American College of Physicians: Internal Medicine — Doctors for Adults ®


E-mail in demand but cost, security worry physicians

From the November/December ACP Observer, copyright 2007 by the American College of Physicians.

Jeffrey P. Friedman, FACP, has a no-e-mail policy. If patient e-mails happen to arrive at his New York University faculty address, Friedman doesn't hit the reply button.

"We have a secretary call them and say we do not have secure e-mail interactions at this point, and would they like to leave a message for the doctor or make an appointment," said Dr. Friedman, an internist with a 42-physician group in Manhattan. "We're not going to use common e-mail to exchange information with patients."

All that could change because Dr. Friedman's practice is considering implementing a secure messaging system. Given that the practice began using electronic medical records in 1998, adding e-mail wouldn't be a big leap from a technology standpoint. But Friedman said there are many issues to consider, including the fact that most insurers don't reimburse for online consultations.

"The last thing this medical group is going to do is give away something for nothing and increase our work load," said Dr. Friedman. "Part of our thinking is that we already gave away the telephone, and we don't want to just give away e-mail. We spend hours a day on the telephone and we don't want to add hours a day to do e-mail and not get paid for it."

Dr. Friedman's concerns are not unusual, according to other doctors and companies that offer secure e-mail. A desire to protect patient privacy, while an understandable goal given HIPAA regulations, is just one of a number of factors that go into the decision on whether to offer e-mail.

"They want to know whether the system is going to be secure," said Richard Abrams, ACP Member, chief medical officer for RMD Networks Inc, in Englewood, Colo., which offers a Web-based system called ReachMyDoctor. "But they also want to know if it's going to add to the burden of their work and they want to know whether it's going to add value to the quality of care they give to their patients, and they want to be compensated for their time and expertise."

Direct and secure

The security question is perhaps the easiest to answer. "This is a closed form of communication," between the doctor and the patient, Dr. Abrams said, "and it is not accessible to outside users of any kind."

As to the other concerns that doctors have, Dr. Abrams lists the benefits of his company's product: "Patients come to the Web site and they then have the ability to request appointments and refills; they can ask and get answers to insurance and billing questions; they can maintain a personal health record with key elements from their medical records ... and they can communicate directly with their doctors." A patient's doctors can also communicate with each other via the system.

The cost varies depending on which system and company a doctor selects. In some cases, the doctor assumes the expense; in other instances, patients pay a subscription fee. Patients also may be charged a set fee for an e-visit, or online consultation with the doctor, which currently only a small number of insurers reimburse.

With the RMD system, for instance, patients typically pay a subscription fee of $8.95 a month for the service, with most of the money collected going back to the doctor, according to Steve Adams, the company's president and CEO.

"Many of our physicians are charging for online consultation, but there seems to be a growing trend of doctors who provide the service for free," said Mr. Adams. "They benefit from the efficiency of online communication versus the never-ending game of returning phone calls."

Tyler Blitz, marketing manager for Kryptiq Corp., a Hillsboro, Ore. company that offers a secure messaging system and other e-products for doctors and healthcare systems, said that from a doctor's perspective, "The e-mail system has to be integrated (with electronic medical records) and it has to be easy." He said doctors quickly come to realize how electronic messaging can "simplify the amount of time they spend following up with patients.


Ken Tarkoff, general manager of consumer solutions at RelayHealth, in Emeryville, Calif., said that given all the attention paid to HIPAA regulations, doctors "know that if they are doing regular e-mail today without security, they have to stop." Secure messaging is just one feature of his company's Web-based connectivity products.

Tarkoff said e-mail can improve efficiency by reducing phone calls and freeing staff for other things. He said large group practices have been quicker than solo practitioners to adopt online communication technology, but his company is planning a marketing campaign aimed at small practices.

"This is the future," he said. "Patients are going to come to expect an online platform that allows them to manage their health care more effectively," adding that as the number of health plans reimbursing for online consultations grow, patients are more likely to find their doctor willing to communicate with them online. Currently, 15 national and regional health plans cover online consultations.

Convenience, continuity

Arvind Cavale, ACP Member, an endocrinologist in Southampton, Pa., near Philadelphia, currently uses non-secure e-mail to communicate with patients, but is moving toward a secure system. He said his patients know the e-mail is not secure, and he uses it only for established patients. He does not do consultations via e-mail.

Donna Sue Dolle, ACP Member, of Nassau Bay, Texas, has decided to offer Web-based communication to her patients.

Donna Sue Dolle, ACP Member, of Nassau Bay, Texas, has decided to offer Web-based communication to her patients.

Dr. Cavale, a solo practitioner, said he will likely use a patient portal designed by the same IT company that designed his electronic medical records system. The messaging system will be integrated into the EMR, allowing, for instance, patients to send in blood sugar readings ask questions in preparation of upcoming office visits, and securely access pre-selected parts of their medical charts.

Dr. Cavale hopes the system will allow him and his nurse practitioner to triage patient inquiries and deal quickly with issues that don't require an appointment in his already overbooked schedule. Diabetes is a 24/7 disease, while "the conventional practice of medicine in general involves episodic care," he said. Having e-mail should help "make it a continuous care process which will eventually result in improved care for chronic diseases. Integrating these messages into patient charts in an EMR is the best documentary evidence to convince payers to reimburse for such care."

Michael Barr, FACP, vice president for practice advocacy and improvement and director of ACP's Center for Practice Innovation, said doctors worry they'll be deluged with e-mails, and will end up doing online work for which they won't get paid instead of doing more billable office visits. Whether to implement e-mail "is a very difficult issue for many offices to work through," he said. "It's a culture change."

Donna Sue Dolle, ACP member, who practices in Nassau Bay, Texas, near Houston, said she soon will begin offering a Web-based communication program designed by Medem. She expects her patients to like the convenience of the service because most of them are busy professionals, but she's not sure how beneficial it will be to her.

"Every time I add new technology, I can better care for my patients in a more efficient way, but I never save money," Dr. Dolle said.


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