Internet, Web sites, Practice management
Stephen M. Sergay, MB, BCh, saw the promise of medical practice Web sites early on. Five years ago, when Salu Inc. began to promote its mission of building neurology Web sites through NeuroHub, Tampa Neurology Associates (www.tampaneurology. com) became one of its first beta sites. "More and more people were coming to the office with information they had downloaded from the Internet, and when we ran an informal survey, we found that large numbers of patients were indeed sophisticated Web users," he said.
Sergay, who is president-elect of the American Academy of Neurology (AAN), placed a computer terminal in the office waiting area and was pleased to find patients using it regularly. "It gave them an introduction to our practice and made us more accessible," he said. "Salu provided the design template and health information for neurology patients, adding value and making it easy to create a Web site. We started to schedule appointments and acquire patient registration data. It saved us time and the cost of mailings."
But NeuroHub, which by early 2001 had an enrollment consisting of 45% of the office-based neurology market, was ultimately unable to sustain its business model and, by March 2004, had shut down. Its final announcement to physicians offered assistance with switching to alternative Web hosts whereby patient data and other practice material could be transferred. Some subscribers switched to neurologychannel (www.neurologychannel.com), a product of Healthcommunities.com (HC) Inc. Tom Lund, director of business development at HC, said, "We were able to extract unique practice information from the NeuroHub Web sites and place it on the practices' new Web sites. Each practice then worked with an assigned Web site manager to individualize and develop it further. Contents were customized to those areas or subspecialties important to each physician." Initially, the sites were supported by various sponsorships, but the company now uses a monthly subscription model: $95 per month for the first year and $65 per month thereafter.
Associated Neurologists in Danbury, CT, has grown from a 2-physician practice in 1971 to a practice consisting of 9 member neurologists and 13 midlevel providers. The commensurate increase in communication needs has prompted the group to look for solutions that improve efficiencies without compromising patient care. Joyce Peters, director of business development for the group, oversees their neurologychannel practice Web site, www.associatedneurologists.com, which was launched in 2000.
"The major benefit is being able to provide patients with convenient access to relevant information 24/7 from the privacy of their home," Peters said. "We feel that this helps patients get to know us before their visit--through provider bios, photos, explanations about how our phone menu works, directions, and photos of our offices. It also allows them to complete forms in advance of their appointment, saving time and postage money. We have found that providing alternate ways to communicate with the office reduces phone call volume. To further promote the site, we periodically create a 'statement stuffer' describing convenient features such as the appointment request form."
She added, "Since patients can find answers on our Web site, our costs have lowered and patient satisfaction has increased due to greater convenience and consistency. For example, patients in the office frequently comment that they like being able to get our forms online. We've discovered that many of our geriatric patients have Web access. We try to always ask a simple question: Do you have Internet access?If so, we give them a flyer with our Web address and examples of useful content. Our site provides links to relevant--and validated--content, including AAN content."
The Division of Epilepsy and Electroencephalography in the Department of Neurology at Long Island Jewish Medical Center in New Hyde Park, NY, is another of the nearly 150 neurology practices that use HC services. For the past 3 years, patients logging on to www.epilepsylongisland.com have been able to download forms in preparation for their office visits, get answers to questions about epilepsy, and preview what the center has to offer. "In epilepsy, one of the frustrations is that if patients are not aware of treatments such as surgery, it is difficult for them to find [information on] such options on their own," explained Division Chief Alan B. Ettinger, MD. The site contains links to various sources of information on patient care, including the book, The Essential Patient Handbook, by Ettinger and Deborah M. Weisbrot, MD. Also included is a section about seizures that was created by neurologychannel and links to sites about other neurologic conditions.
Some physicians choose to develop their own Web sites from vendors who provide Internet services. For the past 21 years, Damon M. Fellman, MD, a neurologist practicing in Hackensack, NJ, has used Network Solutions. With its tools, he recently created the practice Web site www.hackensackneurologygroup.com for his group of 7 neurologists. "I downloaded a template, which the company provided, and it was very user-friendly. The cost was very reasonable, about $150 per year. Our initial goals were simple," Fellman explained. "The most sought-after feature by members of the group was a 'Directions to Our Office' page, saving telephone time for the staff and reducing the likelihood that the patient will be late for the appointment. We also wanted links to professional sites that provide information about neurological disorders. We wanted to be able to help patients to select Web sites that we feel are most useful and accurate from the enormous amount of information and misinformation that is available on the Web."
Fellman posted instructions for the first visit, including reminders to bring referral forms and material about participating insurance plans. He created biographies of the neurologists in his practice so that patients could become familiar with practitioners other than their usual physicians in the event that, for instance, a certain physician was covering for another. Finally, he ordered business cards that display the name of the Web site in large letters. Fellman, a Web design novice by his own admission, exclaimed, "It took me very little time to manage, and I enjoyed the experience."
Brian D. Loftus, MD, however, an engineer in his life before neurology, is clearly an expert. He has been with the Diagnostic Clinic of Houston for the past 11 years since his residency. His site, www.loftusmd.com, began as a way to educate patients about their treatments. "Most of my practice patients have migraines and epilepsy, and the Web pages serve to answer questions about these diseases that I do not have time to answer during my first patient encounter. New patients are referred to the Web site to review this information before their second appointment," he explained. Loftus does all of his own Web design with Dreamweaver on his Macintosh computer. He said, "To help nonpatients find my Web site, I put in Meta tags--little bits of HTML code that provide information about a site--for keywords and description, but I depend on search engines to do their job and find the most relevant listings. I do better on some search engines than others. Some will not list you without your paying an annual fee, and these I avoid."
