January 1998

This month’s interview is slightly different than in previous months. The biggest difference is, the site is proprietary and password protected. You can visit the Curative home page (http://www.curative.com) to find out more about the company but you won’t be able to visit the training site. 

This site also differs because it is the first one we’ve featured where the site sponsor is not the creator. It is a contract site created and built by an outside developer. This is normal on many large corporate projects. A company may be willing to supply the resources it takes to maintain a large site but often  

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does not want to maintain the kind of development staff it takes to create something this comprehensive. They only need to create it once. If they’ve done a good job, maintenance can be done by one or two people. It’s creation, particularly a site this large and complex, can take many highly skilled (and highly paid) people from, possibly, many organizations as well. Most companies prefer making this a one time expense. 

We chose this site because I’ve seen much of it and was working with its developers while it was being built. I know how hard it was to do and how well it was done. Using a medical site as a training example is important. No one is more involved in continuing education than physicians. The medical profession, MDs, nurses, medical technologists and scientists assume life long learning is a part of their job description. The importance of their jobs demands it.  

It is also a good case study in how a company makes the transition from a traditional training/education model to using the Internet as the delivery vehicle for the same training. It also gives us some feel for the success of the process. 

Frank Grubbs has been at Martin-Bastian Communications for the last nine years. His background in corporate communications and instructional design made him particularly suited to produce the Curative site. Since this interview he has left M-B for life as an independent. His first contract is to build a similar site for a Risdall-Linahan Advertising client.  

iBiz: So when did you start working with Curative? 

Grubbs: It started late summer of ‘95. That’s when we started talking about it. We had the vice-president of Medical Affairs, a doctor, from Curative come in with a couple of our long standing clients Carolyn Fylling and Judy Bario. Carolyn and Judy were in charge of the Education part of Curative. They sat down and explained what they were doing.  

They realized very early that Curative was growing quickly and if they didn’t do something to handle the Education they were going to be in trouble. It was really going to limit their growth and the viability of their concept.  

iBiz: What was that concept? Who is Curative and what do they do? 

Grubbs: Curative Health Services, at that time they were called Curative Technologies, started off as kind of a bio-technology company. They ‘d come up with a process that is now called Growth Factor Therapy. It’s based on a product called Procurin™!, that’s their trademark, but the process is Growth Factor Therapy.  

Patients with chronic wounds, these are wounds that are long standing, that don’t heal. Some of them go for months, some go for years. They had come up with a product where they would extract blood from a patient, pull out the platelets, induce them with this material called Thrombin and that would release what are called growth factors. 

These growth factors are kind of the magical elixir here because that’s the stuff that causes cells to grow. It causes skin, muscles and all that stuff to rejuvenate. It’s really amazing stuff. It’s our natural way of healing. But now, by getting the growth factors and putting them directly on the wound, they could speed up healing. But then they discovered that was only part of it. 

The other part of it was looking at the entire system. The whole body and the way it heals. Growth Factor Therapy alone wasn’t enough, so they developed what at that time they called the Algorithm for Wound Healing. That algorithm specified a treatment methodology that involved looking at the vascularization (how the blood flows) of the tissue, looking at the sources of the wound. It involved what they called the etiologies, like diabetes, they could be cancerous. What is the cause of that wound. By treating the whole system, and also using the Growth Factor Therapy if necessary, they were having a very high success rate. 

The real cut to the chase thing was, they would turn what was a chronic wound into what is called an acute wound. The other piece of that puzzle was they would challenge traditional medicine in approaching these wounds.  

iBiz: Challenge them how? 

Grubbs: Physicians have always been trained to be very conservative with tissue. Only cut it back when it’s necessary. Whereas in this treatment paradigm it was, be aggressive with it. Get all the nasty stuff out o’there. A lot of these wounds, on the surface, are just little round things. But underneath they tunnel down through the tissue. It gets down into the bone. If you don’t go down and get all that nasty stuff out, you’re not going to heal the wound. That’s why they’re chronic wounds. 

Now they approached these wounds from all these different directions and developed this treatment paradigm. Then they started developing what they called Wound Care Clinics across the country. 

iBiz: What is that? 

Grubbs: Wound Care Clinics are places where they would bring in physicians and develop these programs to treat chronic wounds. They had to do a significant amount of education to get everybody using this paradigm So Curative really became a wound management program company. They develop wound management programs. They’re not physicians. They’re essentially directors and administrators who put together these programs. They bring in the physicians from their different practices, show them how to do this, provide education, provide the environment, provide the patients and the associative contract link with hospitals to provide the ancillary services they weren’t doing in clinic. Mostly higher level stuff, ORs and stuff like that. Sometimes the procedures had to be done in an operating room. 

But this stuff really caught on. When we first started working with them in ‘95 they had about 75 or 80 wound care centers. Now there’s almost 200, just a couple years later. The foresight they had was this is really going to take off and they’d better be ready. 

iBiz: How were they doing their education before? 

