Health Business Blog

I’ve been testing out infoMed MD, a new website that provides personalized answers to medical questions based on short questionnaires. The technology isn’t especially novel but I kind of like the approach and the way it’s been executed.

The user starts by browsing a list of topics, such as anabolic steroids, bad breath, botox and cataract. After answering a few questions the user reaches a screen that summarizes the answers and provides personalized advice and links. What I like about it is that the answers contain real opinions, not just the usual WebMD stuff. One downside: it costs $6.95 to take each infoMed. I’m not sure how many takers there will be. However, the company also offers custom infoMeds that physicians can integrate into their practices.

Click here for a narrated example of me taking the Botox infoMed.

PS — Oops! Looks like I inadvertently deleted the screencat! I will try to repost it in a few days.

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Check out the latest Cavalcade of Risk blog carnival at The Sentinel Effect.

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Seen on a t-shirt worn by a man in a Brookline, MA ice cream shop:

More People Have Read This Shirt
THAN YOUR BLOG

I checked on the web and found the shirt is made by Despair, Inc. I’ve seen some of the company’s other products before. My favorite are the line of Demotivators –which mock the motivational posters you see in corporate offices.

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Although it’s been a couple of years since my firm, MedPharma Partners has done consulting work in the hospitalist industry, I still keep my subscription to Today’s Hospitalist Magazine because I like its insights into the hospital environment. I read through the June issue today and found a piece entitled New thinking on resuscitation techniques. It discusses new guidelines that call for bystanders who see out-of-hospital cardiac arrests to focus on performing chest compressions and not bother with mouth-to-mouth resuscitation. The article speculates that these guidelines may soon have an impact on in-hospital resuscitation.

That’s interesting enough, but probably wouldn’t merit a blog post. However, I was a little bit shocked as I read on:

Defibrillation times in areas of the hospital outside of telemetry units where defibrillators are immediately available “aren’t much different than in the out-of-hospital setting,” Dr. [Daniel] Davis [of UCSD] said. In addition, doctors and nurses in these areas are not as comfortable assessing potential arrest victims and are often reluctant to initiate chest compressions.

“These providers don’t see a lot of arrests and are no more comfortable determining the presence or absence of a pulse than is your next-door neighbor,” Dr. Davis said…

He’s exaggerating, isn’t he?

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When the debate was raging in Massachusetts about whether to allow MinuteClinics in drug stores I heard some Massachusetts doctors talking about a clever plan to put CVS and its ilk on the defensive: institute a rule barring health care providers from selling tobacco products. Boston Mayor Menino picked up the idea, and based on today’s Wall Street Journal Health Blog post it sounds as though the idea has some resonance.

I don’t like the protectionist angle that would keep drug stores from opening clinics, but the idea of restricting cigarette availability isn’t a bad one. As Health Blog reports, CVS hasn’t ruled out getting rid of cigarettes. On the other hand, it’s a slippery slope.

Drug stores sell a lot of dangerous (or at least unhealthy) products including junk food, soft drinks, herbal medications, insecticides, children’s toys with phthalates, magazines advocating dangerous behaviors, and even prescription drugs with questionable safety profiles. Not in Massachusetts, but elsewhere, drugstores sell alcohol.

If I were a drugstore chain I wouldn’t give in too quickly to product category bans.

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This is a transcript of my recent podcast interview with T-System’s Suzy Thorby.

David Williams:  This is David Williams, co-founder of MedPharma Partners and author of The Health Business Blog. I’m speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales and Relationship Management with T-System, a leading provider of clinical documentation solutions for emergency departments.

Suzy, thanks for being with me today.

Suzy Thorby:  Thank you, David. I appreciate the opportunity.

David:  Suzy, what is the T-System?

Suzy:  The T-System is a chief complaint-specific documentation tool for clinicians in the emergency department. For example, if somebody presents with chest pain in the emergency department (most of our cases present as new, undiagnosed problems), we take the chief complaint, and, basically, if they have pneumonia or osteochondritis or an acute MI, you’re able to rule out the highest risk things.

It helps pull together the things that are most critical on any presentation. It brings your quality indicators to the bedside with you. We do that both with paper documents and our electronic documentation, which is a natural extension of paper products.

David:  Tell me about how the emergency room is different. It sounds like people are presenting with undiagnosed problems, potentially of an urgent nature and without a lot of background knowledge of them. How is it different from what things would be like elsewhere in the hospital?

