Online consults: Faster, easier, more complete

Clinical messaging between physicians who care for the same patients can improve care dramatically, but few doctors or offices are doing it yet.

"When I refer a patient within our network, I know the consultant has all the information I do," says FP Patrick Tranmer, interim head of the department of family medicine at the University of Illinois Chicago Medical Center.

That's because the health care system's information network includes an electronic medical record covering both inpatient and outpatient care. It also features secure doctor-to-doctor communications, Tranmer says. "I can attach a comment to the relevant parts of the chart, giving the specialist the reason for the referral and bringing whatever I'm asking about to his or her attention. We can both access all the labs and radiology reports, and anything done on either the inpatient or outpatient side is there for review the next day. For example, I can read the specialist's report as soon as it's entered. I can't imagine going back to the old system."

That's an example of physician-to-physician connectivity at its best. But outside of high-powered academic medical centers and a handful of pioneering, stand-alone practices, doctor-to-doctor communication is still largely done the old fashioned way—by phone, fax, messenger, and even snail-mail.

"We're not using the Internet to its full capacity in communicating with each other," says Bruce S. Bernheim, an internist with Advocate Medical Group in Chicago. Despite Advocate's relatively high level of online sophistication,* Bernheim says it still doesn't have the tools that would make doctor-to-doctor connections worthwhile. "There are tremendous opportunities for using Web-based communications, especially for nonurgent transfer of information—sharing lab results, sending records for referred patients, getting back reports—but we're not there." George Lesmes, chief information officer for the group, says, "We're just taking our very first steps with this."

Internist Steven D. Atwood of Springfield, MO, notes his large, hospital-owned medical group has the technology required for online communications between doctors, but most physicians simply aren't ready for it. "The doctor population is so completely uneducated about how to use the Internet for clinical purposes that they just stay away from it," he says. "They're not motivated. And when my specialists want to communicate with me, they need immediate dialog, so they resort to paging me." Despite being the Web master for the Internet initiative of the Missouri chapter of the ACP-ASIM, Atwood himself faxes medical records to the consultants to whom he refers.

Critical mass feeds on itself in a Spokane network

In the few places where doctors routinely communicate with each other over the Web, two key factors impel them to participate: a critical mass of participants—a classic chicken-or-egg scenario—and an electronic environment that offers enough clinically relevant features to make it worthwhile to adapt to the new technology. The more useful the features, the more likely physicians are to want to learn it. And the easier it is to use and integrate into existing practice, the quicker that critical mass can be reached.

That's the dynamic at work in Spokane, WA, where about 500 physicians are electronically connected over the Web. The secure "virtual private network" (VPN) was created by Pointshare, a vendor based in Bellevue, WA, and a consortium of area hospitals. Local physicians, hospitals, labs, imaging centers, and payers are all linked together, making it easy to share many kinds of information, including the data needed to close the referral loop.

"The VPN allows us to receive patient data such as lab results and X-rays on a daily basis," says Tom Carli, clinic administrator for Spokane Internal Medicine, an eight-doctor practice. "We're getting reports from our pathologists and radiologists delivered to our desktops. Once a day, we get transcribed hospital reports, which could be for yesterday's ER visit, a discharge summary, or a consult. Those reports arrive in a format that can go directly into our own electronic medical record. An information services person in our office also delivers them to the physician's computer desktop, to make sure they're seen."

Besides delivering referral authorizations and referring doctors' notes to consultants, the system allows two-way information exchange. The primary care physicians can send new test results to specialists and receive their reports, so everyone can keep up to date on referred patients.

One factor that made it easier for Pointshare to build critical mass among physicians was the cooperation of Washington's major payers, who not only agreed to use the vendor's connectivity services but also adopted a standardized referral form. "The administrative side of referrals was a natural starting point, a basic transaction where the network could really make things easier for physicians," notes Rick Rubin, Pointshare's vice president of strategic development. "And once the primary care doctors find it helpful, they're going to want all their specialists to be on the network. So it has a kind of viral effect, in terms of getting the local medical community involved."

