Digital Medicine
For Bettina Kurowski, the memory of her mother’s losing battle with breast cancer 15 years ago provided a painful lesson in medical economics. She recalls her anger at doctors who, even after the cancer had spread throughout her mother’s body, continued to order up more rounds of chemotherapy. A medical researcher, Kurowski believed the potent, costly treatments were unnecessary--her mother was beyond cure and the side effects only made her remaining days worse.
“With cancer, more care, or more expensive care, is not always the best thing,” says Kurowski. “The money that was literally wasted on my mother’s chemotherapy might have been given to someone who might really have benefited, where a cure was possible.”
The experience helped convince Kurowski to get involved with one of the hottest areas in health care--the effort to develop better guidelines for treating specific diseases and gathering better medical-quality information about those illnesses.
With more stringent treatment guidelines, Kurowski says, doctors are less inclined to order expensive and unnecessary medical services, such as excessive chemotherapy.
Kurowski is director of SalickNet, a unit of Los Angeles-based Salick Health Care, at the forefront of efforts to improve cancer treatment and collect data on the care of patients with the nation’s costliest disease.
However, capturing that data requires, among other things, sophisticated information systems. And that’s a task at which medicine, for all its high-tech gadgetry, has been glaringly dysfunctional.
For years, the health-care industry has been notoriously inefficient at the task of gathering medical data in a form that can be distributed electronically among insurers, doctors, hospitals and pharmaceutical companies.
And entrepreneurs have only begun to recognize the potential for bringing the information revolution to health care.
In addition to Dr. Bernard Salick, who launched SalickNet, the field has attracted the likes of Silicon Valley entrepreneur Jim Clark, founder of Netscape Communications, the red-hot Internet software firm. Clark recently started a company called Healtheon Corp. to bring online medical information to doctors and other health-care providers.
“There’s a huge untapped opportunity out there to invest in [health care] information companies,” says Sage Givens, managing partner of Acacia Venture Partners, a San Francisco investment firm specializing in health-care services. “Health care is way behind the rest of industry in automation.”
Myriad problems stand in their way. Perhaps the biggest is that a sizable chunk of the data collected in medicine is confined to insurance billing claims. These claims are designed to provide insurers and government purchasers of health-care data about medical costs, not about the care rendered to patients.
“Insurance companies can tell you the total members in their plan, how much they spent for care, but they can’t tell you how their patients are actually doing,” says Salick, who founded a chain of cancer and dialysis outpatient clinics in 1984, partly out of frustration with the quality of care received by his then-6-year-old daughter after she was stricken with bone cancer.
Dr. Lawrence Piro, director of the Green Cancer Center at San Diego’s Scripps Clinic, illustrates the insurance-claims problem with a hypothetical example of a breast cancer patient who complains of chest pain. If the doctor orders an electrocardiogram and it indicates a mild heart attack, the visit would probably be recorded on insurance records as related to the patient’s breast cancer because that is her primary illness.
And anyone who has ever tried to collect medical records knows that the information resides in disparate locations--insurance companies’ files, doctors’ medical charts, hospital records, nursing homes’ files and so on.
Not only are many of these records kept on paper--doctors’ medical charts, for example--but even computerized records cannot be easily shared because most doctors and hospitals are not electronically linked.
Thus when the Pacific Business Group on Health, a San Francisco employer insurance-purchasing coalition, tried to gather immunization rates at HMOs, it had to hire an outside company to pull more than 30,000 patient files from doctors’ office shelves and compile the information manually.
In addition to Healtheon and SalickNet, which is focusing its efforts on cancer and the managed care market, the field includes Value Oncology Services, a Santa Monica-based unit of Value Health Inc., and an oncology services network set up by the City of Hope cancer centers.
SalickNet, founded in 1994, seeks to help HMOs curb costs in cancer treatment while also exploring ways to improve patient care. Last December, London-based drug maker Zeneca Group acquired a 50% stake in SalickNet’s parent firm, Salick Health Care, for nearly $200 million.
