Patients, Physicians Find Internet Is a Valuable Tool in Medical Care
Technology Feature - October 2002
By Ken Ortolon
Victoria obstetrician-gynecologist Philip T. Suarez, MD, has been Cheryl Johnson's doctor for five years. He provided medical care during two pregnancies, and the two have built a close patient-physician relationship.
Yet, when Ms. Johnson, a Victoria advertising agency owner, has a question or concern about her health, she doesn't call Dr. Suarez. Instead, she sits down at her computer.
"To be able to have access to my doctor through e-mail is just fabulous," Ms. Johnson said. "I feel like it has helped our relationship as far as him being involved with what's going on with me medically. If I have a concern, I can shoot him a quick e-mail and he can shoot me a quick answer. It helps the whole medical process."
Dr. Suarez is one of a growing number of physicians across the country catching on to the potential of electronic communications to improve patient care and increase efficiency in their practices. Physicians were slow to accept electronic communications with patients because of concerns about privacy, potential liability, and reimbursement. But those concerns are being addressed through new ventures such as Medem, Inc., a for-profit company founded by the American Medical Association and a consortium of other state and national medical societies. Medem and a handful of other companies are offering physicians Web site hosting, secure messaging, and online consultation services that facilitate patient-physician communications via the Internet.
Physicians say such services cut through hassles and provide convenience for both physicians and patients. And, experts say patient demand eventually will drive physicians to jump on the e-mail bandwagon if they want to stay in business.
"In a three-to-five-year time frame, it will be like fax machines," said Edward Fotsch, MD, Medem's chief executive officer. "If you really want to be in business, you will offer this service."
Dr. Suarez, who chairs Texas Medical Association's Council on Communication, is an Internet enthusiast and has been using e-mail in his practice for some time. So, it was not surprising that he would jump at the chance to communicate with patients electronically.
"The phone is just getting to be very, very difficult to deal with, particularly as busy as our practice is," Dr. Suarez said. "With online communications, the patient can state her problem, send it to us, and then we can calmly reply. We get her request and she gets our reply at our mutual convenience. So you're not playing continual phone tag."
But the majority of physicians have been slow to embrace electronic communications with patients. National surveys indicate that 90 percent of physicians use e-mail, but a Harris Interactive Poll conducted earlier this year found that only 13 percent use it to communicate with patients. The Texas numbers are a little higher. The 2002 TMA Physician Survey found that 20 percent of Texas physicians communicate with patients via e-mail.
Among the factors contributing to physicians' reluctance to use e-mail with their patients, privacy was the first, and possibly foremost, concern.
Austin psychiatrist Harry B. Rauch, MD, says his patients wanted to communicate with him via e-mail as soon as they found out he had an e-mail address. Initially, he discouraged the practice because of privacy concerns.
"Over the last year or so I've started receiving increasing numbers of messages from my patients over standard e-mail lines," he said. "Working as a psychiatrist, that's a pretty risky mode of communication. So I instructed patients never to use that."
Palestine internist Michael S. Gorby, MD, also had concerns because standard e-mail is not covered by privacy rules established by the federal Health Insurance Portability and Accountability Act.
Other factors include physicians' fear of exposing themselves to additional liability and a reluctance to take on extra work without getting paid for it. Dr. Fotsch says online communications is not a covered benefit in any capitated or fee-for-service health plan of which he is aware.
Patients, however, appear to be demanding the convenience of e-mail communications from their doctors. Another Harris Interactive Poll conducted in April found that 90 percent of adults with e-mail want to communicate with their physicians online, and 37 percent said they are willing to pay for it.
Dr. Fotsch says Medem has the solution to all of those concerns. The company was founded two years ago to create a secure patient-physician communication network. Initially, Medem offered Web site hosting for physicians and provided access to medical news and information for both physicians and patients, using the resources of its member medical societies.
Some 18 months ago, Medem launched a secure messaging service to allow physicians to communicate safely and privately with patients through an encrypted (coded) e-mail system. In June, Medem added the final piece of the puzzle when it launched an online consultation service that includes a mechanism for billing patients for online services.
Patients can access the secure messaging and online consultation features by logging on to their physician's Web site. Medem's online communication system is for use only by patients with whom the physician already has a relationship. In order to log in, the patient must receive a user identification and password from the physician.
Once logged in, patients can e-mail their physician's office to make an appointment, request prescription refills or laboratory test results, or ask questions. (See " Internet Prescribing Requires Proper Groundwork .") If they want an actual consultation about a medical problem, they can choose the online consultation service. Patients are informed up front that they may be charged for the consultation and what the physician's fee is. If the patients agree to be billed, they enter their credit card information, just like they would when making a purchase online. Medem processes the credit card through a third party and pays the physician. It charges the physician $2.50 per each transaction.
Out of nearly 84,000 physician Medem subscribers, more than 8,000 currently use the secure messaging service, and more than 600 are using the online consultation service, Dr. Fotsch says.
Physicians set their own fees for online consultations, although Dr. Fotsch says Medem recommends a fee range between $20 and $30. The national average of physicians currently using online consultation is $25, he says.
