E-Health: Act 2

By BENEDICT CAREY

Dec. 11, 2000 12 AM PT

TIMES HEALTH WRITER

He can come across as a scold, a headmaster, the type who lets no one off easy.

And partly for those reasons, former Surgeon General C. Everett Koop seemed like the person to guide us through the often tedious, sometimes bizarre universe of health information online.

“Here we had the father of public health, someone who is committed to promoting public health, a trusted source of information,” says Mary Cain, a health care researcher at the Institute for the Future, a Menlo Park think tank. “It’s fascinating to think how unique his position was.”

Not that DrKoop.com, the Web site established in his name, was ever a public charity; like other such online health magazines, it was a play to make money. But along the way, DrKoop.com and other consumer sites such as OnHealth.com and MotherNature.com provided alternative, supposedly independent, sources of medical information. We no longer had to rely on a sentence or two from a doctor rushing to the next appointment. We had our own reservoir of knowledge, our own online advocate. That’s why it’s not just investors who take a hit when such so-called health portals hemorrhage money, as most have been doing. In fact, business analysts now agree that advertising-based Web health magazines, as we’ve known them, are simply not viable. “Some of these sites might stick around, in some form, but they’re going to need help,” says Stephen Parente, a University of Minnesota professor who studies health care issues. “The health portals need a sugar daddy.”

In short, the very face of health on the Internet is about to change, analysts say. James Robinson, a health economist at UC Berkeley, concludes in a study published in the November-December issue of the journal Health Affairs that the Internet health care industry “stands at the end of its beginning.” Act 1 is over. And what happens next, experts say, will define our online health experience for years to come.

The good news is that the information itself isn’t going anywhere. The Internet is teeming with an estimated 10,000 to 20,000 health sites, and that number only reflects our appetite.

Some 52 million Americans seek health information online at least once a month, and 21 million of them say that the information affects their decisions about care, according to a survey released in November by the Pew Internet and American Life Project.

However, those millions of people generally aren’t paying for the information, analysts say, so someone else will have to. And that someone will need a large wallet. “About the only possible way to support these general information sites is money from the big players,” says Parente. “The drug companies. The big insurers. Maybe the government.” Dr. Ari Kellen, a partner in the health care practice at McKinsey & Co., a management consulting firm, argues that those in the best position to move in are institutions with an international reputation: the Mayo Clinic, the Johns Hopkins medical institutions, Memorial Sloan-Kettering Cancer Center, to name a few.

“The general information portals have huge value as a place to understand a disease, evaluate treatments, and help select providers,” Kellen said in an interview. “And I think there are a number of potential owners, including the big hospital systems, with brand and reputation.”

In fact, the major research hospitals and the government have had a presence on the Internet for a while. The Mayo Clinic’s site, Mayohealth.org, for example, was the sixth most-visited health site by consumers in November, according to PC Data Online, which tracks Web site traffic. The No. 2 site was the one operated by the National Institutes of Health, NIH.gov, due in large part to its powerful research-finding engine, Medline.

These are the very sources that the health portals have been using for medical information all along, doctors say. “And I expect those sources will remain and expand,” says Dr. Edward Fotsch, chief executive of Medem Inc., a consortium of medical societies, including the American Medical Assn., that are working with doctors to establish their own Web sites.

Big insurers and drug companies have also proved they can attract consumers online. The Swiss-based pharmaceutical firm Novartis owns Healthandage.com, for example, which was the eighth most-visited consumer site last month, according to PC Data. Aetna U.S. Healthcare’s consumer site, Intelihealth.com, was 11th, just ahead of pharmaceutical giant Merck’s Merckmedco.com.

And Kaiser Permanente, the nation’s second-largest HMO, is investing some $100 million to establish its KP Online (https://www.kponline.org) as a full-service site for its 8 million members to handle appointments and prescriptions, submit questions to doctors and access general medical information. “We see this site as a way to reach out to members,” says Dr. Oliver Goldsmith, medical director for Kaiser Permanente in Southern California, “and link them more closely with Kaiser doctors.”

