Secure messaging: Much more than e-mail

October 23, 2000

These new systems allow physicians and patients to communicate online without confidentiality concerns. They can also help you manage Web-based transactions with patients.

Jump to:Choose article section... Insurers see value in physician-patient connectivity Will patients pay for it, or will doctors lose income? Henry Ford is gearing up for secure messaging Doctors and the Web

These new systems allow physicians and patients to communicate online without confidentiality concerns. They can also help you manage Web-based transactions with patients.

Boston internist Richard A. Parker used to exchange e-mail with patients. Now he's joined a small but growing number of doctors who are able to send patients secure online messages, thanks to sophisticated technologies that are relatively new to health care.

The Web-based messaging system Parker uses, called PatientSite, was custom-designed for his integrated delivery network, Care Group, by its chief information officer, John D. Halamka. It's one of a handful of home-grown systems; most physicians with secure messaging obtained it from commercial vendors.

PatientSite allows patients to inspect their online medical records, check lab results, schedule appointments, request prescription refills and referrals, check the status of their bills, and exchange messages with the doctor. But unlike regular e-mail messages, which can be intercepted or changed as they move from the patient's Internet service provider to the physician's ISP, messages sent via PatientSite are virtually guaranteed to remain confidential. That's the point of a secure system: It alleviates physician worries about liability risks resulting from security breaches. The messages patients write on PatientSite are encrypted before going directly to the server, where physicians retrieve them in decrypted form.

Halamka, an emergency physician, designed the system using an audit trail to augment the encryption. "Our audit captures almost every keystroke," he says. Patients can review the audit trail to make sure no one has unauthorized access to any of their medical information—including online messages between them and their doctors.

Partly because of security concerns, e-mail communication between doctors and patients has grown very slowly across the country. According to a study by Medem, a network founded by the AMA and medical specialty societies, only 10 percent of physicians use e-mail daily or weekly to communicate with patients—even though 70 percent have Internet access in their offices.

Family physician Ronald P. Bangasser, medical director of Beaver Medical Group in Redlands, CA, says physicians in his group have shied away from e-mail because of worries over confidentiality. But most patients don't share those concerns, he says. Some have already sent e-mail to their doctors. To satisfy them, Beaver is evaluating vendors who provide secure online communications to patients and other physicians.

Bangasser says he's been approached by dozens of vendors, but he remains skeptical. "We're being careful, because it's really important to do this right," he says. "This is new territory."

Security isn't the only advantage these new messaging systems have over regular e-mail. Many of them come with features designed to improve office workflow. For example, some sort online patient requests for appointments, prescription refills, and referrals and route them to the appropriate staff member, rather than to the physician, so the doctor doesn't have to read and re-route administrative requests.

Physicians who use secure messaging systems say they're just as effective as e-mail in reducing the amount of time that they and staff members must spend on the phone with patients. Charleston, SC, psychiatrist John F. Abess has subscribed to a free Web-based messaging service for more than a year and says he's seen definite improvements in practice efficiency. Although he receives only a few patient messages a day, each is "one less telephone interruption," giving Abess and his assistants better control of their time. Parker says he typically receives four or five messages from patients each day. Responding by computer takes far less time than returning phone calls, he says, so he can usually end his day a little earlier.

"It's been my experience that patients don't abuse this," says Parker. Adds Halamka: "Patients use the administrative functions [prescription refills, appointment requests] far more than the communication functions. The fear that this will turn patients into cyberchondriacs who send e-mail every 15 minutes is unfounded."

Insurers see value in physician-patient connectivity

Physicians aren't the only ones beginning to see value in secure online communication. Insurers are coming on board, too. Last summer, Blue Shield of California agreed to market Healinx, an Alameda, CA, provider of secure messaging services, to its 50,000 contracting physicians. Some 2,500 physicians have already registered, half of the nationwide total Healinx says it has signed up. The company says it will provide the service free to any licensed doctor who has malpractice insurance.

Patients can use Healinx to ask their physician questions, create a doctor-approved medical profile, request prescription refills and referrals to specialists, and schedule appointments. Physicians can use it to automate prescribing and to check for adverse drug interactions.

Physicians who contract with Healinx must agree to provide a timely response to patients. Under its agreement with California Blue Shield, Healinx will follow up with patients and physicians if a patient message remains unopened after 48 hours.

Internist Jeffrey A. Rideout, chief medical officer of Blue Shield, says the plan entered the alliance with Healinx to give members better access to their doctors. "We see this as an extension of phone services" rather than as a substitute for office visits, he says. He hopes that at least 5,000 to 10,000 Blue Shield providers will sign on, extending the service to perhaps 20 percent of Blue Shield's members.

Rideout believes the service will enhance Blue Shield's market appeal, particularly with employers in northern California's Silicon Valley. The Pacific Business Group on Health, which includes Silicon Valley employers, is promoting the use of online patient-physician communications, he notes. "These employers understand the technology. They want that kind of functionality."

Patients do, too. According to a New York-based research firm called Cyber Dialogue, 57 percent of the people who search the Web for health information say they want to communicate with their physician by e-mail. Twenty-two percent say they're likely to switch doctors if they find one who will answer their questions online.

Will patients pay for it, or will doctors lose income?

But do patients want e-mail advice from their doctors enough to pay for it? One unique feature of Healinx is that it permits physicians to charge up to $9.95 per message. The physician need only click on the right symbol, and Healinx will bill the patient's credit card, taking a transaction fee and remitting the rest to the doctor. Physicians aren't required to charge, however.