Suzy:  Well that is a very good point. There is a different standard of care for the emergency department because if someone presents to the ED, they have a different expectation than going to the day surgery area or to their physician’s office. They’re actually frightened enough or sick enough to come to the emergency department. We’re held to a different standard of care.

You don’t really have a diagnosis when they come. Even if you have someone with asthma and it’s an acute exacerbation, perhaps they’re presenting today with pneumonia. You have an episode-based document versus a document that supports the continuum. It becomes part of the continuum but you have an acute episode of a chronic illness or a new illness that is presenting.

In that way the chief complaint-specific documentation works very well.

 You wouldn’t say someone presents with asthma, you would say someone presents with shortness of breath. That way you’re able to make sure if it’s just an exacerbation of their asthma or they have pneumonia, you’ve captured the data that helps support the appropriate disposition and plan of care for that patient.

David:  It sounds like you have both a paper system and an electronic extension as well. Can you talk about the relationship between those two and also how paper versus electronic documentation has different sorts of issues, in the emergency department versus other places?

Suzy:  Yes. We developed the paper system in 1995 and 1996 because of the burden of remembering all the documentation guidelines, when CMS first came out with all the documentation guidelines. 

It is very onerous, making decisions on patient care and providing care when you are trying to remember these guidelines, so the paper system developed as a way to say, if this is what CMS says is an appropriate level of service, let’s make sure we get those things into a document.

It becomes very difficult to remember how many reviews you have done or how many elements of a physical exam. What we did with the paper is basically presented them in a way that was specific to the patient’s complaint. We incorporated in 1996 and it was astonishing because at that time less than one percent of the EDs had any templated documentation.

Basically, everybody thought that dictation was the gold standard. Because dictation tends to be a narrative, you would get the story but miss the elements that supported your level of service. What we did is we made a data centric model that not only captures the clinical data but supports the level of service.

Again, we found that we were able to take things like QA elements right to the bedside. It was a data push rather than a data pull. We were able to push the standards out in a way that physicians could use it at the point of care versus going back retrospectively and finding that the data was missing.

David:  It sounded like when you were starting off that a very small percentage of people were actually using a templated system. So you’re basically replacing a free form system. Is that still the case today when you go into a new customer? What would be the typical state of play? Would it be completely free form or would they have some sort of homegrown system or some competitor in place already?

Suzy:  Interestingly, we have about 30 percent of the EDs in the U.S. where the physicians use the T-sheets. I think that is significant because the more users that we have, the better the documents become. It’s a living body of knowledge. It’s not static. We didn’t develop the templates and they’ve stayed the same. We’ve actually received input from thousands of physicians, compliance officers, reimbursement specialists –and the documents continue to evolve. It’s a dynamic process.

But the biggest challenge was that it was a free form, so you’d have to make a right brain/left brain switch, where you’re used to gathering the data in a storytelling format and now you’re gathering data at the point of care that ultimately support your clinical impression.

I would say it’s the difference between a tape and a CD. If my favorite song on a tape is number five, I have to fast forward or rewind to it. If it’s a CD, I go right to the information I need and I can document it in a nonlinear way. The other key thing is that we were able to do it at the bedside in parallel with the patient visit. You would be able to capture data in a nonlinear way at the bedside and therefore be able to spend more time with the patient at the bedside. Not too many patients are saying, ‘That ED physician spent way too much time with me while I was in the department.’

It solves so many problems that it was astonishing. You didn’t have to wait for a registration clerk to put somebody in the system before you could start doing your documentation. You didn’t have to wait until you had all your lab and x-rays back. You could get the history, your physical exam and you could do it again in parallel with the whole visit, which helped with a lot of bottlenecks.

David:  Now that you’ve gotten up to 30 percent penetration, what are the key drivers these days? Is it simply that when someone comes into an ED that’s not using the T-System they’ll say, gee, we should really have this because this is what I’m used to and it makes so much more sense? How much of a driver is pay for performance?

Suzy:  Look, for example, at Keystone Physicians. You have to consider if you have multiple emergency departments as a physician group that you’re staffing, you have such wide variability of documentation. They said, we will make the commitment to standardize our documentation and even the playing field across our sites.

If you think about all the new things that come out as far as documentation guidelines, present on admission criteria, pay for performance, not only by CMS but now various third party payers, it’s overwhelming to try to remember all of those things when you’re taking care of a patient and also to remember the critical things on a presentation.

If somebody came in with back pain, you don’t want to sit down and do your dictation and ask, ‘Did I check thermal pulses? I can’t remember.’ Maybe you have to call them up and have them come back to the ED, which I actually had a physician tell me he did. It’s better to have the data there with the patient.

