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Published on Physicians Practice (http://www.physicianspractice.com)
To: [email protected]
October 01, 2003 | Health IT [1]
By Bob Keaveney [2]
The current state of physician-patient e-mail
Scott Conard, MD, created TienaHealth after becoming frustrated with rote primary-care medicine
that centered too much on diagnosis and treatment and too little on the root causes of disease.
"We educate patients about their condition and the power they have over controlling it, to the
degree they have any," says Conard. "We try to make them the quarterback, and we're the coach.
They're the ones in the game; it's their body, their life."
It's no surprise, then, that Conard, a fast-talking healthcare visionary, is one of the early adopters of
online technology that may alter the paradigm of physician-patient relations in many practices.
Conard has enrolled his group of 10 physicians and other providers in MyDocOnline Connect, an
Internet-based patient communication service.
By logging into a secure Web site and entering a password and user name, patients can make
appointment requests, gain access to lab reports and other medical information, and review their
accounts. Most interestingly, they may engage in asynchronous "online doctor visits" with Conard
and his physician colleagues.
For the most part, communicating with patients today hasn't much changed from when his father
was a primary-care doctor, Conard says. It's mostly done in person at the office, hospital, or nursing
home.
Yet with the amount of medical information available, and patients' needs exploding, doctors don't
have time to fully discuss everything patients should know during brief in-person encounters. The
physician-patient communication conduit, says Conard, ought to be "a big, wide tube ... with
communication flowing freely back and forth," but in fact is more akin to a drinking straw. Physicians
get precious little information from patients, and patients get a few drops from physicians -- if each
side pulls really hard.
MyDocOnline improves the flow both ways. Patients ask more questions and TienaHealth can send
information on new treatments, research, and other issues to mass numbers of appropriate patients.
Conard can e-mail information to all of his diabetic patients, for instance, instead of sending them an
expensive mailing.
TienaHealth allows its patients to enroll in the system for free, but charges them $35 for each online
physician visit. Patients pay that out-of-pocket; the encounters aren't covered by any of the
practice's payers. During the visits, patients provide information about their current medical
condition, their symptoms (if they're having any), and whatever questions they have for the doctor.
During a rare lull at his office, over lunch, or perhaps that night from home, Conard reviews the
patient's information, checks his records, and makes recommendations to the patient.
"So whether it's the patient wanting to ask a question, get a [prescription] refill, or if someone isn't
sure whether he should come in, he can go to his computer and in a few minutes, I can give him the
answer," Conard says. "The patient doesn't have to leave work early; he doesn't have to drive to my
office."
Patients can only use the service if they have an established relationship with the practice. If the
issues are too complex for electronic communication, the doctor simply advises the patient to make
an appointment without charging for the online visit.
TienaHealth has been using the system since late summer. Although practices have been utilizing
e-mail with increased frequency for a while now, the concept of online physician consultations -- for a
fee -- is fairly new, and the extent to which payers and patients are prepared to accept and pay for
such a concept is unclear. Some private payers may even prohibit practices from charging patients
directly for such services.
That's why your practice should consider carefully what it hopes to accomplish from online patient
communication before diving in. You should also check your contracts first. If used correctly, the
technology may increase efficiency, save time, and aid in managing patients with chronic illnesses.
But will it work as an effective revenue driver? It's too soon to say.
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In TienaHealth's case, the $35 charge is a bit more than the copayment most insured patients would
pay for an in-person visit, but Conard is confident that most will consider it a bargain: "When you
take the energy, time, time away from work, lost wages, and add that to their copay for a regular
visit, plus any deductible, $35 is a good deal for patients; it gives them another option."
Benefits of e-mail
Another well-known provider of physician-patient electronic communication is San Francisco-based
Medem, which was founded by a group of medical associations, including the AMA. Some EMR
vendors are also providing their clients with secure e-mail communication capability. The concept
has piqued the curiosity of many busy practices because it offers hope of solving the problems of
poor patient access and endless patient phone calls, while perhaps adding other benefits.
