Internet Health Day

Andrew S. Grove
San Francisco, Calif.
October 27, 1998

Some of you I know have come from a long way away, some from nearby. But the willingness for each of you to take a day out of your busy schedule -- and I know we have here today leading physicians, the most senior executives in the country, health technology entrepreneurs; you're all busy people -- the willingness for you to take a day out of your schedule to participate in this to talk about the revolution that's taking place around Internet Health, that in itself is a mark of the power of this market shift toward Internet Health.

It was just a little bit over a year ago when Andrew S. Grove and Craig Barrett asked me and my team to take on this seemingly impossible task of analyzing and understanding some of the barriers to computer use in health care. In talking with dozens of leaders in health care -- many of you are here, in fact -- it became obvious that many -- in fact, probably most of you -- share a vision for the improvements in quality, the reductions in cost, gains in efficiency that personal computers in the Internet could deliver in health care.

You share a vision of doctors and patients using Internet-based health information, Internet-based commerce, health-related commerce to deliver care with the efficiency that the Internet has brought to stock, to book buying, a number of other industries. That shared vision is what brings us here today.

We, at Intel, felt that we could provide a forum, a place to have this discussion, a place to showcase that vision that you all share. We want to spotlight some of the people who we think are leading thinkers, pioneers in this field, and help in their own way to establish some momentum behind this area of Internet Health.

A lot of you, and I've gotten this question many times over the last year, ask why Intel? I'm sure you're wondering that. I can assure you we have no plans to enter the health care business. As I think I said to other people, the margins are too low and there's too much regulation.

(Laughter.)

STEVEN McGEADY: But at Intel, we have a culture that's been established and nourished by Dr. Grove, who will be speaking in a moment, of searching for new users and new uses for our core product, the microprocessor and the computer that's built around it. And I've spent much of my career at Intel doing that. Our engagement in those areas, as well as the television and entertainment industries, have made the PC a useful and valuable tool and have helped grow the overall market for the entire PC industry, including, of course, ourselves.

It's in that light we are hosting this meeting as Intel Corporation. No other market segment touches so many lives or touches them so deeply in such an important way as health. But while we at Intel understand that technology -- understand the technology that will inevitably deliver health information and health commerce -- we don't have the skills to tell good medicine from bad medicine. We hope this meeting will prompt you to engage with these new opportunities on the Internet and to ensure that the Internet delivers good medicine, delivers services and information that will contribute to the health and welfare of all Americans.

I want to stop here. I'm not going to say much more today until the end, but I do want to thank two organizations who have helped make this event possible: the American Medical Association and the American Academy of Pediatrics. Their sponsorship is very important to us here today, and I'd like to specifically thank Dr. Bob Musacchio from the AMA and Mr. Anthony Chan from the AAP for making this happen.

(Applause.)

STEVEN McGEADY: Thank you. Now to the real goods. It's my pleasure to introduce the first of our two keynote speakers today.

Dr. Andrew S. Grove participated in the founding of Intel Corporation in 1968. He was one of the Fair Children, as they were called, who came from Fairchild Semiconductor and established the modern semiconductor business. Andrew S. Grove became Intel's president in 1979, he became CEO in 1987, and is now chairman of the board of Intel.

But it was not Andrew S. Grove's position at Intel that led me to ask him to come here today and speak. It was his role as an author. It was his role as an author and a visionary in our industry, recognized as a Times Man of the Year this year, in fact. But Andrew S. Grove is an author of his most recent book entitled "Only the Paranoid Survive," is a speaker on the subject of Strategic Inflection Points, the revolutionary changes that technology can bring to markets, and possibly most important to you here today, how to survive them. And he's a visionary technologist who also became a pioneer consumer of health information. In both of these roles he has a very compelling message. I welcome him here today.

Ladies and gentlemen, please welcome Dr. Andrew Grove.

DR. ANDREW S. GROVE: Thank you. Good morning. Actually, what I would like to start talking about is the "X Factor." The phrase X Factor, to my knowledge, goes back to Alan Greenspan, who, once holding forth about the sustained duration of the good economic climate in the United States, attributed a good portion of it to this unknown and unknowable factor associated with information technologies.