Physicians also must decide if they are going to charge for a consultation on a case-by-case basis. Just because a patient requests an online consultation and agrees to be billed doesn't mean the physician has to charge if he or she does not believe a fee is warranted, Dr. Fotsch says.
Addressing the E-risks
Dr. Fotsch says Medem delayed launching online consultation until it had addressed liability concerns. More than a year ago, Medem created the eRisk Working Group for Healthcare, a coalition of 33 medical liability carriers representing more than 70 percent of insured physicians in the country. That group developed standards to govern patient-physician online interaction. Among other things, they urge physicians to switch from standard e-mail to secure, password-protected messaging systems.
"One of the things that's relatively important on the liability side is that the physicians have to understand, and hopefully understand quickly, that using regular e-mail with patients is a huge problem," Dr. Fotsch said. "More than half of the people who use regular e-mail use it from their workplace and, therefore, their employer owns every bit of that e-mail. There is no privacy."
The guidelines also call for obtaining informed consent from the patient regarding the appropriate use and limitations of online communications. They recommend physicians develop and publish specific guidelines for online communications, such as avoiding emergency use and appropriate expectations for response times.
"You shouldn't just say 'I'll take an e-mail from anyone,'" Dr. Fotsch said. "You should look at your practice and decide on a patient-by-patient basis who is capable of using this form of communication."
Medem is not the only game in town for physicians who want to become e-enabled. MyDocOnline, owned by Aventis Pharmaceuticals Inc., provides Web site hosting and secure messaging. Healinx Corp. also provides online consultations in partnership with Blue Shield of California, Kaiser Permanente, and other health plans.
Dr. Fotsch says Healinx, unlike Medem, is focused on getting health plans to pay for online consultations. Information on the Healinx Web site says, "By streamlining the doctor-patient relationship, Healinx enables payers to improve member satisfaction and retention and reduce their exposure to rising healthcare costs."
Dr. Fotsch says most health plans eventually will pay for online services, and Medem has asked the AMA for a CPT code for online consultations. That request will be considered next spring.
"Sooner or later, the plans will pay for this," Dr. Fotsch said." We're hoping it's later because when the health plans start paying for it they're going to come up with all their rules."
Convenience and Revenue
In the meantime, the response to online communications seems to be overwhelmingly positive from both patients and physicians who've tried it. Drs. Suarez, Gorby, and Rauch say Medem's secure messaging and online consultation services cut telephone hassles, improve office efficiency, and improve their accessibility to their patients.
Dr. Rauch says his patients definitely want to communicate with him online. Often, they do not even expect a reply. "One patient sends me a general communication every four or five days during crises," he said. "She tells me that this has been extremely helpful. I'm not charging her for those communications, so she doesn't expect a response. And yet, she feels very good about being able to communicate these events to me."
Dr. Suarez is the only one of the three who has actually charged a patient for an online consultation and has only done so once. Dr. Rauch says several of his patients have requested online consultations through Medem. Dr. Gorby is unsure yet how his patients will respond to a fee for online communication. "I'm not sure in a small town they will ever see the cost advantage," he said.
But Dr. Suarez is convinced most patients who use e-mail regularly will recognize those cost benefits. When he does charge, it's $30. "So for $30 they can get the same thing as coming into the office for a consultation but they don't have to take off work, they don't have to drive here and park, they don't have to ding up their car in our garage, and they don't have to pay their $15, $20, $35 copay."
Ms. Johnson says she would pay if the price were right. "If I'm paying $45 for an office visit and I can have a question or concern addressed in an e-mail, I certainly wouldn't mind paying for it, because my time is valuable."
In Dr. Fotsch's words, "It's a steal for the patients," and it generates a new revenue stream for the physicians while eliminating unnecessary office visits and reducing the volume of phone calls coming into their offices. He says some physicians currently using online consultations are charging for five to seven consultations per week. At $25 per consultation, that could generate between $6,000 and $9,000 per year.
"For primary care physicians, in particular, that's real money."
Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392, or by email at Ken Ortolon.
Internet Prescribing Requires Proper Groundwork
While the Internet can be an important tool in providing quality health care, physicians need to exercise caution in the realm of Internet prescribing, says the state agency that licenses physicians.
In a policy adopted in December 1999, the Texas State Board of Medical Examiners states that an online or telephonic evaluation of a patient by questionnaire is an inadequate basis for prescribing medications.
"It is unprofessional conduct for a physician to initially prescribe any dangerous drugs or controlled substances without first establishing a proper physician-patient relationship," the board policy states.
The policy says a proper relationship, at a minimum, requires:
- Verifying that the person requesting medication is who he or she claims to be;
- Establishing a diagnosis through the use of accepted medical practices such as a patient history, mental status exam, physical examination, and appropriate diagnostic and laboratory testing;
- Discussing with the patient the diagnosis and the evidence for it, the risks and benefits of various treatment options; and
- Insuring availability of the physician or coverage for the patient for appropriate follow-up care.
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