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Transcript of Web Conference

Session 1: The Potential Impact of Clinical Informatics on Health Care Costs, Quality, and Safety

This Web-assisted audio teleconference series consisted of three events broadcast on July 25, 26, and August 1, 2001, via the World Wide Web and telephone. The program was designed to help State and local policymakers make policy decisions and allocate resources related to health care informatics. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.

Cindy DiBiasi: Good afternoon and welcome to "The Next Revolution: The Role of Informatics in Improving Healthcare." This is the first in a series of three Web-assisted teleconferences for State and local health policymakers sponsored by the User Liaison Program under AHRQ, the Federal Agency for Healthcare Research and Quality.

My name is Cindy DiBiasi and I will be your moderator for today's session, "The Potential Impact of Clinical Informatics on Healthcare Costs, Quality, and Safety." This is the first event of this User Liaison Program Web-assisted teleconference series on the role of informatics in improving healthcare.

The healthcare field has the potential to benefit greatly from innovative applications with informatics. Everything from online access to health information, integrated electronic medical records, and computer-based information systems can provide practitioners with real-time assistance in their decisionmaking and can offer the potential to significantly improve the quality of care and patient safety. But it is important to separate the facts from the hype and better understand how information technology can be used to improve the delivery of healthcare. Today's event will examine that potential and explore what is currently known from health services research concerning the impact of specific clinical informatics interventions on the cost, quality, and safety of healthcare services.

We will also discuss the implications of developments in the area of health informatics for State and local governments. On Thursday, July 26, we will address "Using Informatics to Improve Program Performance: Examples of Innovative State Applications." This Web-assisted teleconference will highlight examples of how information technology is being used in an innovative manner within State-sponsored healthcare programs to improve access, enhance the quality and appropriateness, and reduce the cost of healthcare provided to program beneficiaries.

On Wednesday, August 1, we will address "Getting Information Into the Hands of Decision-Makers: Innovative Applications and Issues." This Web-assisted teleconference will examine two related and innovative approaches to using informatics to make data, in this case hospital discharge data, more rapidly available to policymakers and researchers, and to report insightful, rapid turnaround comparative analysis both within and across States. The results of a recent study on the accessibility and quality of health information available to consumers on the Internet and their implications for public policymakers will also be examined.

Today we are going to take a closer look at the potential impact of clinical informatics on healthcare costs, quality, and safety.

In the studio with me I have two experts who will be participating in our discussion. Dr. Eduardo Ortiz is a Senior Service Fellow with the Agency for Healthcare Research and Quality [AHRQ], the U.S. Department of Health and Human Services [HHS]. Dr. Bruce Bagley is a practicing physician with the Lantha Medical Group and Chairman of the Board of the American Academy of Family Physicians. From Sacramento, California, I also have with us another expert, Michael Kassis. He is Deputy Director and Chief Information Officer of the Healthcare Information Division of the California Office of Statewide Health Planning and Development. Welcome everyone.

Before we begin our discussion I have a few housekeeping items to take care of. If at any point during this event you have Web-related technical difficulties, please use the "Tell" function to contact Tech Support. Also, if you by chance lose the audio stream on your computer at any time, you may dial 1-888-868-9080 and give the password "AHRQ teleconference" and that way you will be able to hear the audio portion of this event on your telephone.

Later in the call our panel of experts will be taking your questions. There are four ways you can communicate your questions to us. If you are on the phone, just press "14" or you may fax your questions to us at (301) 594-0380. You may also E-mail us your question at Or you may directly type your question in a messaging field and hit "enter." Please note that your sent message will not appear in the chat box. If you prefer not to use your name when you communicate with us, that is fine, but we would like to know what State you are from and the name of your department or organization. Please indicate that regardless of the way in which you transmit your questions.