The use of information technologies has in fact fueled the global economy for some period of time now. It has fueled it through capital purchases, but, more importantly, it has fueled it through changing the business processes which modern businesses, large and small, conduct business.

As a result of the utility of computing, particularly that computers are connected to computing, worldwide computer network, I would like to describe our situation as heading steadily toward a vision of a billion, not an apocryphal billion, but literally a billion connected computers around the world, all on a standard computer network. Any computer being able to communicate with and sharing data with any number of computers, large and small, that are connected to this network.

I said it's not an apocryphal number. I would like to give you a status report of where we are in our progress towards this census. This chart shows the number of connected computers, connected personal computers, basically, as a function of time. And it is a 1997 forecast that puts us someplace in the hundred million connected computers status as of today.

As many of you probably realize, this has not been one of the best years of the computer industry in recent times. Growth of personal computers, growth of semiconductor industry that supplies personal computers all have been stymied by problems in Asia and potentially saturation, one thing or another.

But this particular forecast, when we updated it in 1998, bucks the trend and shows that the ‘98 census of connected computers is actually almost twice what we anticipated a year ago to have been. And the growth going forward is higher than what we anticipated before.

This kind of dynamic in an economic climate such as the one that we have had in the last year, year and a half, speaks to its utility. When, in a period of tougher economic climate, the purchase and investments in an infrastructure accelerates, it is only because that infrastructure provides something very, very useful.

There's a corollary data to that which puts this in the context of the adoption of other different kinds of media historically, going back to radio, television, telephones, and lastly, the yellow line is the Internet connected computers. The rate of adoption of this technology as viewed against the history of the rate of adoption of other interconnected communications-related technologies in the last hundred years is simply staggering.

Anecdotal evidence that kind of goes along with this statistical data is all around the place. A recent survey by a local newspaper down in the San Jose area estimated 20 million people connected in the Internet, not just something they connect to, but an indispensable part of their life.

Given this kind of environment, what I submit to you is that the X Factor is very near to doing this work in medicine. And at least some of us who are consumers of the medical industry or the health care industry think it is probably a good thing. And those of you that are on the other side of the divide between patients and suppliers, consumers and suppliers of medical services, might consider this as a Strategic Inflection Point much as the line that Steve mentioned earlier.

Let me -- give you a brief description of what Strategic Inflection Points are about. I use this graphic to describe it. A business progresses along in a basically steady, smooth fashion, and hits a subtle point at which point the curvature of the progression of the elements, of the dynamics of the industry change.

Depending on the action that participants in that industry take at that point, at that inflection point, at which point nothing profound, nothing major, nothing cataclysmic happens at first blush, the curve is still smooth. But depending on the action you take, you go down one path or another path. If your actions are such that they are consistent with the future developments of that curve, you're going to progress onward probably to unprecedented heights. If you do not take those actions or you take actions that are inimical to those developments, you head down.

That's what a Strategic Inflection Point is about. And when you miss those points and you are in the descending branch of that curve, it is extremely difficult to replay history, to reset your progression, and to correct for the action that you didn't take at the inflection point.

Let me give you a few factors that suggest that such an inflection point is near. Of the people online, almost a half of them say that they've used the Internet for looking for health information. Another factor, there are more than 15,000 health-related Web sites available on the Internet. And, incidentally, any number like this has to be viewed as the lower bound of the possible real numbers, because all you know is the site that you find, and you never can exhaustively search the Internet for sites. So that is the lower bound of the number of possible sites dealing with health information. And, consistently, the first bullet head, almost half of all consumers have used the Internet for health information in the last 12 months.

I almost would like to call for a show of hands at this point just to verify this thing. But this is a very biased audience. I don't know which way it is biased.

(Laughter.)

DR. ANDREW S. GROVE: But we'll pass the test. What we're looking for online generally, good health information.

You know, for many, many years, I had a well-worn volume of a book that I looked up when I had some kind of an ouch to see whether it represented heart attack, stroke, cancers, or anything of that sort, and generally reassured myself that it didn't, put the book away.

That book is approximately 25 years old. And it is very, very clumsy to use. And the reason I didn't throw it out, because I got used to what I would call today the human interface. I knew how to find my way in that book. And because of that, I put up with the limitations of a 25-year-old piece of information. All of that is not necessary on today's Internet.

