HIPPA than the healthcare industry in general? by HBInterview on October 17, 2000

Answer 8 - HIPAA dramatically affects DM programs and DM companies. There are over 3,500 pages of HIPAA regs, so I'll focus my answer to issues relating to privacy/confidentiality of data.

DM programs are at the forefront of molding and implementing HIPAA regs. Why? because HIPAA is a make or break issue for independent DM companies....overly restrictive privacy/confidentiality regs threaten to be a deal killer for DM progams and DM companies.

The Disease Management Association of America (www.dmaa.org) is the industry association taking the lead in creating a favorable environment for DM programs. DMAA has developed a position paper which protects patients' private medical information AND allows information to flow freely enough to be used by caregivers. by Vince Kuraitis on October 18, 2000
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Question 9 - If you are operating a disease management program and want to transition it to the internet, what would you need to consider? by HBInterview on October 17, 2000

Answer 9 - The best DM programs will be both "bricks and clicks", that is, will combine the best of the offline and online worlds. While there are some companies that are pureplay Internet DM, they recognize that their role is to support broader DM processes.

There are many "no brainer" activities and processes that can be made more EFFICIENT through the Internet. For example, consider providing patient education materials on a website; consider allowing patients to register and interact with your program over the web.

In the longer run, the Internet offers more strategic opportunities to improve clinical operations and transform business models. Independent DM companies are just starting to address these opportunities. For example, Accordant (www.accordant.com) is a DM company that supports people with 14 rare, chronic diseases. Accordant's patient website is a showcase! by Vince Kuraitis on October 18, 2000
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Question 10 - What are some of the common barriers when implementing disease management processes? by HBInterview on October 17, 2000

Answer 10 - I believe that in the long run, the Internet will provide it's greatest value to ehealth by supporting and coordinating the delivery of clinical care.

In the short run, however, the barriers to disease management are significant:

** Minimal reimbursement for DM programs
** Physician resistance
** Privacy/confidentiality issues
** Technology limitations
** Demographics: Internet usage is roughly inversely correlated with age, and fewer older people with chronic conditions are connected to the Internet
by Vince Kuraitis on October 18, 2000
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Question 11 - Disease Management programs have come under fire recently from physician organizations, specifically the AMA, who according to the article "A Closer Look at Disease Management" in the Physician Practice Digest called DM programs a "technique of managed care". Are physicians generally agreeable to DM programs or is there resistance and why? by HBInterview on October 18, 2000

Answer 11 In an earlier answer I referenced the need to distinguish between:
** DM as a business model
** DM as a process

Yes, physicians generally are negative about DM. As DM has been introduced to physicians, DM has been something done TO THEM rather than FOR them by health plans. While some providers have experimented with DM approaches, most formal DM programs have been introduced to physicians by health plans who have contracted with independent DM companies (see the FedEx Truck Phenomenon at http://www.bhtinfo.com/6_22_99.htm). Physicians react negatively to many current DM business models, and often never get to the question of considering whether DM as a process for improving patient care is good or bad.

Physicians are trained as scientists. DM principles are highly consistent with evidence based medicine. Unfortunately, physicians have come to equate DM with "cookbook medicine" promoted by health plans who are primarily interested in avoiding short term ER visits and hospital admits. The most successful DM programs are the ones that involve physicians early and often in their planning process. by Vince Kuraitis on October 18, 2000
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Question 12 - In your experience are free standing DM programs or those built internally (within an MCO, physician group or hospital) more successful and why? by HBInterview on October 18, 2000

Answer 12 There are success stories for many different DM approaches.

One key factor is to involve physicians early in the DM planning process. This has been done effectively by some outside DM companies, but is generally easier in programs developed by physician groups or hospitals.

Most providers have not embraced DM, particularly as the prospect of receiving capitated reimbursement has faded over the past 2 years. HCFA has a demonstration project under way in which it is experimenting with fee-for-service and other payment approaches for DM services. It's not too early for providers to begin anticipating reimbursement for DM a few years down the road.

As DM evolves, the more common approach is for MCOs to "assemble", rather than make or buy DM programs. That is, developers of DM programs are recognizing that they will need a wide variety of infrastructure and support items (e.g., information systems, patient education, clinical guidelines, etc.) that can be assembled from various vendors. by Vince Kuraitis on October 18, 2000
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Question 13 - I would like to thank you for hosting our forum this week and sharing your thoughts on Disease Management and the internet. Before we conclude, will you give us your vision for DM programs and the internet 5 years from now? What can we expect, will every DM program have an internet component and what new inovations do you forsee? by HBInterview on October 18, 2000

Answer 13 Thanks! I've enjoyed your questions and the opportunity to sit behind my desk and pontificate. :)

The term "disease management" is a lousy term, but we're stuck with it for now. DM has already migrated more to a model of PATIENT centric care -- rather than DISEASE centric care (http://www.bhtinfo.com/6_1_99.htm).

DM business models are struggling, but the process of DM offers great opportunities for improving patient care AND reducing health care costs. Some predictions for 5 years out:
** Web based tools that help patients manage their chronic diseases and conditions will be widespread.
** Remote patient monitoring devices will greatly assist in the process of automating management of chronic disease. Many of these devices will transmit biometric data over the Internet, allowing for continuous monitoring of patients.
** DM progams will be built around the Internet, but most of this will become transparent to patients and clinicians. They will access DM programs and DM data through a wide variety of Internet appliances, many of which will be remote and wireless.
** DM will be driven by patients themselves.
** DM will begin to merge with other fields such as genomics, bioinformatics, biotech. Foresightful DM companies and providers will seize opportunities to improve care and generate new revenues.

Thanks again!
by Vince Kuraitis on October 18, 2000

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