We will have audio tapes of this Web-assisted teleconference series available for purchase after all three events are completed and I will be giving you further details about this at the end of today's show. And finally, an archive of this Web-assisted teleconference will also be available on the AHRQ ULP Web site and that address is

Now I think we are ready to turn to the important matter of discussing the potential impact of clinical informatics on healthcare costs, quality, and safety. Eduardo, I'd like to start with you. Let's begin by clarifying a few definitions. What exactly do we mean by the term "medical or clinical informatics"?

Dr. Eduardo Ortiz: Well, I want to begin by just giving you a couple of definitions that I think describe medical informatics well. One of them is, medical informatics is the application of computer technology to all fields of medicine. This includes medical care, medical teaching, and medical research. Another nice definition that describes it well is medical informatics is the scientific field that deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for problem solving and decisionmaking.

Now, there are other terms utilized as well as medical informatics. Some people use the term "medical information sciences", or "healthcare informatics." There are also people who are splitting the field up and calling medical informatics just one branch of basically a three-tiered thing: medical informatics, public health informatics, and consumer health informatics. The terminology really doesn't matter that much, as long as you understand the gist of what "medical informatics" means.

Now, medical informatics basically just deals with all aspects of understanding and promoting the effective organization, analysis, management, and use of information in healthcare. Ultimately the goal of medical informatics is to improve and optimize use of healthcare information to improve decisionmaking.

Cindy DiBiasi: Can you give me some specific examples of informatics applications?

Dr. Eduardo Ortiz: Well yes. Let me go ahead and begin by just describing a couple of the tools that are commonly used in informatics and most of you out there are probably familiar with these. For example, computers are informatics tools; handheld wireless devices (PDAs) such as your Palm Pilots that a lot of you out there are using nowadays. Those are some informatics tools. Networks and databases are also examples of some tools.

If you want to get into a little bit more in terms of some specific applications, for those of you who are on our Web site, you can basically see I have got a list here. Let me go through a couple of these. For example, electronic medical records would be an example of informatics applications. Electronic order entry and, for those of you who aren't familiar with that term, what that basically means is that is when a clinician enters in medical orders but does it electronically through a computerized system vs. the traditional method of doing it by handwriting. Automated reminders, that is basically when you have an electronic system or computerized system. Let me give you an example. A clinician is seeing a patient with diabetes and this reminder pops up on their computer screen that basically tells the clinician, "Hey, it is time for this patient's influenza vaccine or this patient needs a blood test or needs a referral." So those are automated reminders.

We also have computerized expert systems. These are systems that have been developed to aid clinicians in diagnosis and treatment. They are a little bit more complex than the automated reminders. They may give recommendations in terms of treatment or basically some protocols that are based on guidelines, etc.

Electronic mail is another application that all of you out there are familiar with. We also have things like telemedicine, digital imaging, and voice recognition systems. By all means, this is not a complete list, but these are some examples of some informatics applications that are commonly in use.

Cindy DiBiasi: How widespread is their use?

Dr. Eduardo Ortiz: Well, it kind of depends on the application. For example, if you look at something like administrative databases which are used for billing purposes, pretty much all healthcare systems have those in place and those could be considered an informatics application or an informatics tool, however you want to look at it.

For many of the other applications, they are not very commonly used. Let me give you an example. If you look at something like electronic medical records with electronic order entry, we don't have very good data on how widespread that is, but a couple of surveys that came out recently showed that in one study, about 15 percent of hospital systems had at least implemented partially or completely an electronic medical records system with clinician order entry. Another survey that surveyed pharmacies across the country showed that about 13 percent of hospitals had implemented these systems. It is actually a pretty small percentage and these are just hospital systems, inpatient hospital systems. If you look at things like ambulatory care facilities, nursing homes, things like that, it actually turns out that it is much, much smaller. So, from the data we have, although it not great data, we just know that it is a small minority of sites that have implemented most of these informatics applications.