Grubbs: The way they’d do it before was, they’d do traditional seminar based training. They’d tag the medical directors of these new wound care centers, sometimes the program directors and bring’em in. Take these guys out of their practice, plop’em down in a ballroom someplace, coop’em up for four days and lecture at’em. Then they’d walk’em through the local center and send’em home. I mean, the material was good, they’d have local faculty that would do it and they developed their content that way. And they’d present case studies and topics about vascularization and topics about debridement, the whole paradigm and all this stuff. I sat through one of these, and it was fascinating. But I like all that stuff, and that’s just me. 

So, the problems they were foreseeing was for one, volume. They could only really do these once a month. Which meant that if they were opening three Wound Care Centers this month and the next month; or two or three. It was booked up solid. They would have doctors that are actually practicing that are not trained in this method. It doesn’t mean they’re bad doctors, it just means they don’t have this methodology. 

Another was proliferation. The medical directors would get the training. They would have to go back and train their assistant directors and the nurses and the associate medical staff on how to do this, and the proliferation kind of decreases as you go down. In some cases it didn’t get transferred at all. 

The third was that the methodology of the training is not conducive to high retention. You know, you lecture a guy for four days, and if he gets ten percent of it you’re lucky. Until he gets home and puts it in practice and it gets reinforced, and that kind of stuff. 

The final piece was that they (the physicians) never really had a good central resource to go back to and get information about it. Where do you go? You get on the phone and call your buddy or you talk to your regional director or something, but still there was no central source in place. This is the backbone of this. 

So these were problems and they had to address them. The vice-president of medical affairs at that time had the foresight to realize that needed to be addressed. He knew it would take time to develop so he wanted to get going. So when we sat down that first time, we threw the problem on the table and they said "What we think we need here is a CD-ROM. We’ll put together a CD-ROM that has all this training on it, and then we can send it out and anybody can use it, anywhere and anytime." We said, "Well that’s fine, if that’s what you want. Let’s test the advocacy of this concept. Let’s see if this is what would work." 

So we built a prototype, and we called the prototype The Pathway. The Pathway was a typical CD-ROM type environment, graphically rich, motion-media, lots of options and high-bandwidth graphics. The whole bit. We developed two modules of their ten-module course, and took it to their national meeting. We set up workstations, had a seminar, and open demonstrations and the response was overwhelming. The program directors and docs were just saying "This is great, can you ship us a copy now? When can we have this stuff? This is fantastic we really love it." We had to disappoint them, you know, this was a prototype, not a release version. 

So we went back and met again, and talked about a lot of things like, delivery, accommodating growth, updating information, providing resources, providing communication, and also the financial viability of it. What would be the return on the investment? 

We began to realize that a couple things were going to happen. One was that they really wanted to reduce the dependence on the seminar stuff. They really couldn’t get rid of it entirely because there’s something about physicians interacting with each other, it’s important. It’s a critical component of it. So, by reducing that dependence on it, they could certainly save money, because those seminars are expensive, with travel, entertainment, ballroom, catering, and paying the faculty, I mean, they’re expensive to put on. 

So all these things were getting tossed about, and then the original architects of the project, myself and Michael Wood, were stewing on this idea, and we threw out on the table, ‘Have you ever though about delivering this on the Internet?’ 

Now, take yourself back about two and a half years, and remember the state of the Internet back then. It was kind of this ‘gee whiz’ thing, and homepages were kind of an abstract concept. It was only really perceived as a neat thing that’s out there. There was no  

commerce going on. The concept of intranets was kind of vague. The idea of delivering training using the Internet as a vehicle was almost unheard of. I don’t know of anybody that was doing it. There were people fooling around with it, but nobody was really getting into it and developing a serious curriculum. And I remember Carolyn’s response, "The Inter-what?" You know? So we said, "Look we wanna show you something." 

Well, her husband at that time ran a motorcycle shop, he’s a motorcycle freak. We hooked up, punched into the Honda web-page, and dropped back into their maintenance stuff and found all these maintenance issues, and material. This was solid information, it wasn’t just sell stuff. It was solid, core information. I printed it out and handed it to her, and said, "Here, see what he thinks about how valuable this stuff is." And he was nuts over this, he said, "This is information I’ve been looking for." 

And the light went on. Suddenly they began to understand that you can put real stuff out there, and make it available, and do all the things that we know the Internet to be. Information, good graphics, good images, high interactivity, essential review source, quick update. All those things that we know about now. 

As we noodled the idea around, we hit ‘em with the second salvo. That was, we can save you a large amount of money if we move this over to a client-sever application. We don’t have to deal with reproduction, we don’t have to deal with high-res, high-bandwidth graphics, and on and on and on. We could save a lot of money. Of course that certainly got their attention, and that’s when we really began to define the project. 

