"Build, Be Flexible, and the Patients Will Come?" – Lessons Learned in e-Consulting

• Abstract
• Introduction
• Phase One – Online Consultations
• Phase Two – Personal Health Records
• Phase Three – Disease Management on the Internet
• Lessons Learned and Conclusions
• References

Abstract
This reflective paper documents the author’s involvement over the course of five years with Doctor Global Ltd, (www.doctorglobal.com), a small New Zealand health information technology (IT) company, that changed substantially over that period as it developed a series of excellent telehealth products that were consistently ahead of their time. The progression in the company’s business direction is described and the lessons learned by the author are detailed. It is concluded that timing the entry of new products into the health IT market, and the development of the markets themselves, are more important to a small company than the actual quality or clinical usefulness of the product developed.

Introduction
Academics such as myself, who are involved in health informatics, are frequently approached by commercial organisations for consultation and advice, both paid and unpaid. Companies generally request information about the state of the healthcare market or wish to gain access to that market via the academics’ networks and health knowledge . Most of these requests lead to some short-term communication, and possibly business involvement, but very few lead to the development of a long-term business relationship. In 1998, just after receiving over several million dollars in first round funding, Dr Tom Mulholland, the charismatic CEO and co-founder of the newly formed Doctor Global Ltd, asked me to serve as both a consultant to the company and to be the director of its mental health online clinic.

Phase One – Online Consultations
Doctor Global was originally founded as a health service company to provide general practitioners (GPs) with a facility to undertake email consultations with their patients and, in addition to provide the facility for the patients to seek a second opinion from specialists. The resulting interaction could be printed off by the patient and taken to their primary care doctor to serve as an extra source of medical advice. The philosophy was that many patients may not need to actually visit their GP for some of their health needs, and by using asynchronous communication such as secure email, the GP could organise his/her own time, and serve the patients better and more efficiently. The ultimate goal was to enable the GP to charge for these patient contacts, since at present no fee can be charged for telephone consultations despite often significant time-loss and inconvenience to the GP. The company commenced business in 1998 at a time of excitement and hope in the IT industry, before the "dotcom" collapse; a time of extravagant expectations. It intended to employ a large number of doctors to run multiple email consultation clinics, with patients paying the company for the consultations by credit card, and the company then paying the doctors a portion of the fee. I was asked to overview the quality of consultations in the mental health clinic, develop templates for these, and recruit and train other clinicians to undertake the online clinics.

I was excited by the company’s plans, which I had read in detail and impressed by the CEO and his energy and vision but decided to accept his offer only because at the time I strongly believed, and I still do, that patients will eventually use email (or secure messaging) to routinely contact their health providers, and would eventually have a proportion of their medical consultations online. Six years later, this is now a reality in a number of health systems.^{[ 1 ]}

This first phase mainly involved setting up web-based training programmes and clinical protocols to enable the secure-server-based online consultations to be performed to the highest standard. There were weekly teleconferences with directors of the other clinics (for paediatrics, general medicine, respiratory, surgery, pain, allergy, nutrition, etc) and considerable time was spent developing training consultations, which any clinicians joining the company had to undertake, and clinical questionnaire templates to automate the process as much as possible. All of the clinicians who were recruited had their photos and biographies displayed on the website; all had their qualifications checked with the relevant medical boards; and all had to agree that any consultations that they undertook could be reviewed by the relevant clinic director, or the Medical Director, as a form of quality control. The focus of the company at that stage, driven by the clinically trained CEO, was to ensure that there were high quality, safety driven, clinical systems in place, with an assumption that publicising the availability of secure online consultations would lead to their gradual uptake. The IT side of the business was relatively simple, with a strong focus on a user-friendly website that was highly secure and had good systems in place to prevent data loss, as the company was very aware that the consultations would require the storage of valuable personal health information.

Marketing the online consultation service was, in retrospect, a hit and miss affair, without a strategic focus. Initially the most successful approaches tended to involve the CEO himself, and the clinic directors, using our personal networks to get media attention, thereby going directly to members of the general public who were, of course, our paying customers. As interest grew, more and more clinicians offered their support and at its peak there were over 80 consultants who had completed the accreditation process. Presentations at conferences did not seem to have much effect, as they were made mainly to other health professionals, and it was clear early on that health departments, for both political and financial reasons, in both New Zealand and Australia were not going to pay for a "new " service such as this, nor were they even interested in piloting it.