Whether it is clinical data, quality data, utilization data, CMS data, or quality indicators, having it there during the point of care makes a huge difference in how consistently you capture it. Then you can compare across your enterprise if everyone is doing it the same way. You can make changes according to your practice. So, for example, Keystone Physicians is really helping in meeting their clinical and business objectives based on a prototype that we provide.

David:  Keystone is an outsourced emergency department group so they’re working across different areas. Would they have some of their same employees or contractors working across multiple sites?

Suzy:  Frequently, if you live in one town and they staff two hospitals, they’ll go from hospital to hospital. Again you’re really decreasing variability and allowing the physician to focus on the thing that is most important, which is medical decision making and patient care.

David:  When a hospital is deciding to implement the TSystem or is evaluating it against other sorts of systems or keeping things the same, what is the typical process that you go through and how do they look at it? Who are the constituencies that are involved and do they evaluate financial measures, clinical measures, safety measures, or risk management/defensibility measures? How do they look at it?

Suzy:  All of those. It varies by site. Dictation is very expensive and we see margins of health care decreasing and you get no consistent ability to capture data. They tend to vary widely based on a provider rather than a tool. They will look at things like, ‘What does this do for our bottom line as far as dictation?’, also the medical/legal exposure because you’re able to take your QA indicators to the bedside. You’re able to capture things that support standard of care for the practice of emergency medicine.

Additonally, you’re able to have physicians spending more time with patients. A lot of hospital CEOs are very concerned about their Press Ganey scores or whatever tool they’re using to measure patient satisfaction. You also have utilization review who’s saying, ‘We need to make sure that we have this documentation if we’re going to have an admission.

’

We have present on admission criteria now, which say that if you don’t have it documented that a patient had a urinary tract infection at the time they were admitted, CMS is not going to reimburse you for treatment of that. We generally have a positive impact on reimbursement just because you’re able to get a lot of consistency. Again, it’s right there. You see what you need to document.

I always say with a caveat, if you’re a high performing organization, we want to make you better performing. Maybe you don’t increase reimbursement but you see an extra patient every two hours because you’re able to do it in parallel with the visit as opposed to many documentation methodologies that have to be done in sequence. You can not begin a dictation until you have everything back on a patient and have made a disposition.

It’s the ability to get consistent documentation, to do it in parallel with the visit, to break up the bottlenecks in the ED and provide the quality indicators and the clinical indicators that really help make care better.

David:  What do you find in terms of how hospitals look at T-System within the context of their overall information strategy? For example, do you find a hospital that’s doing a general digitization push but then also would consider putting in the paper-based T-System at that time? Do they tend to go with the electronic T-System or do they say, “Gee, as part of our comprehensive package we’re going to bring in some other solution because it’s integrated in with our main system that we’re putting in’?

Suzy:  A lot of people have a long term IT strategy that says they’re going to have a single enterprise vendor. However, the clinical verticals aren’t that well built out on enterprise vendors. They take the overarching clinical premise and try to make that work in the ED. Because the ED is such a unique environment, you don’t necessarily have the ability to take, for example, a consult in the office where you’re doing follow up on hypertension and make that work in the ED. It’s building out those verticals on the large horizontal platform that is a challenge.

So, people may say, long term, that they’re going to go to an enterprise vendor, but there’s not really one that leverages the technology to make the work flow better, the clinical care better, that has a content that is really collaborative content, not specific to what that hospital needs. And, I think that’s an overarching strategy.

I use Salesforce.com every day. Salesforce works very well for me because they understand my work flow. The technology leverages what I do. And in one of your blogs, somebody said, ‘Getting adoption is difficult with clinicians’. And, it is one of those things that if you don’t leverage their current work flow, it is very difficult to be successful. And you may be successful from an IT perspective with some applications, but we say your core competency in a hospital is patient care.

We leverage the current work flow and the processes to make the patient care better, not detract from it. And I think we do that uniquely. And also, our content, because it’s dynamic. Because we get feedback from users. Because we’re constantly updating our content. That makes a huge difference in how people are able to use it and realize the benefits.

David:  Suzy, I see on your website, a picture of what looks to me like a motion C5 Mobile Clinical Assistant computer and I have to ask you about that since my friend, Scott Eckert, is the founder of that company. Do you work with Motion Computing and what’s your impression of them.

Suzy:  Yes, we do. We have a great relationship with Motion. We have them at a lot of our sites. It’s amazing to me when we first started to implement our electronic record, that the mobile devices weren’t what they are now. You’d have to stand right over it. They weren’t as rugged. And the connectivity was not as good.