So we went into the first wave of development of the Internet delivery system. That was envisioned as ten modules of content based on their current curriculum. That’s how we got started. That’s how we translated it into that mechanism. 

iBiz: How large is it now? 

Grubbs: Well, it went through the first phase, and we developed the ten, but we worried when we started drawing into the content, and this is a classic problem when you talk to clients. "Oh don’t worry, we’ve got all our content you’ll ever need." As we started the design, and assessing what the content was we realized that it was going to expand pretty quickly. Now, where it is, is that it has twenty-one complete modules, and many of those, all of them basically had to be written for this media. The workbooks themselves were not enough. Each module was custom-architected, and images were brought in, and they all had to be digitized and processed, and it became quite a project. There were eleven modules that had to be written from scratch. There were no modules on hyperbaric oxygen. There were no modules on malignant wounds. There were no modules on grafts and flaps and how to handle those surgically. 

iBiz: So did you encounter these as you went along? Did you start to see holes in the curriculum? 

Grubbs: Oh absolutely. I saw that very up-front. I’m an instructional designer by background so, what I tend to do is not just accept what they say, I question it very carefully. At that time, Judy Bario was working there, and she was a clinical nurse in addition to being an educator, so she knew what happens out there in the trenches. She would stand up and give these lectures, and she knew what was going on. Carolyn also was a nurse and she knew what was going on out there. We started seeing that certain things had to be broken out. It was great to do it in an hour lecture, because then you were kind of doing top-level stuff, but if you start hacking those things down, there might be, really, two separate topics. Related, but separate. 

So things started busting apart, and we had to make it into palatable chunks, palatable being kind of tongue-in-cheek, because most of this stuff is pretty disgusting. Of course then we had the other problems of navigation and learning. You know, providing valuable learning experiences, and also, the audience description widened. Initially we were talking doctors. But, when you have a course like this and make it available, you’ve also got to realize that this is a valuable resource for nurses, medical technologists, program directors, everyone. They all have different requirements as to the sophistication of the content. Doctors want all the nuts and bolts, nurses want to know how to handle it in a clinical situation, directors want the overview. We structured the content to accommodate that. There’s high level stuff, you can drill down deeper, and you can drill even deeper to the nuts and bolts. 

That allowed the audience to kind of penetrate what they wanted to do. So we had to build in a navigational structure for that, with a consistent graphical look and all that. So what we ended up with was twenty one separate learning modules. Now another challenge of this is that this is a big system. 

iBiz: How big is it? 

Grubbs: How big is it? The Modules have three main components, actually four if you include the help system, but there are three main components in the modules. There are twenty one separate modules, about 2,000 pages, nearly 600 images, well over a hundred illustrations, so there is a lot of stuff in there. 

Also there are two other components. One is a self-assessment tool we built in called TYK, or Test Your Knowledge. This allows them to get context-based questions on the content. They can select the answer, then show the answer, it shows up in another frame. Then they see the correct answer, a short description of why that’s correct, and links back to the content to allow them to research it further. 

Also within the modules is a text-string search engine, and a very fundamental part of the system which is called Statement of Completion or SOC. The SOC is important because it allows each user to say, to make, an electronic statement saying that they have completed that module.  

So we have the modules, TYK, and the SOC’s. That’s the Modules component. Another main component is resources. We realize that these are physicians, and physicians sometimes don’t wanna go through a teaching thing. They wanna go right to the horse’s mouth and get the literature, get the abstracts. So within the resources, we provide a real breadth of meaty assets. There’s the literature library which includes those things. We’ve got journal articles, abstracts. We have abstract literature summaries, which generates a literature summary with all the popular literature, and what articles are related to wound care, and we published that. There are wound-specific white papers that Curative uses as their kind of de facto, here’s where you go to get that information on Growth Factor Therapy stuff. 

So that’s a fairly big piece of it. It’s all searchable, so you can look up anything you want on diabetes or whatever. So that’s one part. Another part, is what we call the Wound Characteristics Library. That part was targeted more at nurses, because they have very standard rules of evaluating wounds. Mostly by grades, there’s grade 1, 2, 3, 4, 5 there’s a specific criterion for each one, and what constitutes that. Is it a broken bone? Is it malignant? Believe it or not a grade one wound has a lot of different physical looks to it. They don’t all look the same, because of the criteria. So we want to provide a lot of images to show you what grade one wounds are like. So you can click into grade one wounds, and you get a whole lot of grade one images. Or you could go to grade two. 

We also have another criterion called Functional Assessment, and you can go in and get images of the different functional assessments. You can get images of this common problem called fibrin. You can see what fibrin looks like. And eschar, and all these different visual characteristics of wounds in a centrally located library of images. That’s in Resources. 