If patients whose medical issues are routine can be handled remotely and asynchronously, the
theory goes, practices can reserve their in-person appointment slots for new patients and those who
are truly sick. E-mails, unlike phone calls, can be answered when it's convenient for physicians and
staff, so fewer phone calls mean staff will have more time to support the doctors.
It's also plausible that e-mail could decrease malpractice exposure. Miscommunication is less likely.
Physicians can collect their thoughts before typing a message, and because patients have a written
record, they're more likely to understand instructions and follow them. Documentation is easier, too.
Practices with electronic medical records (EMR) can easily attach their e-mails to patient charts,
meaning physicians won't have to take extra time to document every word uttered to a patient over
the phone.
Moreover, adds John Gastright, MD, president of West Ashley Family Medicine in Charleston, S.C.,
"the e-mail-oriented patients really like it a lot. It's how they communicate in their world."
Indeed, in our Internet-dependent culture, many patients prefer e-mail to the telephone or even to
personal contact, so e-mail might serve as a great patient satisfier. About a quarter of physicians
already communicate with patients online, according to a recent Harris Interactive poll, and another
9 percent plan to start in coming months. More than half of those doing so said they started
primarily because their patients were asking for it.
"E-mail is becoming more and more common, and a more preferred mechanism for folks to
communicate, particularly when they're trying to contact someone who's busy," says Steve Ura, vice
president and chief technology officer of A4 Health Systems, an EMR provider that is launching a
Web site enabling physician-patient communication. "Electronic dialogue between the physicians
and patients really makes the best use of everyone's time, and actually allows for better responses
to the patient."
Getting paid
But can you get paid for it? That may be the most intriguing question for practices whose physicians
and nurses spend hours of uncompensated time on the phone, triaging patients and answering their
questions.
"Doctors for a long time have vented a certain frustration that lawyers are able to charge by the
minute whenever they answer the telephone" but physicians can't, notes Nicholas Bonvicino, MD,
senior medical director of Horizon Blue Cross Blue Shield of New Jersey, which this year has
experimented with reimbursing physicians for online visits. As a general surgeon who spent years
working in a group dominated by primary-care physicians, he sympathizes. "Doctors forever have
asked, 'Isn't our time as valuable as a lawyer's?' So the e-consultations could be seen as a way to get
paid for these things."
That's just how Medem CEO Edward Fotsch, MD, sees it. His company enables secure patient
messaging for appointment and prescription refill requests, administrative questions, and online
consultations. Some 10,000 physicians use Medem's e-mail service.
"Our experience so far has been that physicians set incredibly low fees for their online consultations;
the average is $25," he says. "Most attorneys and accountants don't answer the phone for $25. ...
And 50 percent of e-mail inquiries to physicians on our network are answered, then not charged for.
How many questions do you pose to your attorney and not get charged for? The bottom line is that
all physicians have are their brains and their time, and if you're going to take up a fair chunk of both
of those, they need to be compensated."
But it's not clear yet how serious the prospect of charging for e-mail consultations is. Bonvicino, for
one, has become more skeptical about the idea since January, when Horizon began its pilot project
with two rural practices. The insurer agreed to reimburse the practices for online visits on two
conditions: the issues tackled during the visit would have to be, in the doctors' judgment, medically
justifiable as reimbursable encounters, and the patients would have to pay their normal copayments.
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Horizon did not want to open a whole new cost center for itself by reimbursing doctors for things it
currently considers part of what it already pays them - including answering patients' mundane if
time-consuming questions about medication dosage, doctors' instructions, and so forth.
"The question for us," says Bonvicino, "was would we be reimbursing for something that otherwise
we wouldn't be paying for at all? Or would we be reimbursing for a service that's legitimate but less
complicated, and therefore we'd see a cost savings by having it performed online? In other words,
would e-mail replace an office visit, or would it replace a phone call?"