In addition to the basic health information that's available, a growing number of sites, both provided by health organizations and provided by other patients, provide tips about managing chronic diseases, tips about alternative medicine, supplements, dietary supplements, vitamins, and the like. And, increasingly, people use the Web for checking on their health care providers, because with a search engine, it's fairly easy to find out what otherwise would be a mystery.

But the most telling information, which is actually, if you are on the other side of the digital divide, so to say, separated between health care providers and health care consumers, is the one in the red bullet head. Sixty percent of the doctors report that their patients come in with sheaves of information that were printed out of the Internet. So if nothing else, self-defense compels you to take some action.

We like to look at the evolution of the use of connected computing or the Internet in health care in a number of stages. And the first stage of that is when you're dealing with the most elementary use of the Internet, which is as an information source. And this comes through health portals, disease-specific sites, and general research and reference materials.

I had some personal experience with -- as probably a number of you know, I've been diagnosed -- three or four years ago, I was diagnosed with prostate cancer. And around that time, I was out of town. I didn't even have my favorite little book that had about this much (indicating), it turns out, on prostate cancer. Not in terms of thickness of papers. That much in terms of paragraphs, one paragraph about prostate cancer. And I was stuck with the laptop computer in a mountain cabin.

Not knowing what else to do -- this was not very fashionable in ‘94 -- I started searching on prostate cancer on my online service provider. This was preconsumer Internet days. I was a CompuServe* subscriber.

And I found all of the elements that we are talking about in a matter of the first hour of being online. I found basic information, review papers, reviews papers written by some pretty prominent doctors, but more importantly, I rapidly stumbled on what in today's terminology would be described as a support group, where patients were exchanging information and describing their experience with different treatments and different medical procedures.

And it opened up a whole field of knowledge that was very, very pertinent and vitally pertinent to me and got me on to researching the disease both online and off-line very, very substantially with that start, and also tipped me off regarding the power of this medium for people anywhere in terms of information and support sources.

Since that time, CompuServe is not where the action is. The action is on the Internet. And some of those 15,000 sites that are available are shown here. But, literally, dozens or hundreds spring up every day. And, quite clearly, there's going to be evolution here. Consolidation is going to take place ahead of us.

But this method of displaying information is here to stay. But this information is basically static information. This is, in a way, a library at your fingertips, but you cannot conduct a dialogue with a library. But this medium is fundamentally an interactive medium, and it was only a matter of time before interactivity was going to be superimposed on the library style elements of it. And to give you a demonstration of what this might be like, let's welcome Dr. Scott Rifkin, founder and CEO of America's Doctor on AOL to give us a demonstration of this. Dr. Rifkin.

(Applause.)

DR. ANDREW S. GROVE: Tell us about America's Doctor on AOL.

The site is a full-featured site. We have 6,700 library articles that the consumer can download, print, they can e-mail the articles to a friend, frequently asked questions, a news service with online news services, the wire services that get updated every 15 minutes, special events from our various sponsors around the country, which are typically hospitals and insurance companies. But the area we're the most proud of that is unique is "The Doctor Is In" area. The consumer has the ability to go into this area, click through the long disclaimer created by the lawyers.

(Laughter.)

DR. SCOTT RIFKIN: Can't get away without that. Select a topic, children's health, women's health, pharmaceutical questions, dietary, and speak to either a physician or in this case a pharmacist or a dietitian in an area that's of interest to them at the time they want to speak to somebody. So they would then hit -- Oops, we'll go back to -- we're going to click, do this, go back in real quick. We're going to hit that disclaimer, and then we're going to pick the test queue just for test purposes today.

And in a few moments, up on my screen over on this other side will come the ability for Dr. Grove to pose a question and then I'll respond back to that question in real time the way a consumer would.

DR. ANDREW S. GROVE: It says there are 28 people ahead of me. How long do we have to wait?

DR. SCOTT RIFKIN: That's correct.

(Laughter.)

DR. SCOTT RIFKIN: The typical wait --

DR. ANDREW S. GROVE: Gives me a realistic feeling of the waiting room.

(Laughter.)

