"What's your e-mail address, Doctor?"

If patients aren't already asking this question, they will be soon. E-mail services that connect doctors and patients are burgeoning.

By Dorothy L. Pennachio
Senior Editor

Do you exchange e-mail with your patients? More and more physicians do. Capitated doctors find it especially efficient because it can avoid needless office visits. Others find that electronic communication improves patient education and compliance.

"Face-to-face office visits aren't the only way to provide quality care," says Charles M. Kilo, an internist in Portland, OR, and a fellow at the Institute for Healthcare Improvement. "If a doctor sees 20 patients in a day, half don't have to come to the office. They can be taken care of via phone or e-mail."

Physicians need to restructure the way they take care of patients, Kilo says. In many practices, doctors' failure to do so is the reason phones ring off the hook, paperwork never ends, staff feels frantic, and waiting rooms jam up.

Online communication can also significantly reduce the cost of care, according to a recent study by researchers at Stanford University and the University of California, Berkeley. Capitated physicians whose patients used e-mail to communicate with them saved more than $1 per patient per month when compared with control groups. How? The doctors received direct reimbursement from the patients for the care, and there were no office expenses for the nonoffice-based encounters.

Don't bank on saving a lot of time, though. It may seem that e-mail would cut down on the number of phone calls, but savings depend on how the technology is used. In fact, researchers from the University of Michigan Health System recently found that e-mail didn't save money or time for the practice that participated in their trial.

Whether you're already communicating electronically with patients or are just thinking about doing so, you should consider some issues and services that can help you determine if it's right for you.

To protect patients for instance, HIPAA insists that e-mail between physician and patient be secure or encrypted, meaning that if a message is sent to someone it wasn't intended for, the words will appear garbled.

Fortunately, a growing number of services—some free—offer encryption or secure messaging technology for physicians. Among them are:

MDhub. This free service is considered rather primitive compared with others, but you may find it a good way to ease into receiving e-mail from patients. Here's how MDhub works: Your patient goes online to the Mdhub site (www.mdhub.com), plugs in your name and location, or just your phone number, and writes a message limited to about 50 words. It's encrypted and transmitted via fax to your office, where a staffer can clip it to the patient's file. If doctors don't use e-mail and need to reply to patients, they do so by phone or during an office visit.

Your message center's up and running as long as your name is listed in one of The Little Blue Book directories—which contain the names of nearly every practicing physician in the country. Ads in the directory pay for the Web site service. Visit the site yourself to see if you're included.

Medem. Sponsored by the AMA and 43 other medical societies, Medem ( www.medem.com) is used by 84,000 physicians. They refer patients to the site, and some 9,000 of them also use the secure, fee-based messaging service, Online Consultation.

"Patients can schedule an appointment, renew a prescription, ask a general question, or request an online consultation," says Edward Fotsch, a San Francisco emergency medicine physician and CEO of Medem.

IDs and passwords are required. There's no setup cost, but if the physician charges the patient for the communication, Medem charges the physician $2.50. Physicians set their own fees, typically $20 to $30 per consultation. Follow-up questions on the same topic and very simple questions are generally free.

Lynne Carr Columbus, a pain management specialist and anesthesiologist in Palm Harbour, FL, uses Medem. "Elderly patients have difficulty coming to my office for the periodic monitoring that's required for narcotic pain medications," she says. "E-mail enables me to see how they're doing." Columbus says the billing for follow-up online consultations (usually $30) helps document the monitoring. She also finds e-mail convenient for communicating with the snowbirds who head north during the summer. She even used the venue when she was in Budapest recently.

Physicians' Online. Thomas A. Stevenson, an FP in Grand Rapids, MI, and vice chair of the American Osteopathic Information Association, is a bit ahead of his colleagues: He's using Physicians' Online ( www.po.com) while waiting for his group to develop a policy on electronic communication. The secure server offers a free e-mail service to doctors; advertisements that appear at the site pay for it.

Stevenson's staff exchanges e-mails with selected patients regarding everything from appointment changes to lab results. "Patients are very receptive," he says, "and I prefer e-mail to phone calls, because patients don't tend to go on and on as they do on the phone."

MyDocOnline. Some pharmaceutical companies have begun paid e-consultation sites. MyDocOnline (www.mydoconline.com), a subsidiary of Aventis Pharmaceuticals, is one of these. It allows registered patients to access evidence-based guidelines as well as communicate by e-mail with their physicians. The service also provides a type of intranet for IPAs.

"I'd been looking for a way to replace group meetings or group phone calls with other doctors in my IPA," says James E. Barr at Pleasant Run Family Physicians in Neshanic Station, NJ. His IPA includes 31 offices and 110 doctors. Barr's office went live with MyDocOnline first, in February 2002; since then, five others have also connected.