Cindy DiBiasi: When it comes to many of these new technological developments, it is important but it is also difficult to separate fact from fiction, the reality from the hype. What are the latest findings from health services research about the impact of specific informatics applications on things like quality and safety and cost?

Dr. Eduardo Ortiz: We do have some pretty good data on some of these issues so I am going to begin talking about safety. We do have data that show that computerized order-entry systems can reduce medication errors. It can do this in many ways. First of all, it can reduce errors in drug prescribing. It can also reduce errors in drug dosing. It can also reduce errors that can occur in drug interactions. For example, a clinician prescribes a drug for you and you are already on a medication and it may turn out that those two drugs have an interaction that could have a detrimental effect. That could remind clinicians and say, "Hey, this potentially is a problem here. You might want to reconsider giving this drug." It also can reduce medications that are given to patients who have drug allergies. Of course, that depends on the fact that you have to enter in the drug allergy into the information system, but we do have pretty good data from several studies that show that these systems can result in significant improvements in safety.

Cindy DiBiasi: What about the newer innovative technologies? Are there any new or cutting edge applications in the pipeline that you are aware of?

Dr. Eduardo Ortiz: I am going to get to that, but before we get to that let me get on to a couple of other things that we do know in terms of the evidence for informatics applications.

We also know that informatics applications can improve compliance with recommended guidelines so they can improve effectiveness. So for example, we have data that computerized reminders can improve the use of preventative services so they can actually improve the use of certain vaccinations like influenza vaccine, pneumococcal vaccine, or screening tests or other types of preventative services. We also know that they can increase the use of appropriate medications. For example, in certain diseases like diabetes, heart failure, or ischemic heart disease, there are certain medications that have been proven to improve survival and reduce complications. We do have good data that show that some of these computerized reminder systems can improve the use of these recommended medications and therefore are very useful. We also have evidence that they can increase the use of other interventions.

We also have data on quality of care, that computerized decision support systems can improve quality. Part of that is how you define quality. Some people would say if you can reduce errors, isn't that an improvement in quality? Yes, it is. From that perspective it can definitely improve quality. If you look at a tighter definition of quality, we do have data from certain studies that show, for example, that use of computerized decision support systems can increase the prevention of venous thromboembolism. Let me just tell you what that is, very briefly. Venous thromboembolism occurs, let's say you are a patient. You are admitted to the hospital because you are having surgery or you have broken a hip or you have some procedure where you are basically bedridden or you are not moving around like you normally do. Well, you are at risk for developing blood clots that you can get in your leg. Those blood clots can cause complications in the leg system themselves and pieces of that blood clot can also break off and go up into your lung system and cause what is called a pulmonary embolism. Well, we have two studies that actually showed that the use of these computerized decision support tools could increase the use of some of these preventative measures that decrease this risk, so that is very important.

We also have data from studies that show that it can increase appropriate use of antibiotics. We have data also on cost. Electronic medical record systems with decision support tools can reduce costs. Now we don't have very good data on this. We just have very limited data. We have the data and we also, a lot of people who work with these systems feel pretty strongly that they do reduce costs. This can occur through several mechanisms. First of all, you can reduce medical errors and adverse events. Why is this helpful? One, because it can reduce costs that occur through two major mechanisms, costs that are directly attributable to the medical error. For example, if you are admitted to the hospital and there is a medical error that occurs, one of the things that can happen is it complicates your hospitalization. So you might end up staying in the hospital a few more days, so it increases your length of stay. It also may require more procedures or more tests. So it causes an increase in direct costs. The other thing is that it could potentially reduce costs that are associated with litigation from the medical errors that are occurring. From that perspective, we know that they can reduce costs.

