INSIDE "DR. KOOP'S COMMUNITY": Q&A WITH C. EVERETT KOOP

C. Everett Koop

Dr. C. Everett Koop, former U.S. Surgeon General during the Reagan Administration and lifelong academic, has always believed that patients must take an active role in monitoring their health. Koop says he is now even more ardent in his promotion of health self-awareness because of the current state of managed care where patients are hurried through HMO visits, and because of the specter of a huge, aging generation (one baby boomer turns 50 every 8.5 seconds, according to the nonprofit educational organization Population Reference Bureau). Not content with his nonprofit efforts so far to raise that awareness, Koop is turning to the Web to provide consumers with the means to educate themselves on health issues.

On July 20, Koop's company, Empower Health Corp., released its first product: a Web site named Dr. Koop's Community (www.drkoop.com). How will Koop's venture -- which also draws on the deep health information resources of the University of Pennsylvania Health System -- separate itself from the more than 10,000 health- and medical-related sites already on the Web? Koop sees his site's mixture of information, interactivity, E-commerce, and his own credibility as the keys to success. Dr. Koop's Community also offers health chats, user polls, an "Ask Dr. Koop" area where users can receive feedback on specific questions, health-site reviews to inform users of other trustworthy sites, and a virtual pharmacy where consumers can refill their prescriptions online and learn about the myriad adverse drug interactions to avoid.

In a recent interview with Business Week Washington (D.C.) Senior Correspondent John Carey and Business Week Online Reporter Nadav Enbar, Koop talked about his new online venture, the state of U.S. health-care coverage, his vision of the Web's role in the future of health care, and his reaction to the lost tobacco settlement. Here are excerpts of their conversation:

Q: Is the emergence of Dr. Koop's Community the natural progression of the Web medium gaining popularity? Or was its release sparked by the state of health-care coverage in the U.S.?
A: I think both are responsible. If you look back on the beginning of the self-help movement, when all these patient support groups began to get together, long before the days of the Internet, it was because of the dissatisfaction of patients. You might have the very best doctor in the world take off your breast, but if he didn't realize what that did to your sense of femininity and self-esteem and couldn't support you emotionally -- you might just as well as gone to a butcher. It didn't make any difference.

What patients did was to seek out people with the same problems to support each other. Most of the major things that I see happening in medicine, after watching it for 60 years, have been in response to deficiencies in the system. And I think the deficiency in education that we have for today's patients has been severe. We've always treated patients as though they didn't know anything. But you don't have to be terribly smart to understand what a doctor is talking about, if the doctor is willing to put it in your language.

Q: So, you see your Web site as a good way to counter the dwindling time that the average patient now spends with his or her physician?
A: Absolutely. And it also teaches the patient what to ask. I'm very concerned about the fact that [the average length of an HMO visit in the U.S.] isn't really long enough. But you can use those minutes well, or you can use them poorly. If you have a little understanding about what your disease is, write down questions, prioritize them, and say to your doctor: "Now, I've brought five questions, Dr. Smith, and I'm not going to leave until you give me answers that I understand." That puts him on his toes, it puts you in a receptive mood. By golly, you walk away as a satisfied patient. And that doesn't happen very often today.

Q: Are you concerned that patients might skip the doctor entirely and rely solely on your Web site?
A: Oh, no. No, because everything that we do is constantly referring patients back to doctors. We give advice and counsel in general, not specifically. I mean, if the patient calls and says, "I've got this pain in my elbow -- what do I do, Doctor?" he's not going to be answered as though we were seeing a patient in consultation. He's going to be told that we fit most patients who have elbow problems into three categories, and on the basis of what you've told us, the best thing you can do is to go see your primary-care physician. Or if you can skip him, the person who deals with your ailment is probably an orthopedist. And so that might even cut down on one visit to a doctor. We never have viewed patient information as a means for eliminating doctors, but rather as a way to eliminate the unnecessary use that people make of doctors.

Q: Seventeen million aging baby boomers are getting ready to ease into retirement, and there are already 10 million wired retirees. So the market for health care on the Web is there. But attracting eyeballs is the name of the game. How do you plan to put Dr. Koop's Community in front of the masses?
A: We asked our [physicians'] focus groups the question: What do you see as the chief advantage of Dr. Koop's Community? And the most significant answer that we got was their comfort level in referring their patients to a reliable site that is able to lead their patients elsewhere, if necessary, to find the things they have to know. And that's what we see ourselves doing. We not only have the information but we're a catalyst to help users find the other information that might be ancillary to what they find at our site.