Anne Garnier, vice president of marketing at Healinx, says consumer research indicates that patients are willing to pay roughly the equivalent of an insurance co-payment for the convenience of having their physician answer questions online. But they're not willing to pay for online scheduling or general health care information, she adds.

What's less clear is how comfortable physicians feel about asking patients to pay. Garnier says that physicians who attended Healinx focus groups said they appreciate the option to charge—even if they only use it to discourage patients who barrage them with e-mail. But she declined to say how many physicians who use Healinx do charge their patients.

From a strictly financial perspective, physicians have little incentive to charge patients who are in prepaid plans. Whatever doctors can do to reduce demand for office visits by capitated HMO patients puts money in their pockets. But in the case of fee-for-service patients, a doctor would lose income if an online consultation substituted for an office visit.* Even if the consultation doesn't replace a visit—and it usually doesn't—physicians are still providing a nonbillable service, just as they do when giving medical advice over the phone. The question for fee-for-service physicians is whether the added efficiency of things like Web-based scheduling and automated refills makes online messaging worthwhile.

While some major insurers are considering reimbursing physicians for online consultations, none have stepped forward yet. If they do, it will certainly raise questions about why they don't reimburse for telephone advice. "Sooner or later, they're going to have to address reimbursement," says Bangasser. "Physicians should be reimbursed when advising patients to change their medication or medical treatment."

Rideout says Blue Shield and Healinx are designing a study to assess the practicality of reimbursing physicians for certain online consultations. In the meantime, Blue Shield has filed the necessary paperwork with California to make sure Blue Shield participating physicians won't be penalized if they charge the equivalent of a copay for appropriate consultation services through Healinx—should they elect to do so.

But some physicians and vendors say charging patients is a bad idea. "The patient pays insurance premiums and rightfully expects a package of services," says internist Parker. "We're not lawyers who are billing for every minute of our time. I think this starts us down a slippery slope."

"I think it creates a real problem for providers," says Michael Cataldo, vice president of sales for iMcKesson, one of Healinx's competitors. "Here's the choice for the patient: You can phone your doctor for free, or you can e-mail him for $10. Which would you choose?"

Henry Ford is gearing up for secure messaging

After Blue Shield of California's highly publicized endorsement, Healinx says a number of other plans have approached it. More typically, however, the push for patient-physician connectivity is coming from health care systems with large numbers of employed and affiliated physicians.

This past August, for instance, the Henry Ford Health System in Detroit entered a partnership with HealthCentral.com that will allow it to provide secure patient-physician communications. Like Boston's Care Group, Henry Ford will allow patients to log into a secure, personalized Web page, ask questions of physicians and staff, make appointments, and check lab results. For documentation, patients' information requests will be stored in Henry Ford's electronic patient record.

Pam Landis, Internet coordinator for Henry Ford, says the service will begin shortly. The organization's administrators hope this will take some of the burden off the phone system, which logs 15,000 calls a day.

Kaiser Permanente is planning to add a patient-physician communication system to its "Members Only" site in the next year or two, and before that, to provide an online prescription refill service to members in every region. Kaiser HMO members can now send online requests to a pharmacist—or to an "advice nurse" in every region but Southern California—and receive a reply within 24 hours, says Dena Durkin, a communications specialist for Kaiser.

It's not just the well-known health organizations that are forging ahead. iMcKesson says its patient-provider messaging tool, developed by MediVation (which iMcKesson recently acquired), is being used in 31 practice sites staffed by about 550 physicians. Linked to offices' practice management systems, the program is designed for practices with a minimum of eight physicians. The practice pays a one-time, per-doctor implementation fee, an annual subscription charge, and an annual patient fee, based on the number of patients using the system. A 10-doctor practice contracting with iMckesson would pay between $10,000 and $15,000 for the first year and between $5,000 and $10,000 thereafter, assuming that at least 1,000 patients log onto the Web site.

When patients log on, each can jump to his or her own page, with content tailored to that patient's condition. By gleaning information the practice has entered into its appointment, billing, and medical record systems, the iMcKesson program fills the patient's page with customized education material, including articles and books recommended by the doctor, the dates and times of upcoming appointments, and any related instructions. The patient can use the system to make appointments, renew and track prescriptions, and ask the doctor questions.

FP Roy M. Nakamura, who works in the Brunswick, ME, office of Martin's Point Health Care, says his patients have used the system to provide him with timely information, even when specialists don't. A patient with renal tumor and uncontrolled hypertension, for example, sends him weekly updates, including reports on her medication changes. He's found that very helpful.

The online messaging system has reduced the telephone volume at Martin's Point. The number of patient calls at one of the group's offices, for instance, fell from 10,000 in November 1999 to 9,000 per month in the first quarter of 2000—a period when volume would normally be higher than November's.

Salu of Portland, OR, started offering secure messaging services last August, after spending two and a half years building Web sites for 15,000 physicians, according to David Ray, Salu's vice president of marketing. Patients will be able to use the new service to ask their physicians nonurgent questions, request appointments and prescription refills, and check the status of their bills. Salu will draw revenue from various sources, including e-commerce transaction fees from physicians who buy products and services via Salu, and sponsorships from pharmaceutical and device manufacturers.

Salu is focusing on specialists and forging alliances with the specialty societies. Ray claims the company has built Web sites for 55 percent of allergists, 20 percent of neurologists, and 16 percent of cardiologists. It's too early to tell, he adds, how many of those physicians will opt for the secure messaging services.

*See "Do more for your patients by seeing some of them less," Oct. 23, 2000.


Deborah Grandinetti. Secure messaging: Much more than e-mail. Medical Economics 2000;22.