We also know that the use of these decision support tools can result in using equally effective but less costly alternative interventions. What we mean by that is let's say, for example, you have two drugs, Drug A and Drug B. They are both utilized for some type of disease process like diabetes or heart failure or hypertension. It may turn out that both drugs are just as good, but it turns out that one drug is significantly cheaper than the other one, either because it has been on the market longer and there is a generic version or perhaps it is cheaper because the hospital has a big contract and they have gotten a better deal on it. We actually have data that show that if a clinician is ordering a drug and they order Drug B, the reminder system can then say, "Hey, wait a minute. Why don't you think about Drug A?" Drug A is just as good and it costs $.50 instead of $1.00 per pill. So we do have good data on that.

We also know that they can reduce the use of inappropriate tests and finally we do know that we can reduce the ordering of redundant tests. We have one study that showed that it could reduce this by up to 40 percent. This occurs because oftentimes one of the reasons clinicians order tests is because they don't have the test results. For example, a patient was seen in one office and he got a whole battery of tests. A week later they are hospitalized or they see another clinician and the clinician doesn't have those test results, so what do they do? They just order them again. Well, if you had these in an electronic medical record system, then oftentimes they will see these test results and they won't have to re-order them.

Like I said, the data on costs are not great, but we do have data on costs. I think it is important to point out something, though. It turns out that most of the studies that we have on electronic medical records systems and on computerized applications deal with process measures. What they have done is they have demonstrated improvements in process measures using decision support systems, yet few studies have actually assessed patient outcomes. What we mean by that is, process measures, let me give you an example of that. A process measure would be, for example, let's say you have a diabetic patient who gets a certain lab test or gets referred to an ophthalmologist. So the diabetic patient comes in and I am the clinician and I order a specific lab test that is recommended in the diabetes guidelines or I send them to an ophthalmologist because that is also recommended in the guidelines. That would be a process measure. But that is something that you need to think about in terms of that it is different from an outcome measure. An outcome measure would be, does this X diabetic patient actually live longer? Does this diabetic patient go on and develop renal failure? Does this diabetic patient end up requiring an amputation? It is important to stress that we really don't have good data on outcomes measures, but we do have pretty good data on process measures.

Finally, one of the things that we do know is that these medical informatics applications can result in better patient-centered care. What we mean by that is basically there is kind of a strong interest now that medical care should be more focused on the patient and not necessarily just driven from the provider side of things. With these new electronic tools, we can provide more information to patients. We know that that is kind of a double-edged sword because on one hand, more information may be a good thing. On the other hand, for those of you who use the Internet a lot, you know that there is a lot of junk out there. That is a double-edged sword, however, there are some benefits that come from that. This also can facilitate communication between patients and providers through things like electronic mail. It also can facilitate communication between patients and other patients through chat rooms and disease groups and things like that and also among providers with other providers so they can discuss if they have an issue or a question or a problem or maybe multiple physicians are taking care of one patient. It facilitates communication between them. It also facilitates shared decisionmaking between patients and providers.

Cindy DiBiasi: What about these newer innovative technologies? Are there any newer cutting edge applications in the pipeline that you are aware of?

Dr. Eduardo Ortiz: Yes, there are a lot of things in the pipeline. Most of the data that we have out there, most of the work has been done on electronic medical record systems with physician order entry. However, there are a lot of things that are currently either being studied or people are actually using it out there. For example, wireless devices, the PDAs, the Palm Pilots, things like that, are being utilized by a lot of people. Every day the list of people using these and the applications that they are using them for continue to increase. We also have things like automated data capture and transmission, Smart Cards, bar coding, smart automated medication dispensers, interactive patient decision support, and computer simulation for education and training. This by no means is a complete list. Some of these things are already out there being used and some of these things are being studied. We don't really have good data on their effects on outcomes at this point, but there is a lot of exciting technology that is being utilized and tested right now. We are looking forward to seeing what the results are of these technologies.

Cindy DiBiasi: We are going to be coming back to you Eduardo, because actually we are already getting questions on some of your presentations, but Dr. Bruce Bagley, I would like to go to you for a second. You are a physician who sees patients on a day-to-day basis. From a clinical provider's perspective, what is the view of the potential for informatics to improve healthcare in this country?

