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Companies on the cutting edge have learned that expectations, whether great or small, need to be specific before you wander into the world of e-health.
Companies on the cutting edge have learned that expectations, whether great or small, need to be specific before you wander into the world of e-health.
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Thinking about how the Internet could fit into your benefits package? Contemplating a health care site on your company Intranet? Talking to ASPs (application services providers) about a corporate-branded health care portal? Stop where you are, and ask yourself: "What is my purpose in going electronic? What advantages does a virtual solution offer that an off-line, traditional solution doesn't?"
Those are the essential strategy questions for any e-health endeavor, says George Pfieffer, president and founder of The WorkCare Group, a Charlottesville, Va.-based supplier of on-line health and productivity services. Pfieffer thinks the best reason for developing an electronic presence is to build a cross-functional platform for human capital management. "Data exchange is key," he says. "Now your health benefits guy, your retirees guy, your HR guy, your occupational health and safety guy, your wellness guy, etc., can all provide content, share data and do a far more efficient job at managing work/life issues."
Whether your goal is a web-enabled human capital management system, a more cohesive demand management program or simply ensuring that employees know where to find reliable health information on the Internet, it's crucial to have a strategyor at least to recognize the need for one thingsays Chuck Reynolds, a principal of The Benfield Group in St. Louis, Mo. (See "Getting your head on straight" below.) Don't jump into the web just because competitors have or because of some misguided sense that building an Internet health solution is what good corporate citizens are nowadays obliged to do.
Both Reynolds and Seth Serxner, senior vice president at StayWell, a San Bruno, Calif.-based on- and off-line wellness solutions provider, caution against relying on an e-health bullet to slay all health care benefit bugbears and bêtes noires. "E-health is a subset of, not a substitute for, overall health management. Virtuality can't do everything," Serxner contends, "and the Net can't by itself solve the employee health management crisis. However, it can be a very useful tool for the improvement of health communications, population health management, disease management, risk management and productivity management."
Savvy employers see a number of promising tools in the Internet's grab bag of health care applications, including:
What do the corporate Intranet health sites look like? Some are of the prime vendor modeHRA, health news, disease and self-care information, etc., brought to you by a MayoClinic.com or a DoHealth.com or a GlobalMedic.com, but customized and branded with an employer's logo. Other employers have taken the multi-vendor approach, pulling an on-line wellness program from one, an HRA profiling system from another and assembling the parts into an Intranet health site.
Vetting the vendors is a serious task for both those strategies, if only because putting the corporate brand on the site means the employer is in some sense vouching for content. Partnering with reliable third parties has become even more critical as highly touted sites expose shaky financial foundations, dubious Net ethics and inadequate privacy safeguards.
The third option has been to leave the e-health driving up to health plans and insurers. Employees are then invited to "go direct" to their plan's web site to sample on-line products and services. In fact, even corporations that have opted for strategies one or two are still requiring that their plans have an e-health strategy.
So, do the plans in fact have e-health strategies, capabilities, offerings?
"They are all over the place," says Barbara Brickmeier, director of benefits at IBM in Armonk, N.Y. "We used to talk about human years, then dog years, now we talk about web years. A web year is like a monththings are moving that fast. Some plans have a very strong commitment in terms of labor and capital investment. Others don't have a clue."
"Our [employer] clients are now looking at their health care vendors in a very different way," notes Randall Abbott, client strategies leader, Watson Wyatt Worldwide. "Employers now want plans to be technology partners as well as vehicles for providing broader employee health care.
"For example, if I'm an employer and my internal technology is limited I may want the plan to make the technology investment I can't afford to make. We are working with a financial services corporation right now that has asked us to benchmark the major commercial carriers and look at their overall technology architecture, the security they have to protect data, the way they interchange data, their e-commerce philosophy, their point of view on employee self-service (making physician appointments on-line, for example). That's indicative of the kind of in-depth investigation now going on."
Vetting, evaluating and benchmarking e-health solutions have become major corporate HR preoccupations. A typical example is supplied by Judy Webster, director, corporate wellness, Applied Materials, Oakland, Calif. "We're very employee-needs based," Webster notes, "so, first thing, we found out what the customersour employeeswanted from an Intranet health care site. Then we tried to balance those desires against our own ideas of what we should be supplying."
