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Chat transcript: Nicolas Terry on e-health care

November 10, 1999
Web posted at: 1:55 p.m. EST (1855 GMT)

(CNN) -- In the following edited chat, law professor Nicolas Terry discusses the convenience of online health care, privacy issues, regulation of cyberdoctors, the un-wired underclass, and the question, "Is that a real doctor on the other end of the Internet line?" Terry teaches cyberspace law at St. Louis University. He fielded questions in a chat on November 5, 1999, from Washington, D.C.

Chat Moderator: Welcome, Professor Nicolas Terry, to our chat!

Nicolas Terry: Good afternoon from Washington. Let me start with my core position: Cybermedicine refers to the likely transition of key medical services to the Web. This migration should have considerable benefits for patients and providers and is quite consistent with the rapid transition of business-to-business and business-to-consumer services to the Web. Notwithstanding, difficult legal and ethical issues arise.

Chat Moderator: Please lay out for us the legal and ethical issues of e-health.


Nicolas Terry: The core issues relate to the legal structures we currently have in place being inappropriate to cybermedicine regulation. Another set of issues involves future think, that is, what new legal issues will emerging cybermedicine generate?

Question from Jonathan: What is the definition of "key medical services"?

Nicolas Terry: Instantaneous access to medical services without travel or lines in waiting rooms, and the efficient, seamless integration of services such as gatekeeping, patient records, inpatient calendaring and prescription fulfillment.

Question from Margiep: It is difficult enough to discern the quality of medical advice being disseminated on the Web, and this problem seems particularly disconcerting with regard to mental health. Please share your thoughts about "credentialing" of providers on the Web.

Nicolas Terry: I've seen no studies specific to mental health. There are numbers on cancer advice that show error rates.

Question from Jonathan: Is the move to the Web driven by a desire to improve quality of health care, or to cut costs and increase share value?

Nicolas Terry: There is no doubt that providers see the Web as a way of extracting (lowering) costs. However, I am not entirely negative. Providers see the opportunity for improved services also.

Question from Mags: What's your opinion of WebMD? Are they reputable? How does a Web site like that make money? Have they cornered the market?

Nicolas Terry: WebMD is merging with Healtheon and is a large, respected player. There is already considerable competition in both back-end services and patient facing services, e.g., Dr. Koop's (Web site for consumers.)

Chat Moderator: How does e-health care work?

Nicolas Terry: (There are) three basic ideas. First, Healtheon and similar (companies) provide back-end services for (the) health industry. Second, (there are) physician services, from CME (Continuing Medical Education), to books, to community. Third, patient-facing services such as online information, advice and consultation.

Question from Kris: Doesn't WebMD advertise themselves as both for the doctor and the patients? Does that make them a back-end service or a patient facing service?

Nicolas Terry: Healtheon will be doing the back end; WebMD will do the patient facing.

Chat Moderator: How do health Web sites make money? Is it from the sale of advertising, or how?

Nicolas Terry: The patient facing sites will sell advertising and have "preferred" providers. Most of the initial revenue is likely to come from cross-marketing deals with portals, etc.

Question from Sue: How do you know it's a real doctor on the other end of the Internet?

Nicolas Terry: (That's) the $64,000 question! The current answer is to go with the brand names you know. The future answer is look for technology such as AMA/Intel digital credentialing.

Question from Jonathan: If we agree that there will always be a non-wired segment of the population, how will these e-doctors service them?

Nicolas Terry: Access issues promise to be among the most difficult legal issues -- particularly as we already have health access issues in real space.

Chat Moderator: You told CNNfn that it will become much harder for poor people to get health care. Why?

Nicolas Terry: We already have an underclass of non-wired people. They will get wired, but by then the majority of users will have broadband, and so the cycle will continue.

Question from Mags: Are there legal issues that crop up for e-doctors that face-to-face doctors don't have to worry about?

Nicolas Terry: Primarily licensure issues. Doctors are licensed by states, and cyberspace doesn't comprehend state lines.

Question from Candyce: What do you think about putting patient medical records online? Is legislation addressing this matter adequately?

Nicolas Terry: They are already online to an extent, and we haven't properly solved that! As back-end services consolidate and data increases, these issues multiply.

Question from Rory: Are we basically surrendering any concept of privacy with e-healthcare?

Nicolas Terry: The primary issue that must be faced is how far we will allow these services to leverage the patient data they collect.

Question from Rory: Leverage the patient data? What does that mean?

Nicolas Terry: (To leverage patient data is to) profile the patient's needs and conditions, and target advertising and linked services at them.

Question from Mossy: Do you see cybermedicine as an informative service, or a diagnostic and treatment tool?

Nicolas Terry: The former is already in place -- the treatment end is where it goes next.

Question from Mags: For what reasons would I, the patient, want to go to a health Web site?

Nicolas Terry: Because you can get care and prescriptions 24 hours a day from your home.

Question from Robert: There's also a strong social aspect in meeting your doctor face to face. How are e-doctors going to handle that?

Nicolas Terry: Skeptics might argue that this model has already been dismantled by managed care.

Question from Mags: Are there specific laws to govern and protect e-doctors? Or is this still uncharted water?

Nicolas Terry: A few states have updated their licensure and pharmacy statutes to capture cyberspace activity. Most legislative and enforcement activity at the moment is directed at illegal prescription activity.

Question from Candyce: Are HMO and other providers on the bandwagon for this kind of endeavor ... I mean, talk about relatively inexpensive patient care! The bean counters must love this concept.

Nicolas Terry: Absolutely, they are on board. However, cyberspace is a great place for competition and so (could force) improved services.

Chat Moderator: Any final thoughts?

Nicolas Terry: Be very careful out there. Stay with the well-known names, and urge your care provider to value-add with improved face-to-face service.

Chat Moderator: Thank you, Professor Terry, for joining us!

Nicolas Terry: Many thanks for participating.

Chat Moderator:
Nicolas Terry's home page is: and see

A wired world of medicine

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November 4, 1999
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