Dr. Bruce Bagley: Cindy, before we talk about that, it is important to kind of set the environment, what it is like out there. Most of you who are on this conference call just by the nature of it are pretty hooked into technology. Probably your everyday work involves a computer of some kind and you are pretty much in an information-rich environment with tech support and you just think it is the normal course of things. In a typical doctor's office, I hope you have all been to a doctor's office. You probably won't see so much of that around. You will see computerized scheduling; you will see computerized billing. But once you get into the exam room, probably very few of you have seen a computer in the exam room where the doctor actually does the diagnosis and treatment. So just so you know, it is a whole different world out there. It is probably the largest sector of our economy that is yet to discover information technology as a help to do their work.

Let's look at what the new environment looks like. You will see that, and I know this is nothing new to most of you, but it is going to be a cost-conscious environment for medicine. It is going to be customer-driven. It is going to be Web-connected, where everybody has access to information who has a computer, so your doctor is not the only source of your medical information. The interesting concept is that the best practices will be known by all, that anybody with a computer can find out what the latest treatments for what a particular disease might be, and go into your doctor with a stack of Web page printouts and say, "This is what they do for my disease at Johns Hopkins. Why aren't I getting it at your office?" This really needs to put all our health providers on notice that we need to have this information support.

Finally, the patients will become informed purchasers. They will begin to go to places that clearly are supported by information technology in lieu of places that are still winging it. I think the other thing is that safety and quality and accountability will become expected of our system as we have more and more discussion about that. That kind of sets the stage. To see where we are going next, I think we simply will not be able to provide high-quality, cost-effective care without information technology support. I just don't know that we could continue to improve things to provide the best possible care without some help. Most of you would not go to a travel agent that only uses a book to look up the flight schedule or tries to remember everything that is in the flight schedule. You only go to travel agents that use the computer to not only look up flights, but make your reservations. So think about going to a doctor who five years from now only uses what he or she can remember to take care of you. I think it is going to be a similar thing.

Cindy DiBiasi: Do you see the U.S. healthcare system ever going to a completely electronic medical record system?

Dr. Bruce Bagley: I think it has to. We have all the forces in place to make it happen. We finally got the electronic medical records, which are beginning to be real helpful instead of a hindrance. There is a higher and higher call for consistency and quality in healthcare and I don't think we can do that without them.

The American Academy of Family Physicians has a vision that all family physicians will use the Internet in healthcare by 2003 and that all family physicians will use electronic medical records by 2005. I do believe that is probably a stretch goal, but we have to start somewhere and we are doing what we can to cause that to happen.

The next thing I wanted to talk about, Dr. Ortiz talked about a few of these things, but information technology should be able to improve system consistency and reliability. If there is a best possible treatment for a particular disease, then we all probably ought to be doing it the same way. The way to do this is to have information management so that any clinician will have access to the same protocols for, for instance, low back pain or ankle sprain or assessment of gall bladder disease or brain surgery. So that we are all pretty much using the latest information in our day-to-day work.

Information technology can assure precision in medication prescribing. Dr. Ortiz mentioned this also. We have some data that show that as many as 30 percent of all prescriptions written in this country yield a call from the pharmacy to the physician's office for clarification. We think that using electronic medical records and faxing prescriptions directly to the pharmacy should eliminate this.

The electronic medical records should alert clinicians to allergies that patients might have to medications and the potential drug interactions and reliably transfer information to the pharmacy. The electronic medical records that we use in our office now, we are probably faxing them more than 95 percent of the prescriptions to the pharmacy to help to reduce those errors. For instance, if I try to order a medicine and think it comes in 200 mg. pills and it only comes in 20 mg. pills, I won't be able to order that because the only option on my computer is 20 mg. and when it gets to the pharmacy, it is going to be printed out in laser-clear type exactly what that prescription is. It markedly reduces the chances of error.