Another big component in the Resource area is the Wound Summary Library. The Wound Summary Library was built on the premise that doctors like to see case studies. So what we did is we built a content database here. The Wound Summary Library has two pieces two it. The front-end piece is the wound summary itself. This is the synopsis of a case, the presentation, the approach, the images before, during, and after treatment, and a summary. They’re short, one page, and completely searchable by criterion; the wound grade; how it was treated, and what is the source of the wound, the etiology. So if you’re looking for grade five wounds that were caused by venous insufficiency, that is not enough blood to the lungs, which were treated with Procurin™!, their product, it would give you those wound summaries following those criteria. 

Then, once you’ve found the wounds you want, in an association like that you want to present a real key study. If you’ve seen a patient chart before, you know that there’s a lot of stuff in there. We wanna be able to provide as much of that clinical information as they want to see. So they click on a button at the bottom that says extended reports to get a frame that shows what’s available for that case study. It could be the labs. It could be the x-rays. It could be what they call pulse volume recordings, which measures the amount of blood and pressure that is being sent to the wound area. All this stuff that’s in the chart, and those are a bit higher bandwidth, because they’re actually scanned bitmaps of the patient’s chart. We’ve blanked out the patients name, of course, for confidentiality issues. But all that is presented to the doctors just the way they see it in the chart. There really is no other way than to reproduce those into visual format. 

So we don’t have to put those heavy bandwidth things up in the search component, they’re just attached to that specific case if they want to get it. Plus, in each one of those wound summaries we have an audio byte, in which the supplying author of that case gives a recorded overview of it. "This patient came in and when we first saw it we couldn’t believe what this wound looked like. Now after blah blah blah...." It’s a great resource. The best part is, we constructed this so that importing new cases is a snap. We created the administration tool where they can just pile in cases if they wanted to. 

iBiz: They have this at each Care Center? 

Grubbs: No, we don’t let each Wound Care Center get into actual posting stuff. Curative has a Clinical Review Committee that will look at it, decide what is viable, what’s not. They get it all ready for us, and then we do the bitmap scans, but the posting is cheap and easy for them. That’s another component of it, is the Resource area. 

We also have an audio/video library. We don’t really provide audios and videos there. It’s more really so they can access relevant education audios and videos. For example, the American Diabetes Association audio tapes all their presentations, and a lot of them are relevant to wound care, because a big chunk of the patients are diabetics. Right from the library, you can order tapes or videos, its nice and convenient. 

Also, one of the things we found that happened a lot in Curative was that everybody was always asking, "Oh I saw that PowerPoint presentation you did at XYZ meeting, could I get a copy of that?" So what they’ve done is they’ve created a whole bunch of standard, if you will, presentations in PowerPoint. We zipped them all up, and you can call up and download them. They’re kept up to date, if something changes, they change those presentations. That’s a real coup because now what they have is standard messages going out. There is pretty much a standard look and a standard message proliferating in the way people are presenting wound care. 

iBiz: This is a password protected site, but it’s not running over WamNet or a similar private net. Its on the Internet, correct? 

Grubbs: Correct. It’s live on the Internet, and it’s under user-id, password protection right now. We could have gone with deeper security but it really isn’t that necessary. The information is proprietary, but this isn’t like mission-critical information. It’s educational material. 

iBiz: Do each of the Wound Care Centers have a normal interface like any other office, with a user-id and password? 

Grubbs: The way the security system is set up is that we have a database of all the users. So whenever a doc signs on with Curative or they open a new clinic, every individual gets their own user-id and password, not just the Wound Care Center. The administrator at Curative maintains that, so when people leave or when people come on, she’s always changing the user-ids and passwords. She has total control over the user database. 

Also, in order to make this educational experience viable, we configured and installed a dedicated workstation into every single Wound Care Center. I’ll tell you about the role of that in a minute, because that was what really made it work. So now, we can track any user’s SOC’s. We can even go back into the logs and find out how long a user has spent in the modules. We don’t drive that too hard, but we do have that ability. It turned out that that was valuable because when we first rolled it out, some users would go through and, in the space of a half an hour, post SOC’s for all twenty one modules. We went back and said "Uh-uh-uh. There is no way you could have read all this material." 

iBiz: Does Curative have a requirement that new doctors and nurses complete this program? 

Grubbs: They’re moving to that. You gotta keep in mind that when you put something this big into a culture that is not that computer-oriented, you gotta do it carefully. And you gotta do it carefully particularly when you’re dealing with physicians. Physicians are very sensitive people, and they’re also very protective of their education. So to say, "Well you’re a doctor and you’ve been practicing for twenty years, but you can’t practice unless you do this." That’s a little intrusive. So you have to start folding them in, so they can realize that this is not a terrible thing. It’s a good thing. 

iBiz: Is there actually resistance to this learning method? 

Grubbs: Yup. 

iBiz: On what basis? 