Now we’re finding that, with the Motion devices, we get great connectivity. We have great screen resolution, great screen size, and the images are so much better. Handwriting recognition is so much better. What was really a difficult thing to get people to transition to at one point is now easier and easier so they can basically take that device to the bedside and capture the history, the past family social history, review a physical exam. It’s basically the paper sheet metaphor with a mobile device.

David:  You’ve been at this for 12 years, or so. I’m sure you’re not counting, but it’s been a while. If you look ahead five years or so, what would you think might be the biggest difference between where we are today and what you’ll see at that point in time?

Suzy:  Well, I think the biggest differences that I see are these quality measure initiatives or value-based purchasing both within CMS and third-party payers. Now, there are those who would say ‘This is payment reform in sheep’s clothing’, and that may not be too far from the truth. It is basically saying, the fee for service, making more money by delivering more services is not what we want to pay for. We want to pay for appropriate care, appropriate utilization. We don’t want to pay for something that you created in the hospital, for example, pneumonia or a decubitus ulcer, or a urinary tract infection.

That train has left the station and gained speed every day. I’m actually on a work group with the AMA and HIMSS to say ‘How are we going to get electronic records to report on this so that we have consistent, reproducible, quality data on patients when they present? How are we defining the data? How are we recording the data? How is it extracted?’ Those are all things that are going to happen, are already happening. It increases every day.

And so my thinking is that in five years we’re going to be seeing a lot of value-based purchasing and quality measures that must be reported to get reimbursement. So, pay for performance for physicians now is sort of a voluntary thing that you get a little bonus. My thinking is that if you don’t do it, your percentage of Medicare fee schedule is going to drop, or as Aetna’s doing in California, they’re going to say ‘If you are not one of our certified quality providers, you won’t be in network’. And you put the quality stamp on anything and it’s hard for beneficiaries or hospitals or employers to say it’s not good.

But, I think it needs to be watched carefully because there are some agendas that could be followed if it’s not implemented and recorded appropriately and well defined. My issue is that they have quality measures that are poorly defined at times. You’re going, ‘how do we make sure that if this is a quality measure, it’s being measured consistently and predictably across, not just a site, but a state, a system. How are we doing that consistently?’

David:  There’s a lot of talk about consumerism in health care and I would say the Emergency Department might be the last place that you’d expect to see it, but tell me if I’m wrong there or how that might change. Is consumerism something that is actually coming to the floor in the Emergency Department as well, or are patients still pretty much passive when they come in?

Suzy:  No, I think a lot of times what you’ll see is that people will have looked something up before they come in. They’ll have sort of run through the WebMD, ‘What do I think I have’, and will come in with sort of an idea of what they think their plan of care should be. That is something we see in Emergency Departments all the time now.

There are still a lot of patients who will acquiesce to whatever the clinicians tell them when they get to the department, but we’re seeing that more and more. And that empowerment is good. It would be nice at some point for us to have good data on cost/benefit ratios to say, ‘We can do this and it will cost you x, we can do this, it’s 2x and your outcome is going to be the same’.

David:  I’ve been speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales in Relationship Management at T-System.

Suzy, thank you for your time today.

Suzy:  Thank you very much, David. I enjoyed it.

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I’ve posted before about the marketing of infant formula through hospitals and about the practice of sending formula samples to expectant mothers.

Today I glanced through Nurture (Volume 08-1), a promotional magazine from Enfamil baby formula’s maker, Mead Johnson Nutritionals. The publication includes clearly marked advertisements for Enfamil products along with some articles on nursing and other typical new-mom questions, like whether babies can recognize colors and how to involve dads and grandparents in their care.

The formula companies go to some lengths these days to be seen as supportive of breast feeding. The first two-thirds of the relatively long article on returning to work focus on buying a breast pump, stockpiling milk at home and pumping at work. Only in the last third does the discussion turn to baby formula. That should satisfy most critics.
But the most interesting marketing pitches for formula are subtle ones, contained in pieces that are ostensibly medical or parenting advice. Here are two examples:

Q&A:

[Question] My 3-month-old is eating like a champ. Is she ready for solids?

[Answer] Not quite. The American Academy of Pediatrics recommends waiting until your baby is 4 to 6 months before introducing solids. Before then, she won’t have enough control over her tongue and mouth muscles to swallow food, and it may increase her risk of developing allergies. But there’s no need to wait beyond 6 months either, even if you’re worried about allergies…

Subtle marketing message: As baby grows and starts drinking more and more, you may be worried about whether you are producing enough breast milk. Don’t give solid food, but definitely supplement with formula!