DR. SCOTT RIFKIN: The good news, that our average wait time has been five to 10 minutes, which I'll be willing to wage everyone in this room, if they call their own physician, it's not going to be as quick as five to 10 minutes. We actually have a large number of physicians who are online answering these questions very quickly. We're actually ready to respond to a question.

DR. ANDREW S. GROVE: Should I send you a question?

DR. SCOTT RIFKIN: That would be great.

DR. ANDREW S. GROVE: I'm trying out something hard.

DR. SCOTT RIFKIN: The first thing that our docs. ... Now, we're going to recreate what's going on in our call center. We're doing this live through our call center in southern Maryland. The first thing our physician would do would be to access that medical library, those 6,700 articles, and the physician then said -- invite the consumer to read an article. And then I will drop this to them, and you'll see my typing skills. And we would then send that message to the consumer. I would open up, as the physician talking to Dr. Grove, I would open up our library, I would go to common illnesses, I would then hit influenza, and then I would pass that message, and you'll see it come up on Dr. Grove's screen. And there's the article.

That consumer can read this article and then come back online. And while Dr. Grove is reading, as the physician I would type in, "Please read the article." Now, this conversation could take five to 10 minutes online, but we'll compress it a little bit. And the consumer then has the ability to get that article explained to them.

DR. SCOTT RIFKIN: That last word should be "question." That's why I'm not a typist. We actually, for our physicians who can touch type, they do it themselves; otherwise, we give them a typist right there. Very shortly, we'll use voice recognition to be able to make it even quicker for the consumer, and that technology is just starting to get there, which is very nice.

The physician will then -- sends back questions. The first thing they may ask is just -- may give a statement about egg allergies or other allergies that may be an issue. "Are you allergic to any of these?"

Now, the physicians have the ability to be working with three or four consumers at once. It actually could access up to eight but that gets a little confusing. But three or four, once in a while, the consumer is typing, they're typing, the consumer is reading an article, other things are going on at the same time. We would then refer, at this point in this kind of a conversation, that they speak to their physician.

(Laughter.)

DR. SCOTT RIFKIN: Now, keep this in mind, what we want to do is if they read this whole long article, they're going to learn who should get a flu vaccine, what groups are recommended to get the flu vaccine. It's the kind of information a consumer should have.

We're not going to replace the physician. We're not going to diagnose, prescribe, make individual decisions for the consumer. As bandwidth grows, you can surmise those things can go on the Internet, but the purpose of this is to give the best possible information perfectly tailored to the consumer. So as soon as Dr. Grove asks about a specific allergy, we may say, "It's not going to be recommended for you, but speak to your physician."

DR. ANDREW S. GROVE: How is it going so far?

DR. SCOTT RIFKIN: We expected to get a thousand consumers per day accessing this site, the "Talk to a Physician" site. We've had an average of 4,800 consumers per day or 200 million for this year, with little promotion ourselves. We've had as many as 6,000 consumers in a day access "Ask a Doctor" with promotion of the site, and when the Internet has promoted us, it will go forward from that.

DR. ANDREW S. GROVE: I look forward to you being on the Internet, not being an America Online subscriber.

(Applause.)

DR. ANDREW S. GROVE: The next level the sophistication has to do with the formation of communities. And just a bit of history of communities. Communities have always been a major factor of online usage. In fact, the proprietary online services were driven predominantly by chat room activities, communities of interest dealing with each other, including, for example, that CompuServe example that I told you.

And this continues on today on Internet activities. Some additional factors here for you, 33 percent of users, not medical users, altogether Internet users, are part of an online community of some sort. In the case of America Online, that has a very heavy chat history, the number is 43 percent. And when a particular site adds chat room activities to that, to its capabilities, to its offerings, user participation and user census skyrockets.

This has to be exactly that way. I would venture a personal opinion that it will be even more so in medicine because people afflicted with a disease tend to look for support far more than the average person. And I would like to demonstrate that by showing you an application called CHESS. And please welcome Dr. David Gustafson, professor of engineering and medicine from the University of Wisconsin, who is director of the Center for Health Assistance Research and Analysis. Dr. Gustafson.

(Applause.)

DR. DAVID GUSTAFSON: Dr. Grove.

DR. ANDREW S. GROVE: Tell us about CHESS.