The Community Health Association of Spokane, whose four clinics serve low-income patients, uses the regional information network to check eligibility and make referrals. This improves communication between medical offices, the group finds, and helps track patients who've been referred out.

"The Pointshare system saves our providers a lot of time on referrals," says Peg Hopkins, executive director of the Community Health Association. "There's room in the referral form for them to describe what they're referring the patient for, which would be lost in an ordinary administrative referral. The system notifies the payer at the same time the referral goes out to the specialist, so there are fewer problems with authorizations. And even if the specialist doesn't send an electronic report back to us, we will at least be notified that the patient showed up for the referral appointment. We're preparing to convert to an electronic medical record by the end of the year, which will allow us to exchange even more information."

The practice also finds that the Web link helps build and preserve specialist relationships. "As a community health center, we have to beg and borrow to get specialists—who often are donating their services—to treat our patients," explains Hopkins. "In one case, when a patient didn't show up for a scheduled surgery, the surgeon was understandably mad, not only at the patient but at us. Orthopedic surgeons are especially hard to get here, so this episode could have really had an adverse impact on our ability to schedule orthopedic care for other patients." Happily, electronics came to the rescue.

The surgeon in that case, Hopkins notes, knew only the name of the patient who'd failed to appear. He didn't know who the referring doctor was or which clinic he worked in. But because the referral had been made online, the Community Health Association was able to pull up the referral information immediately. Based on that, its staff was able to locate the patient's paper chart while they were still on the phone with the surgeon's office.

"In the chart was the critical piece of information—that the patient didn't speak English, so hadn't even understood that he was scheduled for surgery. When we told the orthopedist's staff that the patient needed an interpreter, they were able to solve the problem, and they were pleased with us for being so responsive.

"With a paper system," adds Hopkins, "this patient would just have fallen through the cracks. We might never have even known he didn't have the surgery."

Interoffice connectivity can also be created within a smaller entity, such as an IPA or medical group. One California IPA, Physicians Medical Group of Santa Cruz County, uses a secure messaging system from Axolotl, a Mountain View, CA, vendor, to link the offices of the group's 77 practices and to provide them with clinical data from local labs, imaging centers, and hospitals. Members access the system via high-speed lines connected to a central Web server.

"If I want to send clinical data to a specialist, I can just flag the appropriate data, write a message, attach it and send it off," says internist Robert B. Keet, a practicing internist with a group that belongs to the IPA as well as chief medical officer of Axolotl. "We use it not only for situations where the patient will have an in-person consultation, but also to do an informal consult, where we ask the specialist for an opinion based on a lab result or some other piece of information."

Doc-to-doc contacts aren't high on the priority list

In most other places, online communication between doctors is lagging behind other forms of health care connectivity. Vendors focus either on patient-physician messaging or on connecting doctors to payers, IPAs, or health systems—but not to each other.

"The doctor-to-doctor e-mail revolution has just begun, and most referral systems are limited to administrative transactions," says Dennis Streveler, senior strategist for WebMD. Moreover, he points out, the vast bulk of outpatient medical records are not in the digital format the Internet requires. "The capability to move parts of electronic medical records online is limited by the very low penetration rate. Only 2 percent of practices have an EMR."

Even when most physicians have EMRs, says internist Steve Atwood, he doubts electronic communication will totally replace the phone in doctor-to-doctor exchanges. "Patients love e-mail because it's 24/7 access when an immediate response is not required. But specialists want to talk to me right after they finish, or at least to dump a message on my nurse right away.

"Over the next five years, doctor-to-doctor communication over the Internet will remain limited," Atwood predicts. "Some physicians will use it to send records with a referral or send back the report of the work that was done, because it's quicker than a fax. But for communication at the time of care, it's not going to happen. There are just times when you want two-way dialog."

