Disease management (DM) vendors and providers are venturing beyond static informational World Wide Web pages on the Internet, producing interactive Web sites as DM tools. The health-care industry is catching up with the information age. In fact, MicroMass Communications spokesman Steve Sloate expects 55% growth in the next two years in DM Internet usage. For this growing use, more user-friendly, interactive, and safer Web sites/applications with additional security measures will help overcome Web fears of the past.

     Among the new uses for Internet DM are applications or programs that will allow clinicians and patients to have two-way DM communication, educational references for physicians and patients, and a growing number of ways to analyze and assess biometrics and other forms of data.

     There are a few ways provider organizations and others in the DM field are testing out the Internet. The three basic ways to post Web sites are on the Internet, an Intranet site, or an Extranet site. The Internet can be accessed by anyone who has the Uniform Resource Locator (URL) for a site or anyone "surfing" the Web. The Intranet is a more secure form of Internet Web site plugged into an existing internal network. Intranets often are used by businesses to help automate business processes, disseminate information, increase employee satisfaction, and foster a collaborative culture. An Extranet is part of a company's Intranet that securely shares part of the firm's information or operations with suppliers, vendors, partners, customers, or other businesses.

     Internet DM will bring production and delivery costs of educational materials to zero, Sloate says. Raleigh, N.C.-based MicroMass is producing its first Web application. "It [Internet] is a powerful tool for disease management," says David Bulger, MicroMass founder and chief technology officer. Partnered with the American Heart Association (AHA), the personalized DM program will be very similar to the "Committed Quitters" program that MicroMass took on in print with smoking cessation product Nicorette in April 1996. AHA's current program, "Heart at Work," will be incorporated into the Web application, whose working title now is "Change of Heart," spokesman Sam Kirby says.

     Scheduled for release this fall, "Change of Heart" aims at managed care efforts for cholesterol, hypertension, and stroke DM. Users will register for the program over the Web by completing a questionnaire and receiving a password, making their file accessible only to them.

     Bulger describes the program as a means of monitoring patients over a period of time to motivate behavioral modification as well as to reduce cholesterol and blood-pressure levels. The Internet program will act as a personal trainer/planner. Opportunities for the patient include updating biometrics (cholesterol levels, etc.), looking at their personalized calendar to see scheduled appointments with doctors, and reading electronic messages or newsletters. After six months, the program will reassess patients' status and areas of concern. An outcomes study found that people were 50% more likely to quit smoking if they used the Nicorette program, Kirby says.

Physician and Patient Education

     The first-ever pharmaceutical formulary on the Web, from Cypress, Calif.-based PacifiCare Health Systems, will return to the Internet this fall. Currently, the formulary is on the company's Intranet. It was removed from the Web until PacifiCare could meet compliance requirements for each state.

     Through the Intranet, with a connection to the PacifiCare network, initially employees (in the test phase) can use the formulary "look-up," a locator of pharmacies across the nation, anywhere. Through the locator, employees and soon members will be able to, while traveling, plug in their location and see which drugs, covered in their own plan, are offered at a local pharmacy.

     Besides the formulary, other online features PacifiCare has available include informational campaigns for health, diet, and diabetes care and a self-care program titled "Healthwise Knowledgebase." The self-care program allows members to come on the site and access symptom and treatment information concerning various diseases.

     PacifiCare executed a beta test launch of "Healthwise Knowledgebase" last March in its Colorado market. The private access for members only received excellent feedback, says PacifiCare Manager of Internet and Business Management Jeff Dailey.

     "Taking charge of your health/diet/diabetes," three new PacifiCare Web sites, contain other methods of self-care DM. The information patients retrieve may eliminate an immediate physician visit if there is some care they can administer themselves, according to Dailey. This reduces unnecessary visits to the doctors and educates patients about their own care.

     CVS Health Connection in New Bedford, Mass. involves the Internet in its DM programs. (DMN, 5/10/98, p. 2) "We use it mostly as an educational tool," Clinical Coordinator Lisa Cohen, Pharm.D. says. "The patients use the computers located within the pharmacy of the CVS, and we give them URLs to use at home if they have Internet access," she says.