DR. DAVID GUSTAFSON: CHESS is the Comprehensive Health Enhancement Support System. CHESS is a computer system that's currently Internet-based and provides support and information and help in making decisions in areas of serious disease.

We've been developing CHESS over the last nine years and it's now available in approximately 25 large health care organizations around the United States. The idea behind CHESS really is to focus on people who are going through a health crisis. When a person is diagnosed with a life-threatening disease, they go into a crisis mode. They desperately need information, they desperately need to talk to other people like them who are going through the same problem that they're going through. And what CHESS does is allow them to do that online.

We take computers into the homes of women who are diagnosed with breast cancer or people who have been diagnosed with heart disease and so on, and we leave the computers there for somewhere between three and eight months. And during that time, they use CHESS to cope with the disease that they're facing.

DR. ANDREW S. GROVE: You provide the computer yourself?

DR. DAVID GUSTAFSON: That's correct, yes. We actually, for people who don't have computers, we deliver the computer to their home, we install it, we train the people to use the machines.

DR. ANDREW S. GROVE: What is the reaction of the patients to this?

DR. DAVID GUSTAFSON: The reaction probably can best be described by listening to and seeing a video of Valerie, one of the people on the south side of Chicago, who had CHESS for several months because of her breast cancer.

(Video playing.)

VALERIE: The at time I was diagnosed with my cancer, someone called me on the telephone and told me about CHESS program, a computer program that all I had to do was just set it on my table at my house and I could actually talk to other people on it. And it's like having a doctor in your own home, you know, that you -- it's like having your own doctor in your front room that you could talk to. And you can ask any questions you want to, and you have the privacy also. You don't have to go out your door. You know, it's not like you have to go and jump in your car, run to the hospital. You just go up in the front-room part of your house and you can ask any question that you can think of. And before you go to sleep that night, the majority of your questions are going to be answered. And you're not going to even be interested in going to sleep because you're going to want to ask questions continuously until you just get drained, have every question you can think of out of your head. It's just wonderful. It's wonderful, and I can't make it any clearer to you.

(Applause.)

DR. SCOTT RIFKIN: Can I show you CHESS?

DR. ANDREW S. GROVE: Please.

DR. SCOTT RIFKIN: Good. CHESS has a number of topics. Right now, breast cancer, HIV, and heart disease comprise the primary uses of CHESS. But we're also in the process of developing new areas and modules like prostate cancer, alcoholism and so on. When a woman turns on the program, she must log in because -- and I'm going to show this in the area of breast cancer. She must log in to give her access to certain aspects of the system and protect access in other areas.

CHESS has three parts to it. One is a set of information services. These are on the left-hand side of this menu. One example of those services is questions and answers. Through a needs assessment that we conducted with around 400 women and their partners, we identified a large number of needs, and in each of these areas of need, we've identified a series of questions.

For instance, as an overview of CHESS, we have a bunch of questions on meaning and cause of breast cancer. After they read that brief answer, they can go into much more detailed information later on if they wish. But the focus of questions and answers is to give brief answers to approximately 500 questions.

Let's see if we can -- there we go. There are other information services. For instance, there's an instant library of around 250 of the key articles on breast cancer. There's a consumer guide that teaches people how to be more informed consumers of health services, a referral directory that allows people to identify providers of care, and a dictionary that allows people to understand some of the key words that they're going to be using. So that's the information part of CHESS.

DR. ANDREW S. GROVE: What about the support part?

DR. DAVID GUSTAFSON: Yes. In the community area, we have two different kinds of services. One is discussion groups. And in that area, we have a number of small facilitated discussion groups. We don't allow more than 45 people in the discussion group at a time because we want them to get to know each other well. The other service, though, is personal stories. Here we've sent science writers into the community to interview patients and family members about what it's like to be a woman with breast cancer. Here, for instance, is Adrienne. She's a woman in her 60s. This is focused around her needs identified and those needs assessments.

DR. ANDREW S. GROVE: So a patient can go in and look at individual stories about other people. What about, what is the support group like?

DR. DAVID GUSTAFSON: The support group, which is the discussion group here, there are a number of discussion groups that a woman can go into. For instance, she can go into one for women with breast cancer only. If she has metastatic breast cancer, she goes into that discussion group. There's a prayer group she can elect to go into. Her partner can go into a partner's group, her children can go into a children's group, and so on. And they carry out discussions. Really, the discussion group is the glue that holds everything together. About 50 percent of all uses of CHESS occur in the discussion group.

