"the basic concept...is that the most successful businesses of this remarkable era will combine the power of the Internet with the ability to operate effectively in the offline world."
	Pottruck uses the brokerage company Charles Schwab as his prime example. Schwab initially launched its online service as a separate operation. "It soon became clear that online customers wanted the same level of service as Schwab's telephone and retail customers, and offline customers wanted the low prices online customers enjoyed. Despite the considerable short term costs, the company decided last year to do away with the online/offline distinction--and the results have been spectacular."
	The focal point of clicks and mortar must be customer relationships. Says Pottruck, "The true meaning of the word 'mortar'....is people." The operative word in clicks and mortar is "AND". Despite the ubiquity of the Internet (clicks), and the commonly accepted adage that health care is a local business (mortar), successful business and clinical models of care management will need to provide the best of both worlds.

You can read a discussion of Ethan Allen's clicks and mortar initiative. 

In health care there are traditional "mortar" (bricks and mortar) organizations. This includes hospitals, physicians and other care providers, and health plans. In most local markets, these players have been combining to develop integrated delivery systems (IDSs).

Then there are newer "clicks" oriented organizations pursuing care management approaches. For example, a number of companies are trying to establish themselves as health information portals (e.g., allhealth.com, a division of ivillage). Others include pure-play e-health companies, clinical software developers, practice management software companies, etc. (These companies are more difficult to peg; remember that the distinguishing factor here is the primary reliance on Internet technology.)

The value proposition of traditional "mortar" oriented organizations typically relates to INTEGRATION. For example, a local IDS might articulate its value proposition as "We coordinate care across the continuum and provide one-stop-shopping in a defined geographic region, thereby lowering costs and improving quality."

The value proposition of a "clicks" company relates more to SPECIALIZATION. For example, an Internet health information portal might articulate its value proposition as "We provide specialized health information--the latest information, from the most credible sources, written in a way that you can understand. We use the Internet to reach a worldwide audience, and that allows us to develop critical mass and scale to provide information to you."

Other types of specialization could include disease knowledge, information systems, technologies, etc.. Which value proposition--INTEGRATION or SPECIALIZATION--is more important? The answer is--BOTH!

And that brings us to the essence of clicks AND mortar-combining the value propositions of SPECIALIZATION and INTEGRATION! We believe successful business models for chronic care patients must combine specialization and integration. (This hybrid model of care has also been referred to as a carve-in. Describing carve-in and carve-out care management models is beyond the scope of this e-newsletter. However, a framework for understanding carve-out, carve-in, and IDS approaches to care management is available on BHT's website. 

Accordant Health Services is one company that has understood the clicks and mortar concept for a long time. Accordant is a disease management (DM) company with a special focus on individuals living with high impact, complex chronic diseases. Its goals are to improve clinical, functional, satisfaction, and cost of care outcomes. Accordant focuses on 14 diseases, including lupus, hemophilia, cystic fibrosis, myasthenia gravis, multiple sclerosis, and rheumatoid arthritis.

Accordant's DM programs are based on the premise that complex, chronic disorders are characterized by catastrophic crises, co-morbidities and complications that are preventable and manageable.

Accordant's services are typically sponsored by health plans. The diseases covered by Accordant are rare--only about 1/2 of 1% (.043%) of the population will have any of them. However, these patients incur an average of $12,000 per year in medical bills.

President Steven Schelhammer notes that "Accordant has had a carve-in approach since it's inception. We work with the patient's existing medical community. Accordant works with the patient's physician to support the existing relationship between the doctor and the patient."

Accordant uses technology to further its clicks and mortar approach. The key to Accordant's success is providing patients and their physicians with information about a patient's condition BEFORE that condition results in a high cost emergency room visit or hospitalization. Both the patient and the physician become empowered through technology and information.

About 40% of Accordant's patients have Internet access and a majority of them choose to connect with the company this way. This is a high level of connectivity, and it shows how patients with complex diseases thirst for information and are willing to be involved in their own care.

Accordant is developing tools using Internet and computer telephony technologies to support its DM programs:

A Patient Web Portal

	serves as a destination for specialized health information
	provides general health, disease, and pharmaceutical information
	creates patient communities for many of Accordant's targeted diseases
	enables direct patient access to leading physicians and national medical experts
	hosts patient-requested chat rooms, bulletin boards, and other online support groups
	delivers online health assessment tools and electronic patient records
	facilitates online communication with Accordant nurses
	provides links to additional resources and medical/physician databases.

A 24-hour medical call center

	1-800 number for easy patient access
	Skills based routing (calls are routed to the most qualified nurse available to speak with a patient)
	Screen pop technologies to support caller ID and automated patient record retrieval
	Call center and Internet integration

Accordant's proprietary decision-support system includes a longitudinal database and customized software to support enrollment and ongoing patient care management. It is also developing a corporate intranet to keep clinical resources used by nurses organized and available instantaneously.

How do patients benefit? Accordant is able to deliver both SPECIALIZATION and INTEGRATION. Accordant uses technology to deliver specialized, up-to-date, research based information to patients. This information is integrated into a care plan that keeps the patient's doctor and local care team all on the same page.

Accordant is pioneering combining the best of the online and offline worlds--clicks and mortar disease management.

The September 20 issue of our e-newsletter featured an article on health care application service providers (ASPs). The TriZetto Group is a health care ASP that has recently filed and updated its prospectus (S1), a document filed with the Securities and Exchange Commission prior to going public.

In particular, the "Prospectus Summary" (p.4) and the section describing the company's "Business" (p.37) provide valuable insights into the market for health care ASPs. TriZetto's initial applications relate to automating existing transactions, with references to future availability of clinical management applications.

Remember the FedEx Truck Phenomenon described in a previous edition of our e-newsletter? This refers to a weak link in the health care value chain that occurs when health plans and physicians don't work together to develop and implement clinical care guidelines. An article in Modern Physician magazine describes how some health plans and physicians are licking this problem. 

Patrick Vega MS, is the editor of a new book entitled Behavioral Disease Management (Manisses Communications Group, 1999). You can read about and order the book. 

One chapter of the book, "Behavioral Health Carve-Ins: The Next Generation of Specialized and Integrated Care Care" is co-authored by Dave Johnson and Vince Kuraitis. Drop a note to vincek@bhtinfo.com if you'd like a complimentary copy (Adobe .pdf format). Please put "BEHAVIORAL DM CHAPTER" in the subject line.