Using employee survey information, Applied Materials went to the vendors and asked about access, content and security as well as management concerns like cost and reputation. "Then we asked to beta test the site," Webster continues. "That's where we'll investigate the depth and reliability of the content, the kinds of transaction available, the security level. If we still like it, we'll then ask that some of our employees be able to try it out. Do they like it? Do they come back to the site? Is the information kept refreshed? Sites that make the cut are then asked to go through an RFP process."
IBM has applied new technology to the next step with an on-line bidding process for health plans. "We use this to short-circuit the arduous, interminable, wish-you-were-dead horror of health plan negotiation," explains Barbara Brickmeier. "But understand that the bidding process is not an auction. Not every plan can submit a bid, nor is the lowest bidder automatically the winner."
To be invited to bid, plans must first submit an RFP package to Hewitt Associates, the benefits consultancy assisting IBM. The RFPs look into financial viability, accreditation profiles, benefit offerings, administrative structure, customer satisfaction and provider networks. Based on these data, the plans are given weighted scores. For example, price per employee might be a 30 percent determinant of the contract decision, with quality being 70 percent. The low-cost plan is not guaranteed to get the highest IBM contribution. The optimal strategy is to subsidize the plan where quality, service and satisfaction are highest, even if that plan has a higher per-employee cost.
Brickmeier says IBM has completed on-line bids in 14 markets (including Arizona, northern and southern California, and New Jersey) involving 66 plans. The company not only saved time and conserved HR resources, it also shaved about 1 percent off the estimated premium without the on-line effort.
Other major corporations have begun to use an on-line HMO bidding process. American Airlines, for one, has claimed it has saved nearly 2.5 percent using an on-line auction to negotiate rates in California and Texas.
Of course, having an e-health presence means nothing if your employees don't have access to the Internet. Ford has a better idea here.
"Every active Ford employee is eligible to receive a computer, printer and monitor," says Denise Clement, MD, Ford's director of health care quality assurance. The free technology program rolled out at Ford's Detroit headquarters in early June. Employees pay only a $5 per month fee for the Internet service provider access. "We want employees to become more familiar with the Internet for a whole variety of reasons," says Clement, "but ready access to wide varieties of health care information is certainly a critical consideration."
Once the employer site is up and running and employees have access, building awareness becomes critical. Health care sites don't sell themselves. To ensure utilization and return visits, "you need to do some internal marketing," says Neil Sullivan, corporate implementation manager, MayoClinic.com.
Laura Cioffi, health promotion manager at the Murray Hill, N.J.-headquarters of Lucent Technologies explains how a reporting application drives her company's efforts: "It's updated daily; it tracks registration, as well as which parts of the site are being visited. So I can get a clear picture of what's working and what may need a promotional boost." Lucent has used both print and electronic media to promote the site and specific elements, such as smoking cessation."
For some employers, the Internet's broadest strength is its sheer availability24/7 with no additional charge for the overtime. Moreover, the Internet's data tracking, storing and manipulating applications form a potentially inexhaustible mine of information. You just need to explain to itpatientlywhat you want to know and how you want that knowledge presented. The Internet is also an efficient, inexpensive and tireless dispenser of information. Whom do you want to inform, what do you want them to know, how often do you want them to know it? Answer the first question, and the other two become a matter of keystrokes and programming.
Some companies view development of a branded health care site as a way to signal active and potential employees that the corporation cares big-time about their health and welfare.
"Our basic commitment to our employees is to provide them with information and programs that will allow them to make informed decisions about their health, so they can maintain and improve their health," says Cioffi. "The Internet is obviously integral to those goals. At the same time, we are also looking to enhance recruitment and retention of valuable personnel."
Many corporate HR departments hope the web can create the optimal health care consumer. Last year Kodak, for example, contracted with a web site called Health Pages, which publishes comparative information on physicians, hospitals and health plans. Merely by keystroking a zip code, Kodak employees can find and compare local physicians in terms of experience, hospital affiliations, office services, even fees.
"Through our web site, we hope to provide employees with information they can use when they meet with their doctors," says Cioffi. "We'd like to see employees better informed about health and disease, so that they can take a more proactive role in health care decision-making. The result should be better care and a more targeted use of resources."
"For me, the value of the Internet lies in on-line health risk assessments and associated follow-up programswhether on- or off-line," says Molly McCauley, director of wellness, Hoffman-LaRoche Inc., the Nutley, N.J.-based pharmaceutical company. "Our emphasis is to help people understand and identify their risks and to choose the course they want to take to act on some of those risks. On-line, you can go at your own pace, and it's totally private. But if you want to, you can initiate a self-intervention." At Hoffman, that can mean using "planners" to alleviate stress or stop smoking, personalized education on risk factors and disease states, invitations to participate in counseling or lunch and learn sessions or a chance to sign up for targeted e-mails and newsletters.