Despite these difficulties a number of online consultations were performed with patients from around the world. The author undertook a number of mental health consultations, charging NZ$20 per consult. The process was straightforward. The patient selected their preferred provider from the relevant clinic’s list, completed a questionnaire we had designed to elicit their basic medical and psychiatric history, and then asked any specific questions that they had. When they submitted this information they were automatically transferred to the enrolment site where they entered their contact and credit card payment information and were told there would be a response to their questions within 48 hours. All of this information remained securely on the Doctor Global servers. The chosen provider was automatically emailed to inform them that a consultation awaited them on the server. The provider then logged into the server and completed the consultation, often including a large amount of pre-selected and available health information as attachments. The patient was then emailed to say that the response was available for them on the web site where they were able to view, download or print as preferred. We found that, over time, it became quite common for patients to want to send the provider a second and even third set of questions, so we finally developed a policy that a single consultation fee included up to two responses from the chosen provider.

Most of the mental health consultations involved questions about medication, so it was important to be able to quote relevant practice guidelines for the country in which the patient was living, and to tell patients to print the information and take it to their "face-to-face" doctors. Patients that the author was consulted by came from New Zealand, Canada and the UK, and, for these countries, clinical guidelines and locally relevant health information was usually available on the Internet.

Other consultations involved advice about diagnosis and, in one case, detailed questions about particular psychotherapeutic techniques. As a provider, partaking in the consultations was a fascinating, sometimes challenging, exercise that was certainly different from conventional face-to-face medical practice, but which was also clinically rewarding as several patients responded with very positive feedback and appreciation. It was also frequently uneconomic in terms of time spent and payment received, but most of the providers who undertook these consultations were doing them mainly for interest rather than financial gain.

From a business perspective, a number of pharmaceutical companies and drug distributors were interested in Doctor Global prescribing their medications online, particularly drugs for weight loss. This was happening on other websites on the Internet at the time, and has continued since, and was a controversial issue internally. Doctor Global’s experience was that it was rarely necessary to consider prescribing, and that it was a good way to get the patient back to their regular physician to recommend that they consult him / her, and ask whether a certain drug could be of value in their particular case. There were frequent consultations most likely from addicts who were seeking narcotics for a variety of reasons. In all cases we did not actually accuse them of drug abuse but gently recommended that if their pain was so bad, they should urgently seek local medical advice In fact e-prescribing was done by Doctor Global much later for the specific condition of male-pattern baldness. This was only done following receipt of a certificate from a registered GP in New Zealand. The benefit to the patient to this process was that Doctor Global had arranged a significant discount with the supplier, which was passed directly to the patient.

Phase Two – Personal Health Records
By about the middle of 2001, it was clear that there was an insufficient growth in the numbers of patients requesting online consultations to make the business sustainable. It was also evident that the company had gradually built a substantial online database structure to support, manage and record the online consultations and had, in effect, built much of what was required for a multimedia, Internet-based, personal electronic health record (EHR), which could incorporate all sorts of data files from letters to digital photos to X-rays. It was decided, therefore, to focus on the promotion of consumer-centric personal health records, which could still be used as an underlying infrastructure to support electronic consultations, but also provide the patient with a portable potentially "complete" record of their health status, from birth to death. Being patient-centric gives the consumer control over access and negates the issues surrounding the consent and privacy of such information.

For the clinicians involved in the company, this was a substantial change in emphasis. We ceased recruiting clinicians to undertake consultations and reduced the emphasis on consultations generally. Large amounts of time were redirected to researching the need for, and markets associated with, personal health records. Personally, I believed then, and still believe, that we will all have access to our own electronic health records one day, so I enthusiastically put my own health information on the Doctor Global system and carried the "Lifesaver" card in my wallet. This card was introduced as a clinically appropriate and useful way of selling the personal records and was intended to be used in emergencies, especially if the owner was unconscious or severely ill. It was designed to look like a credit card with a printed user name and password that allowed anyone reading the card to go to the website, enter the details printed on the card and access key parts of the owner’s medical record which the owner had designated as public when they entered the information – such as next of kin, medical problem list, medications and allergies.

Marketing and selling a personal health record proved to be as challenging as online consultations, but the potential markets were much bigger. There were many possible niche markets, such as a record for newborn babies to replace the traditional baby books recording length, weight and immunisation status, a diabetic record or an oncology record, as well as the generic "one size fits all" approach of a single lifetime longitudinal record.