DR. ANDREW S. GROVE: Have you studied the impact of these electronic discussion groups on their prognosis and the well-being of the patients?

DR. DAVID GUSTAFSON: We've carried on a number of tests on CHESS. We've had three randomized control trials involving about a thousand people. We've also had a number of field tests. And in those, we've learned a lot about the use of the discussion groups. The only test where we have actually compared the online discussion group against psychotherapy is a very small test in adult children of alcoholics. We only had 24 people in this study, so we have to take it with a grain of salt. But the findings are interesting in the following sense. After a 10-week installation, we measured quality of life of people who were receiving group psychotherapy, compared it to the quality of life of people who were using CHESS. In five of six dimensions, the quality of life of the people in group psychotherapy went down. In all six dimensions, quality of life in the people using CHESS went up. And so that gives us reason to believe and some optimism for the potential of these groups to really make a difference.

DR. ANDREW S. GROVE: So let me make sure I understand it. There have been a number of studies showing, particularly in the case of breast cancer, that participation in real-life support groups extends life expectancy and helps the patient. You are saying that in your particular small comparison, the electronic version of the support group was superior in comparison to the live one?

DR. DAVID GUSTAFSON: In terms of quality of life. We can't say anything about longevity or recurrence or anything like that. All we can speak to is issues of quality of life on that dimension.

DR. ANDREW S. GROVE: But the answer to those discussions --

DR. DAVID GUSTAFSON: And we are now involved in five new clinical trials involving around 1,500 people. And those studies will allow us to look at more long-term impacts of the system, not only for breast cancer, but also for heart disease and smoking and a number of other areas.

DR. ANDREW S. GROVE: Now, all of this has to do with the medical impact of participating in online groups. What about the subjective impact? How do the patients like this?

DR. DAVID GUSTAFSON: Well, the subjective impact has really been powerful. One of the things that we have found, for instance, is that the number of use of CHESS among women who are older, say, over age 60 with breast cancer, is at least as high as women who are younger with breast cancer. And their quality of life improvements are at least as good.

We also find people with low education perform on the system as effectively as people with high education. They use it as much and their quality of life goes up at least as much. But maybe the best way of describing the effect and the reactions to the online support groups is to hear again from Valerie.

VIDEO: No kind of way. How's a machine going to help me? You know. No kind of way did I ever think that, though. No. I thought all the way you really get help is through people. But it is through people. The machine is helping you through people. You know, when you feel like you might be talking to your own person about the -- let alone are you talking to other patients with the same problem.

DR. ANDREW S. GROVE: Thank you very much Dr. Gustafson. That's very, very impressive.

DR. DAVID GUSTAFSON: Thank you.

(Applause.)

DR. ANDREW S. GROVE: The next stage of utility layered on top of what we have described is when patients can communicate with the health care provider through the use of electronic media. Again, give you a few facts. This is not one of the shining examples of penetration, because, quite frankly, it requires the willing and enthusiastic participation of the health care providers as part of the network. And the picture here is quite mixed.

Some information is shown here. While the overwhelming majority the doctors use e-mail for communicating with other doctors, an almost negligible portion of those use e-mail to communicate with patients. And of that terrifically small percentage, only 13 percent find it useful. This is very, very strange to me.

What my personal experience says about that X Factor that we've talked about earlier is that the speed and efficiency of communication in a fast-paced economic world is where the X Factor has done its work in industry and commerce.

I can testify to that in terms of our own experience at Intel, where we have 70,000 employees, all of them on electronic mail, and where, by far, the preferred means of communication between each of us, like to the extent of 10-1 preference, is e-mail versus telephones. It is puzzling that this same phenomenon would not be at work in the medical world, in the health care world, and particularly when you consider that another layer of utility comes from conducting garden-variety, routine transactions, ordering medicines, filling prescriptions, asking routine questions, things that are kind of the housekeeping that a company -- the fundamental work of medicine.