Here’s another example:

Make Room for Daddy

Want to get in on a little secret about the daddy-baby bond? Well, you can start by putting Dad on diaper duty. (We though you’d like that!)… The more Dad is involved in day-to-day caregiving tasks, the stronger the bond will be… So have Dad take the night-feeding shift, stroll with baby in a carrier, or just enjoy playtime…

Subtle marketing message: Tired moms definitely deserve a break on the night shift. Of course Mom could pump extra breast milk during the day or just before bedtime, and let Dad give it to Baby, but who has the energy? Just let Dad mix up the formula and feed it to Baby. After Dad does that job a few times the nightly formula routine will become well-established. And while he’s at it can’t Dad just take along a bottle of formula with him for that “stroll with baby in a carrier,” too?

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Welcome to the latest edition of the Health Wonk Review at the Health Business Blog.

Bitter pills

• Pyrrhic victory. Expansion of the Americans with Disabilities Act has coincided with a decline in employment levels among the disabled. Workers Comp Insider.
• No way. Thanks to lobbyists, health care reform has no chance in Congress. Oh, and by the way there’s also no hope of tackling any of the other crises facing the US, including obesity, energy, education, the environment, poverty, and infrastructure replacement. The Health Care Blog.
• Down with the ANA. The American Nurses Association is a big-time loser. All talk and nothing to show for it. Home of the Brave.
• Managed care to the electric chair? The health insurance industry association should change its name to America’s Risk Selection Companies and drop the pretense that its members actually manage care. Managed Care Matters.
• RUC off! How come the proceduralist-dominated RBRVS Update Committee (RUC) is allowed to dictate Medicare reimbursement and why do private insurers slavishly follow CMS’s lead? Health Care Renewal.
• The Medicare monster. If things keep going the way they are right now, Medicare is going to gobble us up. Health Business Blog.

Capitalist contentment and conceit

• Keeping the faith. Some nursing homes maximize profits by keeping nursing staff levels low and treating sanctions for fraud and poor quality as a cost of doing business. That doesn’t mean we need minimum nurse staffing ratios, though. Take that, ANA! Healthcare Economist.
• Ode to high prices. Sure drugs are expensive. But don’t forget all the wonderful innovations the drug companies bring and how terrible the VA is. Healthcare Manumission.
• No right to health care. Everyone has access to medical care in the US. And who says health care is a right anyway? Amateur Economists.
• No right to police protection either. Who needs cops when we have the Second Amendment? And who needs government-sponsored health care instead of good old fashioned self-reliance? Patient Power.
• Take that you bleeding heart, poutine-eating, multi-cultural, igloo-dwelling, took-wearing beer swillers! Why would anyone want to languish on the waiting list in Canada dying of a brain tumor when they could simply get on the plane to Arizona and be cured? InsureBlog.

Sunny side up

• Make mine Medicare. Medicare reform is possible and can lead to reform of the whole system. HealthBeatBlog.
• The bus pass cure. How a $23 bus pass can save almost $1400 –and other tales of IHI-induced bliss. The New Health Dialogue Blog.
• There’s no management like disease management. Sky-high ROI from disease management? Seven reasons why it’s possible. Disease Management Care Blog.
• Brain food. There’s hope for us yet as computerized cognitive assessments catch on. SharpBrains.

Plain old policy

• Killing me softly. Why is Parliament discussing physician-assisted suicide again? Canadian Medicine.
• Introducing the transhuman. Luckily he’s not on the scene yet. (See trend #7). Sentinel Effect.
• So funny I forgot to laugh. When the details of plan benefit design become fodder for stand-up comics, it’s time for a change. Health Access Weblog.
• When ONCHIT’s speak, people listen. Robert Kolodner speaks about health IT, but will he forgive the Manumussionaries? Neil Versel’s Healthcare IT Blog.
• Pragmatism and principle. Birth control pills are cheap enough that we shouldn’t force insurers to provide coverage. Colorado Health Insurance Insider.
• A better way to control imaging costs. EHR + EBM + CPOE, obviously. HealthBlawg
• 1.25 cheers for doctor unions. Anyone ready for collective bargaining by physicians? Probably not. Brain Blogger.
• To plan or not to plan? Should the health care workforce rely on market-based solutions or is government intervention the way to go? Health Affairs Blog.

Thanks for reading. Health Care Policy and Marketplace Review hosts the next edition.