There were many examples of the clinical value of this kind of record, but perhaps the most dramatic was an elderly diabetic woman who wanted to visit her relatives in Germany for Christmas. She was insulin-dependent and had to fly through a number of time-zones to get to Germany from New Zealand. Her own GP advised her on what to do with each meal during the flight, and when she arrived she was able to fill her details of blood sugar, etc into her EHR and it was immediately visible to her GP who was advised of her report – by regular email. Her GP, whom she trusts and who understands her condition very well, was then able to manage her diabetes through the next few days until it stabilised, and she had a wonderful and stress-free vacation. She was relieved of the difficulties of having to consult a new physician in a foreign country with all of the subtle issues of language, philosophy, etc.

Some providers were interested in the record proposal because it was obvious to them that they could transfer some of the work and cost of their practice to patients, who would have to ultimately have to pay for the record. However, the start-up difficulties of accurate data entry proved insuperable as the providers themselves had little time or inclination to transcribe old patient data from their usually handwritten clinical files, and the company did not have sufficient resources to assist in this process. Ultimately, patients themselves could be responsible for this, and recent studies suggest that increasing numbers of patients are now keeping electronic files containing their own health information,^{[ 2 ]} but in 2002 this did not seem a realistic option.

The next approach that we tried was to direct market the personal health records to patients. A contract to sell the records through a New Zealand chain of pharmacies was negotiated, but this direct selling to consumers necessitated a marketing budget that was simply beyond the financial capacity of the company, which at that stage was looking for another round of venture capital funding.

Phase Three – Disease Management on the Internet
When looking at "niche markets" for personal electronic records, particularly related to specific chronic diseases such as diabetes, asthma, ischaemic heart disease and depression, it rapidly became clear that electronic disease management was an important market.^{[ 3 ]} Business models for chronic disease management, unlike personal health records or online consultations, are increasingly well described and a number of programs exist^{[ 4-6 ]} that are specifically designed to collect patient data, analyse it and improve care by generating clinical efficiencies. Doctor Global had already developed a number of self-monitoring tools, which had been introduced early in the company’s history, and the addition of some information-based decision-support tools to the longitudinal record had essentially already created the core of a disease management record. Redeveloping the interface and adding a number of communication options such as chat rooms and voice-over IP led naturally to the development of a comprehensive disease management record, and a large contract with a US health maintenance organisation (HMO). Thus, the Doctor Global focus from 2003 has been on provision of IT disease management solutions for health groups involved in chronic disease management. With this move, and with considerable refinancing and rebadging as an IT provider, the role of clinicians in the company became minimal and their positions, including that of the author, ceased. Doctor Global had completed the five-year transition from being a health service provider to becoming a medical software developer.

Lessons Learned and Conclusions
Two key lessons have been learned through this experience:

1. The timing of any product introduction is crucial. While Doctor Global had technically excellent, high quality, useful, clinical products, the online consultations and personal health records were, in retrospect, clearly ahead of their time, and were not supported by sufficiently advanced attitudinal change and acceptance among providers or patients at the time they were introduced. It is clear that in this example the practice of "build and they will come" did not work, but in the pre-"dotcom" era of the time, before the stock market collapse, this was a common business approach.
2. Maintenance of high ethical standards in the world of health services IT is essential. It was important to resist outside forces and to focus squarely on the delivery of high quality, ethical products and services.

References

1. Liederman EM, Lee JC, Baquero VH, Seites PG. The impact of patient-physician Web messaging on provider productivity. J Healthc Inf Manag. Spring 2005;19(2):81-86.
2. Gunter TD, Terry NP The emergence of national electronic health record architectures in the United States and Australia: models, costs, and questions. J Med Internet Res. 2005 Mar 14;7(1):e3
3. Rundle RL. Healthcare Providers Let Patients View Records Online. The Wall Street Journal. June 25, 2002; B:1.
4. Barbaro V, Bartolini P, Bernarducci R. A portable unit for remote monitoring of pacemaker patients. Journal of Telemedicine and Telecare. 1997;3(2):96-102.
5. Tsang MW, Mok M, Kam G, et al. Improvement in diabetes control with a monitoring system based on a hand-held, touch-screen electronic diary. J Telemed Telecare. 2001;7(1):47-50.
6. Celler BG, Lovell NH, Basilakis J. Using information technology to improve the management of chronic disease. Med J Aust. Sep 1 2003;179(5):242-246.