Private-sector strategies. Although the healthcare sector as a whole lags significantly behind other sectors in integrating informatics and communication technologies, as noted above, some private-sector provider organizations have already made the strategic move toward fully integrated systems. For example, Kaiser Permanente is investing $2 billion for a Web-based system that includes a nationwide clinical information system, patient communication with doctors and nurses for advice, online guidelines and protocols for providers, and all administrative functions. 24 Partners Healthcare System is implementing a system on a virtual private network that includes electronic medical records, patient communication with providers, knowledge resources for doctors, and computerized provider order entry.25 The "100 most wired" hospitals and health systems provide clinicians with access to patient data; offer Internet-based services to patients, clinicians, administrative staff, suppliers, and health plans; and provide online disease management. 26 They appear to be benefiting from better control of expenses, higher productivity, and more efficient use of services. 27
These experiences are helping to clarify not only what works and what doesn't, but also how to measure return on investment. Lessons to date suggest that calculations based on a broad, long-term assessment of returns are more useful than those looking at specific projects or technologies and that while clinical, organizational, and process improvements may be important, so too are market visibility, customer satisfaction, and employee morale.
Collaborative activities. Some healthcare plans and providers are exploring collaborative efforts. Seven health plans formed MedUnite to jointly develop a common Internet-based healthcare business transaction system (www.medunite.com). A group of national and State medical societies established Medem to provide health information for consumers and customized online patient communications for physicians (www.medem.com). Efforts such as these that extend across multiple organizations will be vital components of the NHII, but they also underscore the need for national coordination and leadership.
Enhancing continuity of care and public health outreach: Everyone benefits from automated vaccination records that are part of electronic personal health histories and medical records. Parents can track their children's immunizations over time, even if they see different physicians. Parents and doctors can receive automatic reminders when the next vaccination is due. Local vaccine reporting systems can aggregate anonymous patient data to show immunization rates by individual physician, practice group, and neighborhood. Public health officials can then compare local, State, and national rates, compare rates against CDC guidelines, and target areas for outreach and improvement.
Federal healthcare programs. The Federal healthcare sector, too, is laying the foundation for integrated healthcare and information systems. The Military Health System (MHS) is rolling out its E-Health Project, designed to improve healthcare services and benefits to military personnel and their dependents through the strategic use of the Internet (www.tricareonline.com). The project is designed to provide a common Internet entry point for MHS customers, making it easier for beneficiaries to learn how to access MHS services and benefits. It will also ensure appropriate privacy policies and practices and facilitate portability of benefits. This is the first central effort to develop enterprise-wide business rules and a single, common Internet portal for all U. S. Department of Defense (DoD) patients, providers, and managers. The project is in the early stages of development and will be implemented incrementally.
The U. S. Department of Veterans Affairs' "One VA" initiative is designed to use information technology to improve service to the 26 million men and women who have been honorably discharged from the military and their families. 28 It includes e-mail with providers and other specialists, Internet-based self-service for VA transactions, and many other functions. Several VA hospital systems are among the "100 most wired" listed above, with well-established clinical information systems. Both DoD and VA also have been pioneers in clinical telemedicine. Ultimately, the lessons from these pilot projects can be integrated into the full spectrum of Federal healthcare delivery and health insurance. Their impact on the provision of health care will be felt by private-sector providers as well, through general technology transfer and the purchasing power of the Federal Government.