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In addition to my consulting work (and blogging) I’m chairman of the board of Advanced Practice Strategies, a leading medical risk management company. The company recently signed a strategic partnership with BETA Healthcare Group (BHG), the largest provider of hospital malpractice coverage in California.

As you’ll see from this press release, which BHG posted on its homepage, the partnership makes a lot of sense. Physicians and nurses will be trained to improve patient safety, leading to higher quality and a safer hospital environment. That will reduce complications and adverse events, thereby cutting health care costs and malpractice costs. We’re rolling out this initiative throughout California and other states so patients can expect to reap the benefits soon.

Alamo, CA, July 7, 2008 –As part of a large scale commitment to improving perinatal safety, BETA Healthcare Group (BHG) announced today a strategic partnership with Advanced Practice Strategies (APS), a leader in patient safety education. BHG is very proud to support its member hospitals financially in purchasing APS’s online courses which focus on the key drivers of obstetrical claims.

“BHG and APS share a commitment to improving patient safety and offering clinicians the best tools available for protecting patients and this makes it a great partnership,” said Tom Wander, CEO of BETA Healthcare Group. “Our organization has adopted a framework for improving perinatal care within our member hospitals and we believe that the extraordinary quality of APS education makes it the foundation for our program’s success.”

BHG member hospitals will earn significant reductions in their hospital malpractice premiums when they demonstrate their labor and delivery staff’s competence in fetal monitoring interpretation, use of common nomenclature, and participation in routine strip review.  APS courses address these issues directly and focus on the primary drivers of obstetrical malpractice claims –fetal assessment and monitoring, management of shoulder dystocia and operative vaginal delivery.

In addition, BHG’s participation spearheads an initiative in California by a number of hospitals and hospital systems to improve obstetrical outcomes and reduce malpractice
claims through education.  APS is helping to organize a group purchase of this education throughout the state. Because BHG is the largest provider of hospital malpractice coverage in California, representing over 1,200 labor and delivery clinicians in 35 hospitals, its participation is also helping to provide significant cost savings for the rest of the state’s hospitals.

“We have dedicated ourselves to helping healthcare organizations work toward the uniform practice and teamwork that reduces error. We are, therefore, very proud to be supporting BHG’s vision for improved care,” said Dennis Ferrill, CEO of APS.  “Also, it should not be overlooked that with BHG’s leadership, and the added participation of physician insurers, they are sparking system-wide change and improvement and making it easier for smaller organizations to participate in this education as well.”

To learn more about BETA Healthcare Group call (925) 838-6070 or log onto the company’s website, www.betahg.com.

To learn more about APS and its offering, please contact Shara Cohen at 617-367- 0553 [or email her].

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This is a transcript of my recent podcast interview with Alijor CEO Allison Guimard.

David E. Williams:  This is David Williams, co-founder of MedPharma Partners and author of The Health Business Blog. I am speaking today with Allison Guimard. She is CEO of online health care directory Alijor, which connects patients with physicians and other health care providers.

Allison, thanks for being with me today.

Allison Guimard:  Thanks for having me David.

David:  Allison, what is Alijor?

Allison:  Alijor is an online health care community that is working to connect patients with various types of health care providers. One of the biggest things it is based on is enabling patients to search for a doctor based on cost.

David:  How does somebody go about it? What is the experience like for a patient?

Allison:  You visit Alijor.com and then enter your geographic area. We have quick links to click on. You will click on your geographic area and you will select the specialty that you are searching in. Then, it will basically organize all the data for you.

You are able to organize it from lowest price to highest price and so on. You are able to see the initial consultation cost, the follow up cost, and the procedure cost. In the very near future you will be able to organize it based on various types of procedures. So, you can be even more specific for various kinds of plastic surgery, for various kinds of dermatology and things like that.

The other experience we offer is that patients can go on and actually post their medical problems. If you are looking for back surgery you can go on and go to orthopedic surgery and type in that you have back problems and you are looking for a back surgeon. And then doctors can actually get on and respond to you and tell you their price. It is very consumer oriented, which is nice for patients.

David:  One problem in health care is the lack of transparency on pricing. That sounds like something that you are addressing. There can also be questions where you don’t know exactly what you need before you go in. So, when you talk about the pricing information, how useful does it end up being for a patient? Or is the price often different or is it hard to figure out exactly what they need ahead of time?

Allison:  It is a great question; a question we actually get a lot. We try to get doctors to give us their average price. For example, if you are going to get some sort of plastic surgery, it is going to vary based on the person and the patient and the issues they have. So, we try to get the doctors to consider their lowest and highest costs and then average it out so that patients know.