Early adopters of Internet health technologies like Hoffman-LaRoche and Applied Materials are already in testing and measuring mode. While qualitative evaluations of employee satisfaction are important, empirical accountability is needed as well, says McCauley. "Is there some mix of strategies, off-line and on-line, that improves health status, that lower risk factors, that gets you more control over your health care costs? We're going to look for aggregate data on risk factors and behavioral change. If the data show a certain percentage of our employee population is overweight or at risk for cardiovascular disease, then do we see an increase in participation in programs, a ramping up of distribution of information about heart disease, about diet and exercise? A positive graph here will show that there will be payoffs in health outcomes and lowered expenditures."
Applied Materials has had on-line health applications long enough to aggregate the findings of several iterations of individual health risk appraisals. "We've seen a shift in some of our high risk population," says Webster, "For example, while in the first year we probably had 46 percent at high risk for high cholesterol, this time around we had 40 percent. So it would seem that at least some of the right people are doing the right things."
For some of the more thoughtful corporate health and wellness executives, the Internet has only just begun to reveal its potential. "Consider something like electronic medical records, which is just in its very early stages," says David Rice, director of health care services for Sara Lee Corporation, headquartered in Chicago. "Electronic medical records should make it possible to pull together a broad-based medical record for each patient that simply doesn't exist now." He offers the example of pediatric immunizations. Pediatricians and plans say they try their best, but "there are too many kids not getting their shots until they are about to start school. Those kids have been exposed for two or three years to dread diseases. A really good EMR system on the Internet will close that kind of window of vulnerability."
Rice has one other vision of what Internet applications may someday be able to do: "Put back into medicine and caregiving some of the joy and satisfaction and trust that used to be there." What if the Internet and associated technologies simplified care for patients who have a need but who aren't critically ill? Suppose there were a way for a hypertensive patient to check his BP, easily and rapidly, four or five times a day, and download that data to a system that rings alarm bells only if data are bad. "That's easier on the patient," says Rice, "because he's not sitting in a waiting room for two hours. It's easier on the doc, because he's not devoting time and energy to where it's not really needed."
"So who is in the waiting room?" Rice concludes. "The sickest patients. The patients who really have a need. The patients who truly challenge the provider and the health care system. And if the Internet and web applications can get us to the point where docs are pretty exclusively concentrating on those patients, well, that is where everyone should want medicine to be."
Strategy, process, goals, outcomes measurementsall of these must be considered before an employer establishes on-line e-health presence. The Benfield Group has constructed a web site, ehealth-management.com, to help employers think the process through. Chuck Reynolds, a Benfield Group principal, offers these suggestions for developing an e-health management vision:
Pick reasonable time frames: Don't expect to have your site or solution up and running in no time, but do understand that technological and Internet-cultural innovations can render long-term solutions obsolete even before they are implemented. Think 18 months: time enough to bring a vision to fruition but not so much time that the fruits are overripe.
Focus on goals, on people, on themes: Think carefully, specifically, concretely. Envision how e-health management tools might help health management and HR personnel do their jobs more efficiently and effectively. Devise scenarios: How might an e-health solution help an employee just diagnosed with breast cancer? An employee who's just completed an on-line health risk assessment and is looking for feedback and next steps? A retiree whose spouse has Alzheimer's and who is looking for support?
Match stories and themes with tools and vendors: The task now is to imagineand then to develop or buythe e-health tools and applications that will best reach your goals. For example, you might need to research on-line applications that will help you reach out to underserved populations, such as remote employees, dependents and retirees.
Other strategic concepts to consider include savings, efficiency and employee satisfaction. You'll need to devise ways to measure and calculate those variables. "Remember, too," says Reynolds, "because e-health management is a relatively new concept, most of the information and resources about products and services are consolidated among the vendors. So employers should proceed with some caution."
Finally, Benfield advises, focus is critical, especially when it comes down to vendor selection. Don't allow yourself to be distracted by fancy features and applications that lack utility for your overall e-health strategy.
Robert McCarthy. E-health, your workforce and you: Tales of the early adopters. Business and Health 2001;1:27.