OPTIMIZING FOR SEARCH ENGINES
Steven A. Reid, MD, has had a practice Web site, www.brainsurgeon.com, for the past 10 years. He also personally designs, programs, and maintains it. His site is highly ranked in a Google search for the word "neurosurgeon." "I tried to anticipate the search engine ranking schema and was fortunate to have the foresight to select brain surgeon as my domain name, but this was also just dumb luck," he said.
Although the right Web address can certainly help potential visitors find the site--more likely when the Web address matches the name--there are other ways in which sites can ensure traffic. According to Yahoo, for example, search engines typically rank results based on a complex formula that considers keywords, number of links, page contents, site size, and other elements. Also, search engines change their formulas regularly to ensure that Web site owners are unable to elevate their rankings artificially by manipulating one or more of these criteria.
As Loftus described, adding Meta tags--which usually include a page title, description, and keywords to index the page--helps determine ranking in relevant search results. However, even this has changed. Soon after Web site owners began to insert misleading words about their pages and to use repetition of words in the hope of tricking searchers about relevancy, its weight in the ranking equation dropped. Experts now advise that the best ways to direct traffic to a site--referred to as search engine optimization--are to build a quality site and update it frequently; use noncompetitive keywords and include them in page titles, content, headings, and descriptions; and exchange links to other similar sites. Of course, for those who invest in advertising, paid listing services generally guarantee top results. According to searchenginewatch.com, a site that provides tips and information to site owners trying to improve their ranking, paid listings are an option that should be explored by those who wish to quickly build visibility.
Neil A. Busis, MD, Webmaster of Neurosciences on the Internet, www.neuroguide.com, has been maintaining the site--one of the very first neurology Web sites--since 1994. "Web search optimization à la Google is a link popularity contest--they see how many sites link to you, and the more the better. If you get all sorts of sites to trade links with you, your site will rise in the ratings. It is not about hits, but incoming links. If all neurologists linked to each other, all neurologist sites would increase in rank," Busis explained.
Lund says that many of his subscribers like to monitor their monthly traffic reports, information that includes numbers of hits, pages viewed, unique visitors, time of day, and referral source. Neuroguide, for example, gets 5000 to 8000 unique visitors each week. Peters' practice received 5724 page views and 1531 visits in July 2005. Other business-savvy practices have used this data to track the efficacy of newspaper, electronic, and other marketing programs by examining their traffic patterns in the period after each release.
The interest by neurology practices in developing Web sites seems to be growing. "Neurologychannel comprises the second largest group in HC," Lund said. "There is definitely a trend for neurologists to invest in developing an online presence."
At times, the investment is supported by hospitals or physician organizations that assist member physicians in creating a Web platform for their services. For instance, the Yale Brain Tumor Center (www. yalebraintumorcenter.org) uses the IT services of the Yale Medical Group. Joachim Baehring, MD, assistant professor of neurology and neurosurgery and a neuro-oncologist with the group, said, "It is difficult to judge since we're not tracking the information, but we certainly have seen many 'self-referred' patients who are specifically interested in the clinical studies posted on our Web site. We keep an active trial list that is continuously updated so that the information is available for physicians as well."
As with other technology initiatives for medical practices, it often takes a single visionary member of the practice to lead other busy and overworked physicians in a new venture. Fellman, who had asked members of his practice to write their own professional biographies, was frustrated by a delay in response. "Tired of waiting and perhaps impatient to go online, I eventually went ahead and wrote the bio for one member myself, which he later read and approved," he said.
Not all marketing ventures are ultimately successful, as Loftus noted: "The Web site has had minimal impact on clinical trials. The site needs major design changes to benefit these. Part of this is due to the time-sensitive nature of trials and the time-insensitive nature of the Web. There seems to be about a 3-month delay from the time a new article is posted on the Web site to significant listing on search engines. Since clinical trials enroll only over a few months, this limits its effectiveness."
Furthermore, just because a site has a feature does not mean that patients will necessarily want to use it. Peters has found that very few patients use the prescription refill request form, for example. The practice she serves plans to implement an electronic health record (EHR) by March 2006, so the Web site will evolve to include interactive and secure tools. As Sergay noted, "The ideal site will be integrated with a full EHR, electronic prescribing, and electronic messaging."
As always, medicolegal experts suggest that advice be provided to patients about the limitations of electronic information, particularly for interactive Web sites that include e-messaging. Loftus' site, for example, adds the following disclaimer: "This site is not intended for diagnosis but rather to offer information to make a better informed patient. Discuss any medication changes with your physician prior to making any changes." Although HC also provides an extensive disclaimer, including warnings that it is not a secure site, Peters reflected, "Some patients use the Web site to communicate protected health care information in spite of our disclaimers." *
One Patient's View
How often do patients find their physicians by searching the Internet? It is getting more frequent. According to the May 2005 Pew Internet and American Life Project "Health Information Online," 8 in 10 Internet users have looked for health information online. After a tough time getting answers from several doctors, Kenna Bobber found her neurologist by searching Google for a "Houston neurologist." She said, "Dr Loftus was the first physician listed in the natural search, and I liked his Web site for its straightforwardness. I also liked that it wasn't slick. The most compelling piece of information on his site was a note stating 'If you are a new patient and you are told there is more than a 2-week wait until you can be seen, please email me.'"
Bobber added, "After visiting his site, I felt hopeful that there was a doctor out there [who] was going to listen to me and possibly even help me. The impressions I formed after reading Dr Loftus' Web site were consistent with what I discovered when I met him a week later. His most valuable trait is his compassion for his patients, reflective of the sense of warmth and safety conveyed on his site. Within 2 weeks of my first appointment with him, he confirmed the diagnosis of myasthenia gravis and recommended an aggressive treatment plan that totally took my needs and desires into consideration."