So yes, it can definitely vary, but in the end, it is pretty close is what we have been told.

David:  When a patient posts their information it looks like they can put a basic message on there. Is there a structured questionnaire as well? What is your thinking behind what the patient posts?

Allison:  It is pretty structured. You have to put your geographic area. You have to put your insurance and a couple other pieces of information. We actually provide a really good amount of space for people to insert anything they want to about their medical problems.

We have actually never had complaints about how much space there is to put information in. Some of our responses today are shorter based on the fact that this is a growing part of our website. But, I believe as patients realize, “Hey, we are actually getting a response from doctors here.” I think, they will put more and more information in.

So, it is structured. We give a good space of information for people to put anything and everything they want because patients don’t really get a chance to explain themselves today in health care.

David:  You have doctors and other sorts of providers. What is the thinking in terms of going beyond physicians? Is it primarily weighted toward physicians or alternative or complementary care?
Allison:  We definitely have more complementary care. The reason is that it is one of the things that is often not covered by insurance. We can always get prices from those kind of doctors. They are very used to it.

However, we are definitely expanding into more general practice internal medicine type of specialties, which is taking up some time. One day I would love to say “Hey, I have all the different kinds of specialties,” from general practice, dermatology, plastic surgery, to acupuncture on our site.

One of our other big goals is to eventually have hospitals on our site as well.

David:  How would it work with a hospital?

Allison: What we think will happen is we will just be able to say, “Hey, listen. Here is our average price for heart surgery.” I am sure you have seen it on a couple sites now; they are actually doing this… And we will basically put it on our site and then they will be included, when a patient searches for a heart surgery.

David:  And when you have a provider, whether a traditional provider or alternative or complementary therapy, do you go through some sort of verification or credentialing process before they go on the site? How do you know whom you are dealing with?

Allison:  We really don’t at all. The only thing we ask is that they give their license information. And then, we encourage patients. We make a very big point to say, “Hey, you know, we have not verified this information. Make sure to go ahead and look up their license information. Go to their website and verify that it is a valid license and stuff like that.”

Just like if you go to really any other doctor you should take it upon yourself to do your due diligence and ensure that they really are a doctor and they have credentials and they are going to provide quality care.

David:  What are you finding in terms of the geographic locations of your physicians and the patients that are coming on? It looks like you have a big group in the Bay Area, which I think is where you are based. But, what else are you finding?

Allison:  We are very big in the Bay Area. And we are also very big in New York City; Miami, Florida; Dallas Texas; all the major markets in the US. That is where we are big. And we are still expanding into other areas. The major markets is where there are more doctors and where doctors are more willing to take part in things like this. So, we are definitely much larger in the cities like in Los Angeles, Boston, and places like that.

David:  When you look at specialties like plastic surgery, where people are often shopping around for price and it is something that they are paying out of pocket, do you also have or are you considering having providers that are in other countries? Sort of a medical tourism angle?

Allison:  Yes. Actually we do. We are slowly expanding into Canada and Mexico. And then I think, we will probably expand throughout Central and South America since that is a pretty big medical tourism place. Possibly into India and places like that. One of my employees is relocating to Central America to work on expanding into medical tourism in the next couple months, meeting with some people. I am really excited about that and I think it is going to be a big thing. We definitely are going to be expanding into other countries for medical tourism.

David:  And are the visits that you are arranging or helping to facilitate or putting doctors and patients in touch about — are those all in-person visits or is there an element of electronic visits as well?

Allison:  It is all in person. But, of course, if the patients and doctors want to just communicate through email and do it that way, they are more than welcome to. However, basically once they come to our site and email each other they really leave our system and it is up to them to communicate and set up appointments however they want to.

David:  What is the way that you are financed and how are you hoping to make money, if that is the goal of this business?

Allison:  Yes it is. We are basically angel funded. Our business model is that we will have an advertising system up in about two to three months that is going to enable providers to have a higher listing than other providers. We set up basically a pay per click model. That is how we will be bringing in revenue; through advertising and enabling doctors to have advertising on our site. We may go with some bigger companies, such as insurance companies and pharmaceutical companies who want to advertise. That is our plan for the next two to three months; to get that working and going.

David:  At that point, will a provider still be able to list his or her services for free? Will they just get more favored treatment if they are advertising? Or will you have to pay for your listing?

Allison:  No. They can list for free. You will just have favored treatment. You will basically have a little bit better look to your item. You will be a little bit higher if you are paying us. But, it will still be entirely free for both patients and doctors to use our site.