     CVS shoppers who are not patients are free to use the service too, Cohen explains. For those who do not have Web access at home or work, public libraries have Internet access, but most times they charge for printing. "We allow them to print from `healthy lifestyles' sites and other selected sites for free," Cohen says.

     Rather than surf the Web, patients and shoppers visit the select Web sites chosen by Health Connection for the latest DM information, including reports on symptoms, treatment options, and medications.

Weighing Costs and Benefits

     The AHA program emphasizes intervening through dietary restrictions and exercise levels to decrease risk factors. In addition to biometric measures, these behavioral modifications play an important role in improving outcomes. After six months, says Bulger, the program can reassess patient risk and map out progress patients have made.

     Internet use drops fulfillment costs to zero, according to Sloate. The cost of paper, printing, and stamps are eliminated for whatever percentage of patients uses the Extranet at worksites or the Internet at home.

     Daniel Fell, a partner with Chattanooga's Daniel + Douglas + Norcross (DDN), an online marketing consulting firm, adds that the Internet is good for larger managed care groups such as those of Blue Cross plans, United HealthCare Corp., and Aetna U.S. Healthcare, which may have a hard time building brand loyalty. They offer call centers and nurse centers to do that and, for the same reason, they should implement Web programs that could win favor with Internet users, according to Fell. The top priority for clients is putting the basic information on the Web pages. Common requests are for electronic newsletters, directories for physicians, and sign-ups for classes, he says.

     Suffolk, Va.-based Virginia Obici Health Systems contracted with DDN to create a visual automated program for a kiosk at a local Wal-Mart store. DDN set up the experimental kiosk with a physician directory and healthy menus. The next step, according to Fell, would be to take this concept into the employee setting.

     The total Internet audience may be small now, but health-care providers should not let other organizations beat them to capitalizing on that audience, industry executives say. Giving customers access to information and allowing them to subscribe to "listservs" expands the market for managed care groups. "It's no different from a retail environment," Fell says.

     Physicians and other providers should take advantage of the captive audience in need of information and/or care. Physicians tend to shy away from the technology with excuses such as it is not secure and that their patients do not use the Internet. "However, younger physicians are adopting these technologies and see the Web as a perfect tool to complement what they are doing." Fell says.

     Home health care is also a growing market for use of the Internet in DM. Provider organizations outfit nurses with laptop computers that can access Internet resources and send them out in the field. Furthermore, according to Fell, providers could save thousands of dollars in preventive care by putting downscaled computers in homes for patients to use for education and self-care purposes.

Taking the Technology a Step Further

     StatusOne Health Systems, a new health-care technology firm, uses the Internet to help providers recognize who their high risk or "status one" patients are, says Sue Neckes, vice president of the Hopkinton, Mass.-based company. Once the high-risk patients are identified, StatusOne sends the data to clients via a secure Intranet, which also features additional useful information such as DM protocols (DMN, 4/10/98, p. 4).

     "We can work with them to develop online resources, such as pathways that can help providers better manage care," Neckes says.

     Health-care entities want StatusOne to analyze and identify patients who potentially will consume the most resources, she says. Then the health-care organizations can target those patients with their own specific programs. In addition to identifying the patients for the care managers, StatusOne helps them to develop customized resources. "It brings everything to their fingertips and opens up what they can do, instead of relying on the same few methods care managers know," explains Neckes.

     Although development of DM programs on the Web has been gradual, it has taken some leaps and bounds recently. Programs set for release in the fall, such as the MicroMass-AHA Web application and PacifiCare's online formulary will set the foundation for Web DM, or lack of response may indicate that it was only a passing fad.

     Sloate does not believe that DM on the Internet is a fad; he watches the numbers. "Today, 15% [of patients] are on the Web for these programs, and 85% are using the print versions," he says. Sloate predicts that, at the speed this technology is moving, by the year 2000 70% will be on the Web, and the remaining 30% will be using the print format.

     A few obstacles, such as security issues and accessibility, still hinder adoption of regular DM practices over the Internet. In spite of those obstacles, Web DM benefits such as low expenses, instant feedback, and two-way communication continue to encourage new Internet users and open up the possibilities of extending DM in different directions. -Shana Khan