Grubbs: It runs in two areas. The smallest is those docs that just say, "Yeah I know all this stuff, I don’t need to look at this." The other small group is those physicians who really don’t trust computers. They don’t like ‘em. But you’re going to see that in any population. You know, "I don’t learn by sitting at computers, I learn by working in the clinics." 

Now this was also a consideration in the use of the Internet system, because we realize the doctors, even on the dedicated workstations, when they’re in the clinics, they’re seeing patients. That’s what they’re there for, to see patients. So we wanted to be sure we could  
provide it to them even if they used it online at home, and that’s really been borne out by watching the traffic. Right now, we’re averaging about 300 user sessions a day even, Monday through Sunday. Maybe a little less on Saturday, but it’s about an even 300, plus or minus 10 or 15, that’s how narrow it is. 

iBiz: What about geographically? Is it flat across the board there too? 

Grubbs: Well it’s regionalized to where Curative is, of course. They’re heavy in Florida, and they’re heavy in Texas and in California. They don’t have any in the upper Midwest. I mean, they have some in this area, but like Montana, there’s not a lot there. Keep in mind that when we talk 300 user sessions a day, that is really significant when you realize that the user population is slightly over 3,000. That’s a lot of usage. 

iBiz: Do you find recurring usage? 

Grubbs: Oh yeah. They come back to it for reference. Yeah, they use it as a system, it’s not just to take a class. Also, the third component which I didn’t talk about is the Communications component. They come back to visit that. That’s kind of your basic stuff. There’s topic-based threaded discussions. There’s conferencing. There’s Course-ware News, where I update all the changes and stuff that goes into the courseware on a pretty much weekly basis. Also there’s Curative News, which is a Curative newsletter. So there’s the Communications component also. They come back into that fairly regularly to see what’s going on. 

iBiz: Do you find the conferencing is a viable tool? 

Grubbs: I think it’s really just there. There’s a lot of neat ideas and speculations behind it, like "Hey, let’s provide conferencing! They could all do it with their keyboards!" But, first off, most of them are lousy typists, and it takes a while to get the hang of conferencing. There’s delays between the time you type and it hits, and also, just recently, conferencing software is really starting to get sophisticated. Back when we put that in, it was pretty much just written in CGI, so it’s not high-functional. 

iBiz: Do you find that since this project started two years ago that you had to go back and redesign and rework some of the earlier work that you did? 

Grubbs: Interestingly enough, no. You can look at it from a couple of different areas. One is content. The content has been pretty stable, there’s been typos, and somebody catches a glitch here and there, but the functionality in the modules has been rock-steady. We had some trouble in the threaded discussions, and now we’ve got that quite stable, but the resources and the modules are rock-stable. They’re bulletproof. Current technology would say all that content would be driven out of the database through active server pages. That’s the way people are doing big chunks of content. Back then we did this all in hard core HTML. But I’ll tell you what, there’s no risk. That thing just runs like a tank. That’s one of the advantages of the system, the content is not so volatile that it’s changing hourly, you know. This year we’re going to go through a complete editorial revision of all the modules, so they’ll be kicked up a notch professionally. But structurally, it’s not really going to change. The navigation is solid, the look is solid. 

iBiz: So how much time did this take? I mean, it took two years to get from there to here, but was this a full-time project and for how many people? 

Grubbs: There’s a couple issues here. As you say it took two years, but there were a couple big lags. We hit like a three month lag in contracts, and we hit a three month lag when there were some changes in the upper administration. The real work got done in about five quarters, that was the real work. That’s when it really got done, and that’s really significant, hearing how much of that content had to be generated. We had several teams. Now there were two companies heavily involved, and that was Martin-Bastian Communications, and that was IVL. And the way we split this up was that Martin-Bastian was in charge of the client wrangling as we like to call it, the project management, the top-end system design and the content management. IVL was responsible for the programming, the integration of the media, the graphic design, the look and feel, and the building and maintaining of the database. So they were basically doing the technical, and we were doing the content side of it and the project management. 

Probably at it’s highest peak we had anywhere from nine to twelve people going at it full bore. That was when it was really just crankin’, the modules were falling in, there were no decision points. It was just get this stuff through and get it set up, because we had a fixed roll-out date. It wasn’t just when it’s done, roll it out. We had a fixed date. Curative’s smart, because they know that you can’t just roll this out and expect everybody to embrace it. So as the production was really winding up, I was spending a lot of my time at Curative, helping them sow the seeds of the culture. 

The two main contacts at Curative were Carolyn Fylling, who’s Director of Educational Services at Curative, and Christie Pines, who is the system administrator for this project. She’s the manager of interactive services there. Christie is the one that’s the nuts and bolts. She’s the system side of it and Carolyn is really the overall person and the content person. She is responsible for the medical content and all that. It was a great team, and the thing you gotta realize is that when we built this, there was the core team. There was myself, there was Carolyn, there was Christie, there was Michael Wood on the front-end. Then Michael left IVL and Steve Calvitt picked it up. Greg Schutta was my right-hand person here, he helped me. Greg is very organized, he gets everything in the right file folders, double checks. Without Greg, those modules would not have been done as accurately as they are now. He’s the kind of guy who keeps everything in the right slot.  