Increasingly, the water is surrounding the castle here. And it is happening on over-the-counter areas, where it is unregulated, it is happening in alternative medicine areas, it is happening in nutritional supplements and all of that stuff. Sites that can fulfill these transaction requirements proliferate.

It is probably a major question of what it takes to allow the clear benefits of interconnected technologies, interpersonal communications to extend to the world of patient-to-doctor communications. And I would like to welcome Dr. David Stern, assistant professor of internal medicine from the University of Michigan who is engaged in such a study. Dr. Stern.

DR. DAVID STERN: Good morning.

(Applause.)

DR. ANDREW S. GROVE: Good morning. Tell us about your study.

DR. DAVID STERN: Well, we're doing a study at the University of Michigan in collaboration with CHOICES, which is the Center for Health Care Outcomes, Innovation, and Cost Effectiveness Studies. The scope of the study is quite large because our center is quite large. We've got 30 health care centers, 120 outpatient clinics, 878 inpatient beds, and over 800 residents and fellows at the university. Our particular study is focusing on the internal medicine residents and the over 7,000 patients that they care for at both the University and at the VA hospitals.

DR. ANDREW S. GROVE: So what is the study about?

DR. DAVID STERN: The study itself has the goals of evaluating the content, the efficiency, and the satisfaction of both patients and physicians with their e-mail communication.

DR. ANDREW S. GROVE: Can you give us a demonstration of it?

DR. DAVID STERN: Sure. Let's say, for example, on a patient -- and here we're using one of my patients from the VA, Mr. Haggerty, who logs onto our Web page. And he has a number of options. And one of the benefits of this particular study is that it is going to ease the communication burden on physicians by allowing patients to use these various transactions. We've used the word "transactional e-mail" so that we can properly tag e-mails coming from patients to refer them to the appropriate physician, clerk, nurse, or pharmacist.

So, as a patient, Mr. Haggerty comes in and says, well, today I've run out of my medicine, and I think I'd like to get a referral -- a refill of that. So I click on the "Refill." He writes in which medicine of his he'd like to refill, digoxin, for instance. And because he wants to get three months of refills, he writes in "90 days" and tells me where he'd like to pick it up, here, the University of Michigan campus pharmacy. And he can write in additional comments down here if he'd like. "I need to get this Fed Ex*'ed to me tomorrow because I'm running out today." Can then scroll down and submit it.

Now, one of the great benefits of the e-mail that we've set up for these physicians and patients in the study that I, as Mr. Haggerty's physician, may not get that e-mail immediately. I'm busy, at two hospitals. I may not get on my e-mail that quickly. So we've situated a nurse between the physicians and the patients so that these e-mails go directly to both the physician and also to a triage nurse. We step over here and show you what the triage nurse sees.

Because the patients have already identified a characteristic tag for that e-mail, the transaction type, you'll see over on this side the nurse has "Prescriptions," "Questions," "Laboratory Results," "Referrals" and "Billing." So for simple questions like billing, that the nurse is going to have nothing to do with, she'll simply send it off to the billing clerk to manage that question, or referrals, etc.

In this particular case, the prescription for Mr. Haggerty just popped up on the screen here as unopened. And the nurse can then look at that and see that Mr. Haggerty, my patient, Dr. David Stern, is looking for digoxin, 90 tablets. A very simple procedure for her, then, is to reply to that message. And, of course, she's going to reply to him to let him know that the prescription is ready. But she can also reply to me, the physician, to let me know that my patient has asked for a refill. And she can send it off to the pharmacy, in this case, the University of Michigan campus pharmacy.

DR. ANDREW S. GROVE: So the nurse is authorized to fill this prescription, and you get notified, and whenever you log in on your e-mail system next, you find that out.

DR. DAVID STERN: That's correct. The nurse has protocols for responding to these sorts of things over the telephone. This simply automates it and makes it easier for her and the physician. Then they can simply send that message.

DR. ANDREW S. GROVE: And what are you looking for in this study?

DR. DAVID STERN: We're looking for a few things. One, because it's a research study, we're counting the number of e-mails by transaction type. There's no guarantee that the kinds of communication that you and I have, for example, in an office or even over the telephone are going to be the same as the kinds of communication that we have been e-mail.

Second, we're also looking for decreases in the phone traffic coming into our clinic as well as increases in patient and physician satisfaction.

