College of American Pathologists
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Winona, Web forge healthy connection

January 2001
Mark Uehling

No laboratory reports to mail. No one to call with lab results. No telephone tag. Nothing to fax, file, or fold.

That scenario is emerging not at Cedars Sinai or the Cleveland Clinic but at 99-bed Community Memorial Hospital in Winona, Minn. Founded in 1894, the Winona hospital has a vision for reporting lab results and communicating with patients far larger than stereotypes of small-town America would allow.

Winona is a Mississippi River town, pop. 26,683, just north of LaCrosse, Wis., and just east of Rochester, Minn. (with its Mayo Clinic). Despite a competitive environment, Community Memorial is profitable, independent, thriving. It would seem an odd place for executives from Cerner Corp. (1999 revenues: $340 million) to drop out of the sky in a Lear jet. The men and women from Cerner were not coming for the town’s Steamboat Days festival.

The Cerner people were interested in Winona’s informational plumbing. Thanks to the generosity of a local tycoon, the residents of the town are unusually well-connected, with glass fiber-optic cable and copper cable-TV wiring that connect many homes, businesses, and government offices. For Cerner, that infrastructure was an unprecedented scientific and business opportunity.

The idea behind Winona Health Online is at once grandiose and simple: Use the town’s unusual wiring to give each patient his or her own well-guarded online page on a special Web site. Let each page contain his or her up-to-the-minute, personal medical information. You just had a Pap test? It’s there. You just set up an appointment with your cardiologist? It’s there. Your cholesterol result from your previous visit? On the screen.

For their part, the hospital and Cerner stand to gain as much information as the consumer. Topping the list of their questions: Do patients’ calls decline as they can get questions answered online? Do existing patients with their own Winona medical Web pages elect to keep using Community Memorial? Winona Health Online’s backers even hope they will be able to calculate whether the project can make Winona as a community healthier than surrounding towns in the region.

"The Winona project represents the future of health care as we see it, with the consumer at the center of the universe," says Robert Watson, the Denver-based vice president and general manager, Cerner IQHealth. "When you run focus groups of consumers and frankly of physicians, one of the things that comes out of every one of those interactions is the ability to have access to their clinical data. The lab piece is very important."

"People have been talking about this for 20 years," Watson adds. "Nobody’s wanted to do it. Nobody’s taken the risk. We did it."

The ramifications for the laboratory are hardly clear at this juncture. But Denny Rollmann, administrative director of the lab in Winona, is optimistic. "This project is a way of showing that though we are a small hospital, technologically we are going to be able to do things our bigger competitors would like to do."

Rollmann reports the project was switched on in mid-October 2000. "We’re just getting going on this," says Rollmann. "We’re not at a point where we can tell you we have tons of patients or tons of lab results." So it’s too early to say whether there are lower numbers of incoming calls about Pap tests or mammograms, the only two results flowing to the personalized Web pages at this stage.

But considering the complexity of the task at hand, the fact that Rollmann reports no major problems is itself testimony to Cerner’s technical skills. The hospital has an information system from CPSI. And Rollmann and his cohorts in the laboratory had previously rigged up a Microsoft database for cytology. There was not a single piece of Cerner hardware in Winona prior to the Winona Health deal. In short, virgin territory.

Cerner predicted it would be able to work with any competitor’s product—and it did. The company figured out a way to take equipment and software from four or five disparate vendors and at least two computer networks and put it all seamlessly online for consumers.

The Winona project is being phased in. After the Pap tests and mammograms, cholesterol results and prothrombin times may be next. But does Mrs. Jones read exactly what the pathologist wrote about her Pap test? Will Miss Smith learn of her cervical cancer in her morning e-mail? No. Only good news will be conveyed by electronic mail or Web page alerts. Bad news will be communicated by a physician.

And even the good news will be managed. Cerner and the hospital realized much of the technical language in any laboratory report might be unintelligible—or upsetting. So the gynecologist or family practice physician peers at her computer screen, examining what the radiologist or pathologist has written.

Then the clinician selects one of seven canned summaries of a particular report. In essence, the wisdom of the radiologist or pathologist is translated to a level any patient can understand. It is that translated information, not the original pathology report, that arrives in the patient’s personal online health folder.