Cindy DiBiasi: Do you think there is going to be a decrease in prescription errors by physicians if this is out there?

Dr. Bruce Bagley: Absolutely. We have seen it already. We get fewer calls from the pharmacy about those types of things. The pharmacist is not making as many assumptions as they used to make about what this piece of paper actually says. It is a much better way to communicate.

Finally, and I think this is extremely important, I think information technology will help to support appropriate patient education. On our current system, very little happens between visits. You go see the doctor for ten or fifteen minutes and you talk about all your problems and then you go see the doctor three months later or six months later or a year later and you talk for another fifteen minutes and absolutely nothing happens in between. Now, if you have diabetes or hypertension or high cholesterol, shouldn't my computer spit out a little message to you every couple of weeks and say how are you doing on your cholesterol and if you want to send it back in, then tell us how your diet has been or take your blood pressure at home and put it on your Web page and we will put it in your electronic medical record chart. Those are all options that are not available right now.

Cindy DiBiasi: You mentioned it will be a few years before some of these things are adopted and saying that is even a stretch, that is optimistic. Why is that? What do you think these barriers are to adopting these applications?

Dr. Bruce Bagley: There are a couple ways to look at that. We have barriers to adopting re-design ideas in the office. In other words, the office of today was designed probably 50 years ago to bring the doctor and the patient face-to-face to diagnose and treat disease. More and more we are being expected to do many different tasks and our current office design just does not support that.

Some of the barriers to acceptance of re-design in the office are that physicians are currently, certainly primary care physicians, overwhelmed in their offices. They are going from start to finish flat out, no time to turn around, and just seeing patients and trying to document that well and do a good job. So when you come in and say, "I have got a deal for you. We are going to take your whole office apart and put it back together and it will be all different and much better." They don't have time to hear that message. That is the first thing. Change takes an allocation of resources and that is not something that people who have been doing the same thing for a long time tend to do very well. Physicians see the idea of a short return on investment rather than a long, so if you tell them they have to spend $50,000 per clinician for an information system, they see that as a one-time $50,000 bill. They don't amortize it over the next five years and think about the finance aspect rather than just the "Gee, I have got to pay this bill and where is the money going to come from?"

The other problem is certainly in larger organizations, is the importance of culture change. Cultures of organizations support the way that it is now. They don't very well support the way it should be. Change and leading change is important.

Finally, it requires information technology that is not currently available. Most doctors' offices, as Dr. Ortiz said, have billing computers and scheduling computers but that is about as far as it goes. Probably less than 15 percent of all physicians in this country use anything that we would call an electronic medical record at this time.

Those are the barriers to re-design. Also there are barriers to electronic medical records technology. That would be, in most physician organizations, there is a lack of real organization. If you think about the one, two, three, four, five doctors' offices, it is not really a mature organization. There is a lack of organization in systems thinking which is really required to put this, to mold this into an electronic format. I can remember when we first started up electronic scheduling. We had people scheduling on these big books and they would have so many different rules to make appointments by that it would take six months to train an operator to do the books. But we have brought in the computer and we said, "Look, we can't have all these rules. We have a few basic rules." It is much easier for the computer, although if we knew we could make the computer do that, we would use that to change the behavior of the physicians that say, "This is the way we are going to do it," and try to get some systematic thinking to it.

There is a tremendous fear out there, especially in the primary care business, which is a narrow margin business, that the implementation of computerized medical records will cause a reduction in productivity. If that happens for long enough, they will be out of business. If a vendor comes in and says, "You are going to have a 20 percent or 30 percent reduction in productivity for six months while we get this thing up and running," you just know out of hand that that is going to put you out of business. You don't want anything to do with it. That is a significant barrier.

Cindy DiBiasi: Just so everyone is clear, why don't you explain an electronic medical record.