I think e-mail like this is a very powerful tool that -- if we can learn to manage it well and fit it into the work flow of physicians and of patients. If we can manage it well, it's going to be a powerful tool that will -- even though physicians and patients have some concerns about using e-mail, it's going to be -- patients are really going to latch onto it.

DR. ANDREW S. GROVE: Patients have concerns about --

DR. DAVID STERN: Patients have concerns about confidentiality on e-mail. Patients have concerns that their physician won't call them back when they use the telephone. This is the sort of way to improve and enhance that sort of communication. They have concerns, and we think we have some solutions here that will address them.

DR. ANDREW S. GROVE: And the physician's concerns are?

DR. DAVID STERN: The physician's primary concerns are work overload. The average primary-care provider has over 2,000 patients in their panel, and physicians that -- one of the explanations for the comment that you made earlier about physicians not using e-mail to communicate in a similar way that your people in your business do is in part because they think if they open up the floodgates to 2,000 patients, suddenly their e-mail would be overloaded by that. This particular system allows triaging and prioritization of e-mail in a way that makes it more effective for the physician.

DR. ANDREW S. GROVE: Dr. Stern, this reminds me of the evolution of e-mail in business as well, because for various considerations, when e-mail started, for example, at Intel, what I had done was my secretary received my e-mails, printed those out, gave those to me, I scribbled something on it, gave it back to her, and she filled it out. And I don't know whether I was worried that thousands of Intel employees were going to send me e-mail, but it seemed like a natural extension of how we operated with the pink slips, telephone messages.

And I finally came to the conclusion that this is utter nonsense and it throws out all the benefits of the immediacy of e-mail. And for 10, 15 years, we've operated without any of the triage secretaries being in between. And I suspect the same thing is going to happen. And the other thing is, although there are 70,000 Intel employees who have access to my e-mail address, they don't send me e-mails.

(Laughter.)

DR. ANDREW S. GROVE: And I think you're going to find that the 2,000 patients that each of your internists care for will be equally economical to do so. So good luck with your study.

DR. DAVID STERN: Thank you very much.

DR. ANDREW S. GROVE: Thank you, Dr. Stern.

(Applause.)

DR. ANDREW S. GROVE: One additional thought as a health-care consumer. Most of my communication when it takes place in the telephone is electronic as well. I'll leave a message with the triage nurse who transcribes it, gets an answer back, and leaves it on my voice mail. So inasmuch as personal nature of the communications, all we are doing is smoothing that work flow that is already a reality in a phone-tag world that we live in.

The gist of all of this is that we are at a Strategic Inflection Point. We are in a period of major change that is dictated by the fact that consumers of health care services are ahead of the profession in their embrace of electronic means of getting information, participating in supportive groups, handling transactions and communicating. And this is likely to drive the acceptance of these techniques throughout the medical profession.

I've found in studying how organizations deal with Strategic Inflection Points that there are a variety of stages familiar to all of us, similar to how people deal with their own crises. The stages involve denial, escape. And only after the inevitability of these abilities are imprinted on you online do you take pertinent action, accept the reality of the change and the pertinent action.

A very important finding having to do with Strategic Inflection Point is if you want to prosper on the other side of the Strategic Inflection Point, you must take action before you get there. As I mentioned earlier, taking action once those curves have diverged leads to very, very tragic and dramatic circumstances.

And finally, what you're witnessing by the drive that is brought about by the computer-savvy online consumers, there is a rule that I like to call the rule of technological inevitability. Anything that can be done in technology will be done. And I think connected computers, Internet-connected computers, and medicine are slated to collide, converge, and become one in the same. And the time to shape the future is while we are at that Inflection Point before those two curves have diverged.

And shaping the future is extremely important, and the role of the medical community is vital in that, because the Internet provides quality. But before the Internet provides quality, people have to accept and take pertinent action in shaping the type of information that is provided to them.

People's lives are at stake and the evolution of this medium both as a productivity enhancer and as a lifesaver is at stake. And in order for all of us, on both sides of this question, to get on the right curve, action by the medical community, health care community, is necessary. And only through those actions is it likely that medicine and health care will be able to take advantage of the X Factor.

Thank you very much.

(Applause.)

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