On the IVL side Daniel Gumnit was the overall person, and Steven Calvitt and Michael Wood were the project leaders. They traded off about halfway through the project. Then Brett Treptow did all the graphic design. Clay Stiles did probably 95% of the HTML programming. Him and another guy named Franc, I don’t know his last name, he’s French. Right now, Tom Zemlin over at IVL is the system administrator. It’s being hosted at IDL. 

iBiz: But the system administrator is really Christie from Curative, correct? 

Grubbs: Yes, Christie Pines. Now when she started she didn’t know a whole lot about this. She is a sharp lady. She just jumped right into this, picked it all up. She really probably knows more about HTML and all this other stuff than I do. She just dives into it. And now she’s got very good control of much of what goes on. We designed it that way because we want to transfer a lot of the maintenance and a lot of this stuff off to them. Why pay us for that? Pay us for the design, and the concept, and the original systems. 

iBiz: How much maintenance are you doing on the site right now? 

Grubbs: From our point of view, very little right now. From Christie’s point of view it takes a fair amount because it’s maintaining the user database. There’s people coming in, coming out, changing passwords, losing passwords. Our maintenance right now is pretty much limited to content issues. If something changes in the field, we have to change these modules. Sometimes clients report a bug. It’s funny, you really begin to get to know how much the users are getting into this. We get reports of one word that is incorrect, but it’s like deep down in a research study that says "compares patients with diabetes to patients." It should have been without diabetes and it says with diabetes, and it’s like way down, in the small type, down in there, and they catch it. We got one that reported that a radiograph was inverted left to right. If you look at an x-ray, most people are not gonna know, but this guy caught that. They’re really seeing the small stuff. 

iBiz: And they’re reporting back then? 

Grubbs: Yup, we have a comment system built in. Wherever they are (in the system), they can hit right in to the comment system. They’re asked in the form to report what page they’re on, where they’re at, what they saw, and then submit it. Christie sends those to me, and I order it fixed. Sometimes when there’s a question or comment, we get open-ended stuff like, "We don’t really do that at our center. Is that the way we should be doing that at Curative?" We send those to Carolyn, she gets a ruling on it and tells me exactly how to fix it. We go and fix them. Then we post in the Curative News that we received this comment and this is our position on it. 

iBiz: So everybody knows what’s going on? 

Grubbs: Everybody knows what’s going on and they know if they’ve been heard. 

iBiz: What is the overall user feeling coming about the project? Now that it’s been working awhile? 

Grubbs: Well it’s interesting. We get it from two directions. One is the real users, the docs, and the people I’ve talked to out in the field, they really like it. They like being able to have it there. The new docs coming into the system really like it because they come into this world of wound care and they’re very interested in it. Docs typically, when they come into a new area of their practice, wanna know everything about it. So now we say, here’s a user-id and password. It’s not like we say, here’s four manuals of stuff you gotta read, by the way you gotta sit through a seminar in six months. It’s like, here, go look, and they dive right into it. That’s where we see the highest acceptance. 

The other is the nurses and staff, who are really looking forward to it. People tend to underrate what the nurses do, but they’re the ones who know what’s going on in the clinics. They’re the nuts and bolts, you know, it’s like having the greatest receptionist in the world, you can’t overstate how valuable that person is. And they have a desire to know. 

Where we had resistance was some of the grandfather-types, you know, the ones that had done it for a while. Although there are some real exceptions to that. We trained one doctor, who was almost 70 years old, been in it for a long time, never touched a computer in his life. Within an hour, he was all through it. He danced through it. He understood it. He could work it. It’s very intuitive. 

Now, the other big measure of acceptance was from program directors. The program directors are essentially the administrators, they’re not medical people. They have a big challenge, particularly in the set up of a center. They have about 90 days, come in, get the facility up, get it staffed, get the patients. They want their people knowledgeable. Healing outcomes is their critical benchmark.  

They’ve said they love this. They don’t have to spend a lot of their time teaching the docs. They just say here’s an environment; go do it. We expect you to be this far through it by the time you actually see patients. Program Directors love it. They just love it. 

The first roll out of this was in February of 1997. We did a national meeting. We did a presentation, showed ‘em how to do it. Showed ‘em how easy it was. Then we had a workshop that ran all day long. 30 computers set-up, all on-line and we went one-on-one with all the Program Directors and walked ‘em through it. They loved it. 

What we also hadn’t told them was; when they got back to their centers there were new computers sitting there waiting for them. So they came right out of that training and they were right into it. Ready to go. 

iBiz: How about Curative? What kind of feedback are you getting? 