Dr. Bruce Bagley: We can go to that. Why don't we go to this slide on electronic medical record functionalities? First is that you can do interoffice messaging and prescription writing, order entry, lab reports and generation. We can do referrals electronically. Right now I have two full-time people making appointments and writing referrals. That will soon go on to our electronic medical record [EMR] and cause a lot less work. Certainly using the super bill, right now we are circling a charge on a super bill and then somebody has to post that on to the electronic medical record. That will soon become an automated feature on the computer. Those are typical EMR functionalities.

In addition, we have entering the office visit, and that has a number of different components. The nurse's note, where the nurse takes the patient into the room and asks what the chief complaint is, takes vital signs, reviews medications. And then finally the physician note, where the doctor enters the encounter into the record and that may be dictated or use voice recognition, use drop-down lists or keyboard. Some bonus EMR functionalities would be the use of genograms so we can keep track of family history in an efficient way. Flow sheets and graphing for things like babies' weights and heights and cholesterol monitoring, sugar monitoring, that type of thing. We can scan in consults from other physicians or imaging reports that can then be viewed on the electronic medical record. And finally, it is nice to have a patient photograph to have a relationship with the patient when they call on the phone, you may recognize the name and you call them up on the phone and you might recognize the voice, but there is nothing quite like having a picture of the person you are talking to on the other end to be helpful in that relationship.

So those would be what I would call typical EMR functionalities, separate from the billing and scheduling part.

Cindy DiBiasi: We are going to get back to you on some of the other parts of the EMR and barriers, but why don't we just wrap up a little bit because we have Mike standing by, too. What do you think the role of the Internet is in the future practice of medicine?

Dr. Bruce Bagley: I think that patient access to providers is very difficult right now. You have to call your physician's office; somebody will take a message. They may get back to you the same morning or the same day, but seldom in ten minutes. There is a tremendous barrier to access. I think that the most important thing that electronic medical records and the Internet will provide is access to providers so that my patients can E-mail to me a question that they might have that isn't really urgent, but they don't have to sit and wait by the phone for me to call them back. I will just E-mail them back a few lines of an answer or have one of my nurses take care of it, depending on the topic.

That would be a tremendous bonus. Very few physicians are now using E-mail directly every day in the office. I think that would be great if we would do that. A large percentage of our patients are ready; very few of our physicians are ready.

Patients can use the Internet to learn about their own disease. They can become experts on their own disease by using the Internet. I think this is a wonderful thing. Although it is a little bit threatening to some physicians, it is wonderful for patients. I have had a patient come in and say, "Doc, I went on the Internet and I think I have prostatitis and I want this Cipro stuff to fix it up." After examining him and talking with him, I said, "Well, I think you have prostatitis. Here is that Cipro stuff." That is OK with me and I think that is an informed patient. Now whether that person should be making that decision, getting that medicine without the intervention of some clinician is probably not correct. I think that is the way things are going to go. So the more people know about their own diseases, the better.

Physicians need to have access to the latest evidence about information related to the diagnosis and treatment; I talked about this already. Everybody needs to be aware of what the latest treatments for diseases are. The idea of being able to share information on a community-wide basis with appropriate attention to confidentiality, but if as Dr. Ortiz said, if you have lab tests done or cardiac catheterization done in another city, why shouldn't that information be available to your clinician if you happen to show up in an emergency room in Florida or something like that. That should be very helpful.

The idea that I mentioned before about ongoing patient education and monitoring where people, for instance, who have diabetes, could be checking their sugars at home and go on the Web and enter their daily blood sugars into their own medical record in some way so they could be watched by a clinician without the need to be talking at the same time on the telephone about those issues. So I think that those are major bonuses that will come from the Internet in the future.

Cindy DiBiasi: We are going to come right back to you because we have a lot of questions that have come in while you were talking. I would like to go to Mike Kassis who is standing by now in California. Mike, we talked a lot about health care applications of informatics technology. What does this mean for State government and what are the different roles the State government can play that can influence the adoption of this technology?

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