"The doctors are getting the unedited report," Rollmann explains, "and they have a series of seven different buttons they can click on that basically say ’normal Pap smear’ or any number of things they would want the patient to know in terms of followup. They can relay that information to the patient’s private medical Web page. The doctors are filtering the results so they will make sense to the consumer."

The system has been designed to elevate the needs of the health care consumer above all others. Rollmann says, "The patient is trying to figure out, ’Is this a negative Pap smear, is there some kind of inflammatory process going on, is this cancer?’ The doctor is able to relay to the patient what he would do if he were able to pick up the phone and call the patient."

Rollmann does not foresee major cost savings for the laboratory. "The price of doing a cholesterol is still the price of doing a cholesterol. You have to have a blood sample. But once we have the information, how do we get it to the doctors so that it’s in a format that makes their lives easier? How do we get it to patients in a way that makes them want to come back to our hospital laboratory?" The Winona project is the answer, he says.

And Rollmann does think Winona Health Online could simplify the process of reporting results. "It can save us time, if we get to a point where we can use this to get the results to physicians instead of printing the slips up and getting them in envelopes and putting the doctors’ names on them. We are hoping we can find efficiencies on the reporting so physicians can get their data on a timely basis."

The same is true of patients. Rollmann notes that select populations-people on dialysis or blood thinners, say-are comfortable understanding their routine lab results. "They know what their cyclosporin should run," says Rollmann. "They’re much more savvy consumers. If we can set up their personal Web site where they can put their lab results, then we’ll be able to disseminate that more quickly without a lot of work from the laboratory."

Rollmann’s colleague, pathologist William McNeil, MD, is looking forward, too, to the day when the Cerner technology is fully phased in. "I’m an optimistic supporter of the whole process," says Dr. McNeil. He supports the project’s patient-centric philosophy and hopes it serves to unite the community and cement the hospital’s reputation.

Beyond that, he is confident the Cerner computers won’t be hacked. Dr. McNeil says the same adolescent recluses who have easily penetrated computers at the FBI and Microsoft, among other victims, will not be able to break into the medical records of Winona’s residents. Some of the precautions combine the mundane-visiting a bank in town, say, and showing your driver’s license-with aspects right out of James Bond. Cerner, for example, has thumb and retinal scanners at its data bunker in Missouri.

Says Dr. McNeil on ensuring his community’s privacy: "I feel okay about that. It’s as close to being secure as you can be in the modern world. [Cerner is] doing the logical thing. They’ve hired enthusiastic hacker types to test their security. Cerner was bragging that the boys have been unsuccessful so far."

But there is concern in Dr. McNeil’s voice as he discusses the limitations of the Winona project for physicians. "We were very excited," he reports. "We got less excited as we realized it’s more limited than we initially realized. As a pathologist, I can’t necessarily call up information on a patient that I’m interested in to help me with my end of the practice."

As Dr. McNeil explains: "We don’t have an electronic medical record. It would be ideal if we could build a more comprehensive medical record on top of this patient’s page that allowed the physician to have the information they need that the patient can’t deal with." Hopefully, he says Cerner plans to expand the types of information stored on each patient’s health Web page. "Eventually," he has been told, "there will be more there that is appropriate for physicians’ needs than there currently is."

Some of the system’s design has been determined not by Cerner’s programming wizards or its executives, but by the limitations of his own hospital’s computational infrastructure. In an era where computers become obsolete more or less annually, Dr. McNeil suggests Winona’s hardware and software are perhaps not as state of the art as the cables under its streets.

"The major clinic in town," Dr. McNeil reports, "is less than innovative in its approach to information systems. The hospital and clinic are lagging behind Cerner’s abilities to control the data." The good news, Dr. McNeil says, is that "our hospital board is technophilic."

Cerner’s Watson says a patient logging into the Winona system who has been diagnosed with, say, lymphoma will automatically get news and other reliable information about cancer. A new mother will get similar material about immunizations.

That personalization extends to every area of the project. So a patient with an allergy to a particular medicine would be in the pharmacy’s computer system and, in theory, physicians who saw the patient at 4:00 AM in the emergency room would be spared from inadvertently administering that medication. A patient who had previously had extensive blood work might not need it repeated.