Grubbs: Right after the roll out, almost immediately, Curative wanted to evaluate return on investment. We said don’t do that yet. It’s gotta soak in, people have to get used to using it. 

iBiz: Did they? 

Grubbs: Well, within two months they completely stopped their seminar training system. They said we’re not going to spend any more money on that. Here’s this new tool let’s make it work. In October/November they started to do a return on investment of it. What they found was, the initial return on investment was OK. It wasn’t through the ceiling in terms of hard dollars. Y’know, seminars cancelled equals hard dollars. Money spent on the software equals hard dollars. What they found that is hard to measure, and I don’t think they’ve figured this out yet, is the soft dollar return. 

That return falls into two areas. One was the increase of successful wound outcomes in the centers. Did the percentage of healing outcomes go up. Truthfully I’m trying to figure that out. 

The second area is one of even softer dollars. It became, the Curative Courseware as it’s called, became a value add tool (for Curative.) The way Curative conducts business, remember they’re not in the business of treating wounds, they’re in the business of setting up wound management programs. So when they go to large systems like Columbia (Columbia/HCA Healthcare Corporation is one of the largest owners of private hospitals in the nation) and say, "We’d like to set up a series of wound care centers in association with Columbia Hospitals in South Florida. Let’s open up 15 of them." They need leverage. Columbia’s response could be, "Well what are you bringing?" 

Curative can respond, "We’re bringing this treatment paradigm, the management of the clinical systems and we’re bringing education." Every time that makes the eyebrows go up. "What do you mean education?" The answer is, "Here’s the clinical courseware. Look how deep, rich and viable it is." In several cases it may not have been the factor in getting the contract signed but it was a mitigating factor. That’s hard to measure. How do you say this was the reason you got the contract. It may not be the only piece but it was a big piece. Hospitals are saying "Great! We don’t have to invest resource to train those docs. You worry about it." 

That’s been a big part of the evaluation. It’s very hard to measure the return on investment. So since then we started asking the question, "How do we know the translates to real live ability to treat wounds. How do we know? How can we test that?" Then the question went one step farther. "Can we use this technology to evaluate physicians knowledge? Or as a tool to evaluate a physician?" 

Keep in mind when you evaluate physicians that’s a big deal. It’s clinical. It’s interaction with patients. It’s healing outcomes. It’s financial return. It’s knowledge. It’s a lot of stuff that’s critical. And we wanted to focus it and keep it linked to the courseware. How can we see if they had translated this knowledge into treating patients. 

iBiz: Tough question. How did it work out? 

Grubbs: Well we embarked on a new venture. That was to create what we call the Clinical Review System. Initially this was thought of as an evaluation tool. How do you evaluate students. To begin we asked how do doctors work? What do they do? 

Well, they get a certain amount of information about a patient. They develop a diagnosis and they develop a management plan. Then they come back at the next visit. Evaluate new information, do a diagnosis and develop a management plan. And that’s how patients are treated. That’s pretty simple. 

What made it complex was; patients change from visit to visit. Also two doctors may have slightly different approaches and basically come up with the same result. But there are right ways and there are wrong ways and there are grey areas in between. How do we measure that? 

The third complexity is that this decision may cause this to happen. Or it may cause that to happen. Then it becomes a massively branching thing. We decided to avoid that one. You can get off into billions of permutations and they didn’t have the funding or time to work with that.  

So rule number one was we would go in kind of a linear track. Not every decision the physician made would affect the next visit. We built the Clinical Review system as a series of visits. 

Here’s a patient case. Here’s visit number one. Here’s the assessment of that patient; heart, lungs, ENT, the complaint, etc. Here’s your information. Now you’re (the physician is) required to make a diagnosis. You’re presented with a variety of diagnosis options. There’s primary, secondary medical diagnosis with each one. You diagnose Diabetes, vascular insufficiency. It’s very simple. It’s all click boxes. 

Then you’re allowed to do the same thing with the management. There’s OR procedures, clinical procedures, blood work, coverings, the whole bit. Between diagnosis and management plans, which are really the interactions, there’s 134 possible selections, on one visit. Now here’s where the system got beautiful. 

In the background we developed a scoring system on it. It’s basically like golf. Points are bad but you’re gonna get some. The idea is to hit par or to hit about what people are asking for. There is another discrimination in the system. Before you can get into the CRS it checks the user’s speciality in the user database and if you’re a podiatrist, for example. You only get cases about feet. 

The other premise we had to land on was the author of the case as kinda being the standard. Because there’s different choices, different authors might approach a similar case in different ways. We can’t make those judgements. But we have to have someone determine what is correct and what is incorrect.  