FP Joseph E. Scherger, a practicing FP and associate dean at the University of California Irvine College of Medicine, doesn't dispute that point. But for some purposes, he says, e-mail works better than other communication modes, because it's instantaneous, yet can be answered at a physician's convenience. "If I have to communicate by paper mail with a specialist, it can take two or three weeks to close the loop. It may sit there in his in-box for days before he gets to it. On the other hand, if I pick up the phone and call him, either I'll interrupt whatever he's doing or we'll waste a lot of time playing phone tag. But e-mail provides the advantages of both writing and phoning—we each use it at our own convenience, but the transfer is immediate."

Web-based health records as a doc-to-doc conduit

Because patients are more enthusiastic than physicians about electronic health communications, some connectivity vendors see the patient as the logical conduit between doctors. "In our fragmented health system, the most likely vector for communications will be the patient," says Streveler. "The consumer health record will be the organizing principle, the means by which communication occurs. A patient-controlled database of medical information can be made available to a new physician as the patient moves through the system. The patient becomes the mediator."

That's part of what underlies an initiative at Blue Shield of California, which is trying to persuade its more than 50,000 contracted physicians to hook up online with their patients through a secure messaging system provided by Healinx, a vendor in Alameda, CA. Some 5,000 physicians have registered on the system nationwide since it was launched in 1999, according to Jeffrey Rideout, Blue Shield's chief medical officer. (see "Secure messaging: Much more than e-mail")

Healinx has the patient enter "critical data elements, including medications, allergies, and a diagnosis/symptom list that the patient puts into the system," says Rideout. "The physician with whom the patient wants to communicate then confirms and locks that record in the system. So it's based on what the patient and physician confirm together. If more than one physician is involved, each might have responsibility for different parts of the record."

Physicians can communicate with the other doctors who use Healinx as well as with their own patients. And while patients have to give permission for anyone else to see their online health records, they can provide access to multiple physicians. "It's not designed as a physician-physician system," Rideout allows. "Still, for a patient with multiple points of care, it can be a single place to allow physicians to share information."

EMRs would help link docs, but they're not a prerequisite

Most experts agree the full potential of doctor-to-doctor connectivity won't be realized until EMRs are far more common than they are today. But some in the health care industry feel that clinical messaging can be valuable in its current forms.

"People get frozen, waiting for the perfect EMR before they'll get started," says Peg Hopkins of Spokane's Community Health Association. "I say: Don't wait. Don't make the perfect the enemy of the good. Your investment isn't in hardware and software, it's in training your people and getting them used to handling these systems. Pick a good system, and accept that it will change. Teach your people to deal with what's there now, and they'll adapt when the time comes."

Indeed, a less ambitious communication strategy may be more successful, so long as it meets a real physician need. "You only get so many shots at this," says Tom Carli of Spokane Internal Medicine. "If you convert the physicians but the system is cumbersome, getting them to adapt a second time is much more difficult."

To win over physicians, the interoffice messaging system has to be worth the effort. "We're having an easier time here now, because outside entities are providing clinical content that our doctors need," notes Carli. "That's the attraction. Our doctors adopt the system because they get something. You have to get the purveyors of content—the labs, the imaging service, the hospital—to put it out there."

But even at the most minimal level—simple e-mails between physicians who share patients— connectivity can improve care and efficiency, as long as it's done in a secure environment. "I don't have an EMR, but I e-mail to consultants all the time," says FP Joseph Scherger of UC Irvine. "It takes me two or three minutes to send a message introducing the patient and giving the relevant information, and the specialist can just hit 'reply' after he's seen the patient to let me know what he's done.

"Just recently, I referred a patient with a snoring problem to an otolaryngologist, who ordered a sleep study. The results were sent to me, but not to the ENT. Eventually the patient e-mailed to ask if I had the results. When I realized I did, and that the study had showed a serious obstruction with decreased oxygen, I e-mailed the patient and the ENT and got things back on track. E-mail gives me a way to follow up, to see that things don't fall through the cracks."

*See "How connectivity is changing practice," July 10, 2000.

 

Lauren Walker. Online consults: Faster, easier, more complete. Medical Economics 2000;22.