As HMOs grow increasingly popular among employers and the government as a way to rein in medical costs, employers and other purchasers of health care have pressured HMOs to collect data to demonstrate how well they are doing in treating people with chronic disease or severe illnesses.
Many experts say the cancer field, which accounts for roughly 10% of the nation’s annual medical tab, is an area ripe for such research. Studies have shown that cancer treatment--and costs--can vary widely across the country.
“Oncology is more haphazard than we’d like to believe it is,” notes Bobbi Presser, an executive with Cigna Healthcare of Arizona.
That’s an obvious problem for insurers attempting to hold down costs while at the same time demonstrating that their cost-containment efforts are not harming--and may actually be improving--medical quality.
SalickNet has developed a type of “expert system” in which it tapped the expertise of cancer specialists across the country to determine the best treatments for patients with specific conditions. And it used “fuzzy logic” computer analysis to help it analyze the differences in treatment strategies recommended by the specialists.
Since guidelines are only meaningful if doctors use them, Salick wants to makes its treatment algorithms easily available to doctors by putting personal or hand-held computers in their offices.
“The goal is to have a system where, if you’re part of SalickNet, the information technology is there to make real-time decisions, not retrospective ones,” Kurowski said. “It would display on the screen maybe five or six treatment standards” for the physician to consider.
In Florida, the company claims to be compiling the largest database in the country that charts every aspect of the care of actual cancer patients, regardless of whether they were treated in Salick-owned clinics or by Salick-affiliated doctors.
“The most significant difference is we track patients over time and location,” Kurowski said. “Typically, what happens now is each individual portion of the system collects its own data. The hospital has its own records but little or no information on what happens at the doctor’s office or a home health-care agency.”
And most HMOs and other insurers don’t track patients’ medical histories after they leave the health plan.
SalickNet’s biggest hurdle will be convincing prospective customers--HMOs and large medical groups--of the value of its product. Given the managed care industry’s self-professed interest in being held more accountable for medical quality than traditional insurers, one might think it would be easy to market a product that promises lower costs and better care.
But Salick has found it a tough sell so far.
SalickNet has only one customer, Physicians Corp. of America, a Florida-based HMO with 110,000 members. It has also signed a letter of intent to provide oncology services for the Cigna HMO in Arizona, a 420,000-member HMO. And it is in discussions with some health-care companies in California.
The reason for the resistance of a few HMOs has been strictly bottom line, Kurowski says.
Some HMO executives worry about attracting a disproportionate share of sicker patients “if they become known as the plan that provides high-quality cancer care,” Kurowski notes. “The last thing they want is to attract more people with these diseases.”
David Olmos covers health care for The Times. He can be reached by e-mail at david.olmos@latimes.com.
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Containing Cancer Costs
SalickNet Inc. was founded in 1994 to try to bring the economies of managed care to the nation’s costliest disease--cancer. The company uses a network of doctors and hospitals, supported by a computer system, to track treatments and outcomes. The company’s network includes 11 outpatient centers around the country, along with teaching and community hospitals and 200 doctors and other providers. The computer network is linked through servers in Miami and Los Angeles. SalickNet oversees cancer care for 110,000 health maintenance organization patients in Florida. Here’s how SalickNet works:
1. An HMO member goes to his or her primary care physician. If the doctor suspects cancer, the HMO or medical group refers the patient to SalickNet.
2. The SalickNet computer database selects a doctor for the patient to see. The database, which stores and updates information on guidelines, treatments, outcomes, demographics and costs, among other things, will base physician selection on factors such as what type of cancer is suspected, whether it is an initial case or a recurrence, and the patient’s preferences and physical location.
3. The physician makes an evaluation and submits a treatment plan to the nurse caseworkers and medical directors at SalickNet.
4. An approved treatment plan is then implemented. Information about the treatment--quality studies, guideline evaluations, outcomes and efficiency studies--is fed back into the SalickNet computers.
5. The network updates its database with the new information and can then recommend changes in treatment for an individual patient or systemwide changes in treatment guidelines.