"There are some hurdles, such as getting patients to register. But once that's done, they easily log on, just as they would with AOL. The most accepting doctors are ones who use e-mail in their personal life," he says.

Can you get paid for electronic consults?

Patients don't mind paying for the convenience of e-mailing their doctors, says Medem's Fotsch. "If you add up copays, lost wages, and other expenses involved in office visits, they actually save money if they can consult their doctors electronically."

Don't expect to make much—if anything—through third-party payers, though. "For now, Medicare and most private health plans don't pay for e-mail consults," says Fotsch. "As we know, plans don't spend a lot of time figuring out new ways to put money in our pockets." He says plans will likely begin paying when they can guarantee cost savings or when employers start canceling contracts that don't provide for electronic communication.

The prospect of payment from insurers may sound good, but Fotsch thinks that doctors might actually lose money on online consults once health plans start reimbursing for them. "They'll want a copay from the patient. The patient will pay that, but then doctors may have to try to chase down the health plan to pay a $15 bill ($25 less a $10 copay). The cost to the doctor's office for kicking out a bill is typically $10 or $15."

Nevertheless, some doctors are trying to convince plans to consider the idea. "We're working on a pilot program with Horizon Blue Cross Blue Shield of New Jersey to see if they'll reimburse us for Internet visits," says Barr. If the carrier agrees, the negotiated rate will depend on complexity and time spent.

Watch out for these pitfalls

If you opt to communicate electronically with your patients, keep these warnings and tips in mind:

• Don't write anything on an e-mail that you don't want clipped to the patient's file, because that's where it should end up.
• Even though patients are constantly reminded by the messaging centers never to use e-mail for any type of medical emergency, remind them often. When they have serious problems, they should always call your office or go to an emergency department.
• Make sure your patient resides where you think he does. Practicing across state lines doesn't sit well with licensing agencies. "We were operating an asthma service," says Craig Skevington, CEO of Flow Management Technologies, which provides MyHealth.com to 60,000 physicians. "A patient had been e-mailing with a physician in Colorado, but then he moved out of state and never told the physician. Unbeknownst to him, the physician licensed in Colorado was practicing medicine in the state of Texas."

Risk management guidelines for online communication with patients can be found at www.medem.com/erisk.html. The rules, developed by the eRisk Working Group for Healthcare, which includes more than 30 malpractice carriers, medical societies, representatives of state medical licensing boards, and Medem, range from how soon a doctor should respond to a patient's medical question (no later than the second office day, the consortium suggests) to what a patient must do if he loses his password (you give him a new one only if he comes to the office). A notable recommendation is to offer e-mail visits only to existing patients whose medical history you're familiar with, particularly when a fee is charged. See also "E-mail patients? Don't be nervous. Do be careful," Sept. 3, 2001 for additional tips on how to e-mail patients without running afoul of HIPAA regulations.

Some doctors communicate with patients they've never met

The e-mail systems mentioned so far are meant to be used by doctors for communication with their own patients, not with strangers. A handful of systems, termed "online doc-in-a-box" services, however, don't draw that distinction—and may be treading on thin ice.

One example is EasyDiagnosis ( www.easydiagnosis.com), which despite its name, claims it neither diagnoses nor provides medical advice over the Internet. Created by Martin F. Sturman, a Media, PA, internist, the site aims to help patients figure out for themselves what might be ailing them and helps to organize diagnostic strategy. "It's meant to educate patients so they can go to their own doctors with accurate information," he says. Patients who use the site pay a fee of $25 a year.

NetLiveMD (www.netlivemd.com) started as a free service for FP Dean M. Tomasello's patients, so they could ask questions. But it grew so large that the Walworth, WI, physician started charging. Now about 300 people the doctor has never seen are the mainstay of his operation. They pay either $25 per e-mailed question or a $49 annual membership fee plus $19 per question.

It's HIPAA-compliant, he says, because he and his staff of physicians don't diagnose, prescribe, or treat; they just give information specific to the questions they receive. At the end of each response, the NetLiveMD physicians supply questions that the patient can ask his or her own doctor.

"NetLiveMD empowers the patient so that the patient-physician interaction works better," Tomasello says.

In October, the Illinois Department of Professional Regulation ordered an online consultation company owned by Roche Diagnostics, MyDoc.com, to stop prescribing and treating online patients. The report cited the "unlicensed practice of medicine . . . treating patients over the Internet and prescribing medication to patients over the Internet without the benefit of performing a physical examination on the patient."

 

Dorothy Pennachio. "What's your e-mail address, Doctor?". Medical Economics 2003;2:66.