Q: Are you working with the U.S. government to give you an endorsement?
A: No. I don't think the government ever endorses this sort of stuff, initially. You know, I'm awfully close to government, both in its administrative form and its political form, and it never occurred to me to ask for their endorsement. I don't know where to ask.

Q: Is your site viewed as a moneymaking possibility?
A: Well, the thing that impelled me to do this, finally, was the fact that I couldn't get this information out to patients through any nonprofit medium that I've tried. And so we had to make it a commercial endeavor and get our money from pharmaceuticals, home-care products companies, and home-health advertising. I cannot say whether our site will be a moneymaker or not. But at least [advertising revenue] provides the money for us to make it possible to service consumers.

Q: And you will not be charging people to use the site?
A: No. Users will not pay a penny. We plan to launch our personal health record (which will enable consumers to track and record their personal medical information electronically and communicate their medical background with health-care providers and pharmacies) later on this year. Currently, other Internet sites allow you to establish personal health records for something like $19.95. But they don't come with any information. They just give you an outline on how to make your own health record. Meanwhile, our personal health records will be owned by the patient, obtained on the Internet, and be totally free. They'll also be hooked up to Dr. Koop's Community, so that you can access any information that you want -- from any health-related event that happened in your life to any medical advice you got from a physician or health company. That will all be totally free to consumers.

Q: Would the pharmaceutical industry be interested in the sort of trends of questions that people ask?
A: Oh, I'm sure they would be. But, you know, one of the things that we are absolutely committed to, and that I have been all my life -- especially since I've worked for the last seven years with Al Gore on the interface of health-care delivery with high-tech communications systems -- is the protection of patient privacy and the confidentiality of the patient's record.

So, if a pharmaceutical house asked us a question about patients who had, let's say, emphysema, we'd be perfectly happy to tell them that in our databank of the X number of patients with emphysema, this many were male, this many were female, this many were over 50, and this many were under 50. But we would never reveal anything about a given patient that could be identified. So, it would just be epidemiologic material that would be helpful to everybody.

Q: What company has signed up to advertise or to support you?
A: I can't tell you the specifics at this point, but the pharamaceuticals are the principal providers of revenue on the site. We make contracts with them for a specific entity. If they are in the field of hypertension drugs, for example, then they could advertise their hypertensive drugs, their diuretics, and that sort of stuff in that area of our site. That enables patients interested in knowing more about specific drugs to go from the purely educational material that is Dr. Koop's Community, straight into the advertising world with the ease of just one click.

Q: Will patients clearly understand the difference between medical information and advertising?
A: Oh, absolutely. Because you have to leave one community to go to the other.

Q: Looking ahead, what other big changes will be coming, and what impact might those changes have beyond the delivery of health and the cost?
A: We're in the Information Age, and people are now understanding that information is not something that belongs to somebody else, but they can have access to it. So, that puts people on a pretty even playing field. The next thing they understand is that if their privacy is protected, then they can make a medical record available to those whom they wish. So when somebody signs up for Dr. Koop's Personal Medical Record, the access is open to the primary-care physician.

Suppose that you're skiing in Aspen, and you break a leg. What do you do about this long medical record that the [local] doctor really ought to know if he's going to treat you properly? If you give him access to your medical record, he has it instantaneously. That's the kind of thing that everybody who's ever been caught traveling with a serious illness or gets into an accident wishes that they had. Now we have it available to them, and I think that's going to be a tremendous boon.

Q: How would that actually work?
A: The doctor would go to our Web site, and using the password given to him by the patient, he would be able to access the patient's medical record. If that medical record were properly kept, it would not only have all the patient's history but also advice given by physicians, medications given by physicians, prescriptions filled by pharmacies, and so forth. So, at a glance, you'd know pretty much the life of the patient, and what the present trauma might elicit in the form of reaction in the patient with that particular profile.