David:  And what about the rating system that you have? I saw that there was an opportunity for people to rate their providers. How does that work and what are you expecting to come out of that?

Allison:  That actually went up a little over a month ago and is slowly starting to be used. Basically, you go on and when you are asked about a doctor, or if you just know of a doctor, or you heard of a doctor through a friend, you can go on, go to the doctor’s profile, and basically just click from one to five stars, select how many stars you want to rate them, provide any feedback you want to provide. As we get more and more ratings we will develop some sort of rating score for that doctor.

A couple doctors have ratings, but it is definitely a growing service. Not everyone has used it yet.

David:  Now, you have been in business for at least a couple of years. There are some websites that have emerged since then and there are some that have been on the scene for a while. I was just wondering how you think about positioning yourself relative to them.

I am thinking about sites like HealthGrades where people could see information about the quality or satisfaction of a doctor; American Well, which is going to be setting up to allow more immediate communication, Carol.com, which is also offering pricing information, or MedHelp where somebody can post information about their particular condition and then have a physician answer that for free. How do you think of yourself in that universe? Are there other companies that are relevant to think about as well?

Allison:  There are a couple of things that are very different about Alijor. One of the biggest things is that we do provide email addresses for doctors. You can email doctors directly from our site, which is unusual for the other sites that you mentioned.

I think, one of the biggest things is the fact that we enable patients to post their information for free. They get to go on and post information and doctors can respond. I believe MedHelp enables them to post their information in more of a forum like atmosphere. And then other patients and consumers can respond. Doctors can respond too. But, ours is a little bit more directly tied to patients posting their problem and then doctors responding with a price.

The other big thing is that we enable doctors or ask them –almost require now– doctors to post their fees. A couple other sites do. A couple other sites have fees. You go on our site and at least 70 to 80 percent of the doctors on our site have their fees on the site. That is pretty exciting.

I know Health Grades, in order to even see fees for the doctors you have to purchase it I believe. It is not free. Also we have dentists and all kinds of alternative doctors, which other sites don’t have.

I think, the last, biggest thing I can point out is that every single doctor who is on our site is there voluntarily. We have contacted them, we have asked them if they wanted to be on and they have said yes. And they put their information on themselves. That is really pretty much the most exciting thing about our site; is that they are all there voluntarily.

David:  Allison, what do you measure when you think about the success of the site? Are you measuring traffic or number of physicians? What are your key metrics and how are you doing on those metrics?

Allison: Our key metrics are basically visitors on a weekly and monthly basis. And then also how many patients are searching for doctors on a weekly and monthly basis of course. And right now, we have on average, just about 3000 visitors a week by consumers, patients and doctors alike, for around 12,000 to 13,000 visits a month. And then we have on a weekly basis about 4000 consumers actually searching for providers. I think, that is fantastic. About two or three months ago we were not even hitting the 1000 mark. So, it is pretty exciting that we have grown so fast.

And then, of course, we do base it off of patient postings and patients getting on the site. That is a slowly growing process. We have a couple patient postings a week basically.

And then also, the last metric that we really look at is providers posting their information. Today, we have about 15,000 provider postings and are rapidly growing. Our goal is by December to be hitting somewhere around 150,000 provider postings on our site.

David:  So, you expect to get… Did you say you had 15,000 now or 50,000?

Allison:  We have 15,000 now. What has been exciting about it is it took us a long time to start getting those. Basically, in the past couple months is when we have really gotten a good chunk of those. Our belief is that we can do it. That is our goal and hopefully we will hit that.

David:  Great. So, what are your plans for the future, say beyond 2008?

Allison:  Our plans for the future are really just to keep growing and keep getting more and more doctors. I would like to say that at some point in the future we will have a really good percent of the American population and I guess worldwide population of health care providers on the site so that we can really enable all consumers to make a more educated decision about their doctors and not just see a certain percentage of doctors, but see a good percentage of them.

We are going to be starting a couple blogs the next couple months. So, that will be a plan for 2009. Also, advertising is coming out in probably August or September. So, hopefully, we will be bringing in revenue for 2009.

We are going to keep doing a couple redesigns to the site. We have a great tech team that I have hired in the past couple months. So, we will have a great search system. One of the big things I am focused on is really enabling consumers and doctors alike to have a good experience on our site; a good search experience and just be very clear. A lot of sites are crowded and not very self explanatory. So, that is one of the big things we are working on: just developing a very clear and intuitive site.

David:  I’ve been speaking with Allison Guimard. She is CEO of Alijor. Allison, thanks for your time today.

Allison:  Thank you David for having me.

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