Horizon will be collecting data until the end of the year. But early results are mixed. For one thing,
many patients balked at the idea of paying a copayment -- they must provide a credit card number
to enroll -- to get the kind of information online that they were accustomed to getting for free over
the phone. And doctors didn't like having to tell their staffs to refrain from providing such
information, says Bonvicino.
Why not just drop the copayment for online users? Because doing so would amount to discriminating
against non-computer users, and would also defeat the purpose of copayments, which is to spread
costs around while encouraging patients to be more judicious about their use of the healthcare
system.
Fotsch rejects the idea that e-mail is a mechanism for physicians to charge patients for services
patients are currently used to getting for free: "What they're used to doing is calling the office and
getting a recording, or the opportunity to wait on hold. They rarely get to the doctor; they usually
speak to a nurse if they speak to anyone. And then they usually get a couple of minutes on whatever
the issue is, and if it can't be handled simply, they're told: 'You sound awfully concerned; maybe
you'd better come in.'"
Although he says that insurance reimbursement for e-mail consultations is probably not in the
near-term offing -- "Insurers aren't looking for new things to pay doctors for" -- Fotsch argues that
patients will pay for online consultations out-of-pocket, provided it's presented as an additional
service rather than as a replacement. In the Harris poll, 40 percent of patients said they'd pay $120
a year to communicate online with their physicians.
Common uses
For now, however, many practices are using e-mail strictly to add efficiency to their practices, reduce
call volume, and satisfy busy, tech-oriented patients. Those benefits alone are worth it to those
practices.
"The biggest [patient inquiry] that we get via e-mail is for prescription refills," says Gastright. "And
that's OK because it reduces staff time. Otherwise, the patient calls in for the refill, the receptionist
answers the phone, transfers the patient to the nurse, the nurse writes the information down, checks
with the doctor, the doctor approves the refill. But if the patient e-mails the doctor directly, there's
no voice interaction -- and the e-mails go into our EMR, documenting the communication occurred."
When the e-mail is linked to a practice's EMR, the physician can simply review the patient's chart
and easily approve the refill with a few clicks, says Gastright. Patients also e-mail with other
questions they'd normally call about. The practice doesn't charge patients for answering these
queries, but Gastright says the time e-mail saves him is worth it regardless.
Family physician Paul Ehrmann's group, Family Health Care Center of Royal Oak, Mich., has been
e-mailing patients for some time now, and recently began using a secure Web-based messaging
system provided by MedAxxis, its practice management software vendor, allowing it to expand and
refine its communication with patients.
The service from MedAxxis does not cost the practice any additional money, and Ehrmann says he
wouldn't be comfortable charging patients a fee. "I've heard about that trend, but I see it as just part
of the normal routine of providing care," he says. "Unless it gets really out of hand, I don't think it will
be necessary. It's hard to know where to draw the line -- what do you charge for and what don't you?
And I don't want to risk getting into contentious issues with patients about that."
Besides, it's difficult, if not impossible, to diagnose most conditions over e-mail, in Ehrmann's
opinion. He once had a patient with acute appendicitis e-mail him her symptoms, not realizing how
serious it was. "Sometimes, patients misinterpret things," he says.
It goes almost without saying that practices should use secure e-mail systems if they're going to use
e-mail at all. A Web-based service like MyDocOnline or Medem that requires user names and
passwords are safe bets, as are services provided by your EMR vendor. Whatever service you use,
make sure it complies with all HIPAA security and privacy regulations.
"My feeling is that physicians and their clinical staff should be looking to use e-mail as frequently as
their patients are willing to do so," says Ura. "There are fewer interruptions throughout the day and
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you can provide more thoughtful responses. We just think it's a better way all around."
Bob Keaveney, associate editor for Physicians Practice, can be reached
at [email protected].
This article originally appeared in the October 2003 issue of Physicians Practice.
Disclosures:
Source URL: http://www.physicianspractice.com/articles/e-mailyourpracticecom
Links:
[1] http://www.physicianspractice.com/health-it
[2] http://www.physicianspractice.com/authors/bob-keaveney
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