Q: One of the things that you've been certainly in the forefront of, over the years, is this whole idea of preventive medicine. And we have this phenomenon of everyone knowing that there are a bunch of lifestyle factors, from obesity to smoking that contribute to health problems...
A: There's a whole section of Dr. Koop's Community called "Health and Wellness Centers." And that's all based upon the problems of prevention. For years, the professions of health, public health, and of medicine were divergent. And what I'm finding now, through dialogues that I've been involved in for the last four years or so, is that those divergent paths are beginning to converge on each other again. And I think what you're going to find -- it's going to be helped along by economics -- is that medicine and public health are going to come together more and more. What that means is that prevention is going to play a larger part in peoples' lives.

It's very interesting, having been in medicine for 50 years, and then in public health after that, to realize that the key to the economics of medicine is prevention. The difficulty is that we live in a society that is really enraptured by health. We love to read about health. We, as readers, television viewers, and Internet users, are really very health-conscious. But it's for the glamour that goes with health. We love to read about baboon heart transplants, liver transplants, and Teflon knees. But as soon as you talk about prevention, it sounds to us like Nancy Reagan's just-say-no [antidrug] program. Until we can convince the public that the preventive changes in lifestyle -- although not glamorous -- not only lead to a healthier and a longer life but also to a much cheaper cost of medicine, it's going to be hard. I don't think anybody in public health underestimates that difficulty of that.

Q: Looking to the future, do you see Web having a big stake in the development of health care?
A: My own opinion is that the section of the Web that will grow the fastest is going to be involved with health. Look at what it was just a few years ago. Something like 40% of the online population was visiting health-related sites, and back then it was really hard to gauge what that 40% was really comprised of. But, I think by concentrating with the system we have of rating sites and providing reliable, up-to-date information, that the word will get around, and patients will know that there is a search engine that can lead them to what they want to find out. Once that reliability is established, I think consumers will flock to the Internet and use it increasingly for health-related reasons.

Q: Back to the here and now, can you talk about your sense of what happened in Congress regarding tobacco this year, and whether the failure to act will have any political consequences, or what might happen next?
A: The simplest thing I can say is that it was a very disappointing time for me. From June a year ago, I worked about 100 hours a week on trying to make this work. And I think we had a great shot at it. The thing that impressed me was that the public's sense of outrage at hearing about the tobacco-industry secrets never was translated to legislative action.

I'm not a pundit, but we are living in a very prosperous time, and everybody is pretty happy about things. But, I think if we were at a time of depression, economically, that the sense of outrage that people felt about the tobacco lies would have gotten to Congress, and they would have said, "hey, our constituency is pretty upset about this." But I heard innumerable senators and congressmen come back from their vacations and say, "In my weekly clinics at home, nobody asked me a question about tobacco. They're just weren't worried about it."

The second thing is that I think that we had some serious political problems, in that we couldn't really get together the right bipartisan connection to make people think that this was something that the entire Congress was concerned about. From the beginning, it was a Republican-vs.-Democrat thing. And it was very disappointing to see that because I know people on both sides of the aisle, and there is a very hard core in Congress that has the health of the American people at heart. In the long run, however, you have to recognize that money does talk.

Q: How's that?
A: There are two ways that money has affected the things that happened over the past two months in Washington. One is immediate: the tremendous amount of money that [the tobacco companies] poured into an advertising campaign. They were successful in convincing the average American, I think, that this wasn't about smoking, it was really about big government, and about government taking over and running your lives, and taxing you -- especially you poor smokers, who really should have all the sympathy in the world. It was very effective advertising. And as far as I know, the organized public health community spent $1 million to counteract [tobacco's] $300 million campaign. That's pretty David-and-Goliath to me.

But then the other thing, I think, is that you can't discount the long-term financial support of members of Congress by the tobacco industry. People say, well, does that mean that they bought favors? It doesn't necessarily mean that they bought favors, but when you accept that kind of largesse from somebody, you know, in your heart, that something is expected in return, and it can't help but affect your judgment.

Q: Put that all together, and the prospects don't seem good for anything to bring [the tobacco debate] back or to revive it.
A: I don't think it's going to be possible to do anything, in this session of Congress. And people say, "Well, that's O.K., you can do it next session." I think the thing they will have lost, by the next session of Congress, is the momentum we had. Never in my lifetime has there been such antitobacco momentum.