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

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Is there a doctor online?

Health plans and others are trying to break down the barriers that keep physicians from communicating with patients online.

Copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

Talk to patients, and many say they would love to talk to their physicians online to order prescriptions, get basic advice and schedule appointments. Talk to physicians, however, and most will rattle off a list of concerns about the dangers of communicating online, from protecting the privacy of medical information to avoiding floods of patient e-mail.

While it's true that for years a handful of physicians and medical groups have been experimenting with tools and systems that enable them to contact patients online, their efforts have been limited. Now, however, a large employer group and several health care insurers are testing new online communications systems. They hope to address physicians' concerns about privacy, the volume of patient e-mail and, perhaps most importantly for physicians, reimbursement.

New projects

Earlier this year, the Silicon Valley Employers Forum, a group of self-insured employers that includes high-tech giants like Cisco Systems Inc., Oracle Corp. and Adobe Systems Inc., launched a pilot program to research online communications between patients and their physicians.

To make it easy for physicians to participate, doctors can use their own computer and Internet connections to log onto the Web and get patient information. All they need to participate is a computer and an Internet connection.

Once physicians have established a user ID and password, they can access patient appointments, immunization schedules, lab results, diagnoses, prescriptions and contraindications, and medical records. Physicians can also create customized Web pages on the site to give patients more detailed information about themselves and their practices.

While patients can use the site for basic transactions like prescription refills and appointments, they can also get medical advice from their physicians. The program's software might ask diabetic patients, for example, for their most recent glucose count. The software interprets the answer to generate a series of progressively more detailed questions about new developments, symptoms, medications and recent lab results. Each answer prompts the software to formulate more precise, medically revealing questions.

The software then analyzes this information and sends it to the patient's physician in a form resembling a clinical case presentation. The doctor can respond to the patient electronically and prescribe a medication, order a test or schedule an office appointment.

First Health Group of Downer's Grove, Ill., a national PPO network that works with 280,000 physicians, uses its own "e-visit" software to link patients and physicians. Established patients enter basic information about their chronic conditions (e.g. asthma, diabetes, heart disease) into a computerized template customized to each condition.

The software asks additional questions based on the patient's responses. Doctors then analyze the software's report and act accordingly, communicating their recommendations to the patient electronically, by phone or in person, as the patient requests.

Some of these programs give physicians guidance about how to interact with patients. Blue Shield of California, which is also testing a program that will give patients online access to about 1,000 physicians, requires participating physicians to answer patients' e-mail messages within 48 hours. Physicians must also meet Blue Shield quality-assurance standards, address simple requests like prescription refills and appointment requests at no charge, and limit their use of the program to simple interactions with established patients.

Financial issues

Analysts say that one of the biggest obstacles to making these experiments succeed is money. Who is going to pay for the systems and for the time physicians spend online?

In terms of paying for the overall system, participation in the Silicon Valley program is free for both physicians and patients. Insurers pay a per-transaction administrative fee every time a patient or physician uses the service.

Other programs say they are considering offering basic service free of charge, but charging subscribers for enhanced access, such as 24-hour messaging.

In terms of physician reimbursement, several programs are paying physicians for the time they spend with patients online. The Silicon Valley program plans to reimburse physicians $20 for "e-visits." And Blue Shield of California pays physicians $20 for online patient encounters.

Jeff Rideout, FACP, senior vice president and chief medical officer at Blue Shield, acknowledged that $20 is less than what physicians receive for an office visit, but it's more than they get for phone consultations-nothing.

First Health pays its network doctors $25 per "e-visit" with their chronically ill patients, explained Scott P. Smith, FACP, national medical director for First Health.

The network does not review these "e-visit" claims for appropriateness, Dr. Smith said. "If the doctor says it's a visit, it's a visit," he said.

The various models being used to pay physicians underscore payers' ambivalence toward their yet-unproven results. "The industry is trying to find its way around these things," explained said Paul C. Tang, FACP, chief medical information officer at Palo Alto Medical Foundation, which uses electronic communication technologies. "But in the end, I think it has to be a reimbursable item, because it involves using physicians' time."

Physician concerns

Because security is a big concern among both physicians and patients, many of these programs protect data by placing restrictions on what kinds of content different users can access.

While the Silicon Valley program allows doctors to tap into the network using their own computers, it stores all patient information on servers provided by Healinx Corp., an Alameda, Calif. start-up that specializes in secure online communications.

Kaiser Permanente, which is preparing to roll out a system connecting patients and providers, is setting up care teams, which will include physicians and assisting personnel (nurses, physician assistants, lab techs, etc.), depending on whether the patient is in primary, tertiary or intensive care.

Care teams in the mid-Atlantic region will begin testing Kaiser's forthcoming "patient/care team secure messaging" later this year. Physician participants in the trial will see only their own patients' charts, lab results and insurance information. Nurses may see a subset of that data, and patients will see only what their doctors--and privacy regulations--allow.

The team approach also helps physicians avoid an avalanche of patient e-mail. Physicians who have already started exchanging e-mail with patients say the volume of patient e-mail is manageable. Patty McGann, MD, medical director at the Palo Alto Medical Foundation Los Altos Center, acknowledged that she was initially concerned that e-mailing patients would cut nurses out of the communications loop with patients and that physicians would be besieged by messages from patients.

She explained that some functions, such as responding to patients' questions via e-mail, mimic normal office procedures. Nurses receive and route the requests so they don't stack up on doctors' desks.

Physicians who have already begun exchanging e-mail with patients say it is faster than trying to connect with patients via the phone. John Kaschko, MD, a general internist at the Eastside Primary Care Clinic of 800-physician multispecialty Group Health Cooperative, in Redmond, Wash., said he likes communicating with patients online because the questions he gets are often more complete, precise and detailed than those taken by a nurse over a phone.

"When I get a message in the patient's own words," he explained, "I know exactly what they're asking." Because he is dealing with established patients, he can more easily deduce meanings and inferences that might be lost in a phone message. He also likes the instant feedback patients can give: their replies usually indicate whether his instructions were fully understood and, he notes, "I like hearing 'Thank you.'"

William Hoffman is a freelance writer in Fairfax, Va.

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