The community seems to understand the possibilities, Watson says. As of early December, some 450 people in the town had registered to use Winona Health Online. He’s especially excited by one piece of data: During a recent week, visitors to Winona Health Online spent an hour on average. That’s an eternity on the Internet.

The flip side of all that time online, of course, is that data are being collected about each patient as well as for each patient. So in addition to gathering information about a patient’s disease, the Cerner system will scientifically assess whether the patient had a different medical outcome than a neighbor who never logged in, or spent less time online.

Says Watson: "We created this environment so that we have the ability to do some good solid research and have an outcomes team of outside, non-Cerner professionals essentially overseeing the research. We think it’s important that one of the vendors in this field put a stake in the ground and actually take a position that a connected community is a safer and healthier community."

Cerner declines to discuss the cost of the program in Winona. But Watson can outline three distinct expenses for any hospital that wants its own Winona effort. There’s a one-time fee to set up a Web site like Winona Health Online ($50,000 to $150,000); there’s the matter of physically connecting a particular physician practice or other office to the system (typically $5,000 to $25,000 per location); and there is a fee for each consumer who signs up ($25 per user for the first year and $15 per user thereafter). Adding it all up, Watson suggests the first year might cost $150,000 to $400,000. After that, upkeep of the Web site would involve additional fees in the range of $50,000 to $150,000 annually.

In Winona, the hospital will bear most of the cost. Though the numbers are high, Watson maintains the cost is modest compared with what the marketing plan of even a small community hospital costs. "It doesn’t seem to be a hurdle," says Watson of the cost. "For a hospital, it’s clearly not an issue."

Watson admits laboratories not connected to the Internet or a hospital network may have incidental additional costs. But he says those costs for the lab should be easily recovered because physicians who order tests will prefer a connected lab to one that is not. "To the extent that a lab is enabled for electronic transactions," says Watson, "labs will want to participate in this because it has the potential to increase their volume relative to other labs that are not connected."

Watson says new customers are already on the cusp of signing up to be the next Winona. That’s because marketing costs to get one new inpatient are so high. Watson estimates U.S. hospitals typically spend $188 to attract a new patient who calls the hospital, gets a referral, makes an appointment, and is admitted to the hospital within a three-year period after an advertisement runs. (Only at that point does the hospital get a return on its investment.) "In this case, if they spend $200,000 a year with us, we can touch five, six, seven thousand patients a year in the community, nearly every day, at no additional cost."

Watson is essentially offering to create and maintain ongoing patient contacts for about $40 per patient annually, assuming $200,000 in costs and 5,000 patients enlisted, but at this early stage there are no reliable statistics about whether online-savvy registrees will use medical services at comparable rates to traditional patients. That’s a supposition that could be proved or disproved in the coming years.

For now, Watson is traveling the land making two dozen presentations monthly about the Winona technology. Interest in the Winona project is high, he says. His only concession is that projects of this type may not happen in institutions that lack a single strong decision-maker.

Says Watson: "The lab results are critical, the pharmacy data is critical, the radiology data is critical. In Winona, we got everybody to play. Clearly that is not going to happen everywhere we go. I think for this to be effective in a community, you have to have one hospital. And the hospital administrator or the chairman of the board of the hospital have to be strong enough leaders to essentially tell their staffs and the pharmacy, ’This is the right thing to do. It’s part of our mission.’"

Still, Watson can also envision a day when patients might spur hesitant labs or physician practices or pharmacies into action. "If the pharmacy is not participating, I can guarantee you that the first time a consumer walks in and says, ’You know, I’m a member of Kansas City Health Online, and I would like to be able to get my prescriptions here but you’re not participating,’ what do you think they’re going to do?"

Watson cites a recent visit to a 200-bed hospital in Indiana. "It’s in a very competitive environment. Within 75 miles of them are another 700 hospital beds in three facilities. The CEO’s view was, ’I’m interested in anything I can do that allows me to connect to my community, my physicians, my consumers, and my patients, and provide them with a service that is going to make them think of me first, versus thinking of St. Francis or whatever the other hospital is down the road.’ This is a much lower cost, much more efficient way to get more touches to the consumer."

Mark Uehling is a freelance writer in Chicago. The Winona Health Online project’s Internet address is