In the next few years, experts say, look for these institutions to consolidate their power online and develop their own versions of Web health magazines--pulling customers away from sites such as DrKoop.com.

Thus the new boss: same as the old one. With the same possible conflicts of interest, the same mixed record in communicating to consumers.

Says Parente, “If a major drug company takes over a site, I don’t know how much consumers are going to trust them, at first.” Other e-health observers agree: Drug companies will have to work to earn public trust--and the same goes for big insurers who provide information to their own customers.

“I greatly value the information I get from my HMO online,” Deryk Van Brunt, an executive vice president at HealthCentral.com, a consumer site that sells drugstore items. “But if I go to their site to learn about a procedure, and they tell me it’s not necessary, and they don’t pay for it--well, the first thing I’m going to do is hop online and check that out.”

But where to start? Let’s face it, most of us have no idea upfront which site is best going to answer our questions. We simply start with a few search terms--”depression, treatment”--and punch them into a search screen like Altavista.com or Google.com. A second later we’re staring at a rogue’s gallery of URLs, from the obtuse to the absurd.

“The problem isn’t so much that there’s too little information on the Web,” says Fotsch, “but that there’s too much.”

That’s why some e-health observers foresee the arrival of a new type of service--a kind of online filter.

“Consumers are going to be taken in by hucksters as much online as they are offline,” says Cain, the Institute for the Future researcher, “but I think what we’re going to end up having is authoritative sources from clinics that are available to the public, and maybe some sort of filter, a Consumer Reports type of group or government service, that helps people interpret that information.”

Some sites already attempt to provide this kind of service. Medmatrix.org, for example, provides quick, one- to five-star ratings for hundreds of medical sites. And many of the medical societies--the American Academy of Pediatrics, for example--post reviews of other sites in their particular specialty.

Yet so far, no single site is providing ongoing, in-depth reviews strictly for consumers. “And if we do get one,” says Cain, “there would be a subscription for it. And I think people would pay.”

Meanwhile, there is the one expert that most of us trust: our own doctor. He or she not only knows something about us, but can get us a prescription, a referral, a dose of common sense.

“Right now, people pick up the phone and talk to doctors and listen to them,” says Van Brunt. “At the end of the day, we are moving toward an environment where patients are simply calling their doctors online. I think within five years most doctors and insurers are going to have their own sites, and this is one way they will communicate with patients.”

According to an ongoing physician survey supervised by Fotsch, about 50% of doctors already have their own Web site or belong to a practice that maintains one. And about 10% of doctors communicate regularly with patients online.

“Most of this traffic is appointments, questions about prescriptions, and so on,” says Fotsch. “But eventually I see patients e-mailing their doctor questions like, ‘I’m 45 years old and just got married. What’s the likelihood I’ll get pregnant?’ or ‘Should I be on hormone replacement therapy?’ And maybe they’d get three or four paragraphs back from their doctor. Surveys have shown that consumers would pay for this, and I think this should be a huge wake-up call for doctors.”

If the experts are right, then, the electronic health care landscape will soon look a whole lot like . . . the brick and mortar one.

Instead of starting with DrKoop.com to learn about a disease, that is, we might begin at the Web site of our hospital or insurance plan, such as Aetna or Kaiser. To check that information and learn more, we could use some kind of Consumer Reports service to find the best specialized sites--Mayo, say, or UCLA, or the Scripps Clinic. And if we want to go deeper still, down to the original research, there’s always Medline.

Finally, at the end of all this, we could pose several well-informed, specific questions to our own doctor--who knows us, who knows our personal health history, and who could provide just the answer we need.

All made possible, in one sense, by the efforts of the online health magazines. “The DrKoops of the world went that last mile, taking sophisticated medical information and bringing it all the way to the consumer,” Parente says, “and in that sense, they have performed a public service.”

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E-Health: Act 2

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