The scoring system works like this; if the answer the user selects agrees with what the author says, zero points. If it doesn’t agree, but it’s not a bad choice, one that’s not going to make a whole lot of difference, five points. If it’s not really the best choice, ten points. Wrong choice, doesn’t agree with the author, he wouldn’t do it that way, twenty-five points. Then we have what we call a heinous crime, like ordering an amputation of a leg when the patient has something wrong with his arm. Something really dumb, or putting Growth Factor Therapy on a malignant wound. That would be pretty stupid, so for that you get fifty points. If you’ve got a 134 point options you can really rack up points. 

Now, what happens is, when you submit that visit it’s scored. It’s compared, against the standard we’ve established. If you exceed that score standard, you’re ejected from the system. You’re kicked out and you can’t go to the next visit. OK? 

There’s another cool thing that goes on behind the scenes. First off, you can’t get into the Clinical Review system unless you’ve filed a Statement of Completition for all the modules. You have to have certified all the modules before you get in. So that’s the gateway.  

Now if you get kicked out, it takes a look at the areas that you were missing and it identifies modules you need to review. It gives you a list of those review areas and it de-certifies those modules off your Statement of Completition record. You have to go back and re-certify those modules. Once you’ve done that and you come back into the Clinical Review system you get a different case. 

IBiz: What’s the incentive for the physician to do this? 

Grubbs: There’s two. We’ve developed a relationship with the University of South Alabama and they give CME (Continuing Medical Education) credits to physicians for each module they certify on. That’s the other important thing about the SOC, when they file that their record is sent to the University of South Alabama and they get CME credit for it. Those just got kicked up to Level 1 and that’s very significant. That’s the number one incentive, they get credit for doing the work. 

In the Clinical Review system the incentive. . . Now first off that’s not fully implemented yet. It’s just coming out of Beta and they’ve got some issues inside their (Curative’s) culture right now. They don’t want to say, "You’ve got to do this."  

Eventually they want to say you’ve got to do this to practice. That’s the theory. But politically that’s an extremely difficult thing to say. Right now they’re struggling with saying you have to complete the courseware before you can practice. If they throw this one more thing at them there might be a mutiny. Again it’s back to this thing of infusing the technology gently into the culture. So what we’re doing now is adapting it a little bit to make it an interesting exercise, a self-test. 

The other thing we’ve done on the administrative side is, we realized that doctors are the ones that are going to write the cases. Now the thing that makes it really viable is lots of cases.  

We also wanted to make it so that physicians could easily create a case. There’s a lot of scoring in there, you’ve got to think about how the whole thing is set up. So we built a tool in a Java applet that we can give to them either on CD Rom, or they can download it off the net. They can then go through and build a case on-line. It (the applet) saves it back to a text file. They send us some images to associate with it. We have peer committees review it. They give us the final piece and it goes right into the database. Error checked and good to go. 

IBiz: So the students are creating the courseware? 

Grubbs: Right and it’s great because we’re tapping into real world cases. 

IBiz: Now where’s this all going to go? Is the project complete? 

Grubbs: No, no, no, no. . . never complete. Keep in mind this is falling under the umbrella of the education department. We’re already talking to them about training in a lot of other areas. This is physician training. I’ve already worked up a schematic for Program Director training. That’s got some neat potentials in it. Say you’re a Program Director, you’ve got 90 days to set up a program. How do you do that? What’s your resource? In the past, same old thing, here’s six notebooks full of information.  

Curative has developed a great methodology. They’ve got spreadsheets where you go through and select your equipment. They have preferred vendors. They have preferred equipment. They know the costs. If you’re going to set up a two exam room facility, this is the basic stuff you need. If you’re gonna get more contract money this is what you need. Here’s some nice to have things. 

What we want to do is move that into an active piece where you could literally go through a form. If you have a two room exam facility you go through and check what you want/need. It tallys up your totals and spits out a list of vendors, with order forms. There’s a lot of neat things.  

We could put other training pieces in place. For example Program Directors have to go through Joint Commission (the Joint Commission on Hospitals) Inspections. When the JCH comes in to do a review, how do you handle that? We can do simulations of those situations. They’re gonna ask for some things you don’t have to give’em. There are others where you better have your ducks in a row or you’re gonna be in trouble with your certification. Those are the kinds of things we want to build into it. 

Another area is sales training. Lets train their salespeople in how to sell this stuff. They need a little bit of the wound care stuff. They need a little bit of the wound management program stuff. They need all these things. 

Another big one is medical technology training or Nurses training. There are a lot of areas and they could all be delivered on-line. 

IBiz: Was this project more complex because of the subject matter? 

Grubbs: No I think it becoming more complex, more wide in it’s application, because Curative realizes it’s intrinsic value as part of their growth. It’s how they’re going to leap forward. They can streamline processes, get a salesperson from zero in a shorter time, get wound care centers up and running in a shorter time. They can get doctors trained in a shorter time. It’s basic to their growth. 

iBiz