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How
would you like to email your doctor? Patients
are clamoring for it. Many doctors hate the idea. But the smart money is
on the patients to win this one, and it’s a biggie: E-mail contact
with doctors. E-mail, to
state the obvious, has become part of life: 61 percent of US adults now
use the Internet, and more than half use e-mail on any given day,
according to the Pew Internet and American Life Survey. A Harris
Interactive survey last spring showed that nearly 90 percent of wired
folks want to communicate with their physicians online to ask questions,
set up appointments, refill prescriptions, and get test results. Moreover,
patients say they are willing to pay for e-visits. They figure that even
paying for e-mail, they’ll come out ahead: To see the doctor: a
patient often winds up missing half a day of work. So, why won’t
doctors just get with the program? Some do, actually, because e-mail is
“asynchronous” (the patient and doctor don’t have to be online at
once) and because the e-mails can go right into the patient’s records.
E-mail “lets me communicate in a time-insensitive way with perfect
documentation,” says Dr. David Ives, medical director for the
Affiliated Physicians Group, a primary care group that admits patients
to Beth Israel Deaconess Medical Center. Angela Lawrence, one of his
patients, loves it, too. Lawrence has HIV. ”I don’t have to
interrupt his day or take an hour out of my day to get through to him to
ask if I should adjust my dosage on this or that,” she says. Still, most
doctors resist e-mail because they’re scared. They’re scared that
e-mail will add work to their already-rushed days. They are scared that
patients will bombard them with dumb questions. They’re scared that
they might get sued for some e-mistake, a liability nightmare. And
they’re scared of the “culture” shift that direct access will
create (which, of course, is precisely what patients want.) “Doctors
are used to controlling interactions with patients,” says Dr. Tom
Ferguson, a senior research fellow at the Pew project. “With e-mail,
they are not in charge.” But most important, doctors are afraid, with
good reason, that they won’t get paid for their time. Currently,
lawyers, accountants and many other professionals turn on the
billable-hours clock the minute the phone rings. But doctors do not get
a penny for all the hours they spend on the phone with patients. The
solution is obvious: Pay doctors to e-mail their patients, either via
insurance or direct pay by patients or some combination of both.
Granted, it may not be totally straightforward. For instance, if
e-visits substantially replaced face-to-face visits, doctors could lose
out, says Dr. Daniel Sands, clinical director of electronic patient
records and communication at Beth Israel Deaconess Medical Center in
Boston. (In the interest of full disclosure, I am a part-time consultant
at Beth Israel and sit on a committee studying ways to improve
electronic communications between patients and doctors.) ”Doctors
need to be reimbursed fairly,” says Sands. On the other hand, if
e-mail with non-urgent cases allows doctors to have more visits with
sicker patients whom they can bill at higher rates, doctors could
benefit. A key ingredient for safe patient-doctor electronic
communication, Sands adds, is protecting confidentiality, something
regular e-mail may not do. One way is
via secure web-based sites, such as Beth Israel’s PatientSite. In this
system and similar models, the patient uses a password and ID to get
onto the site and from there, e-mails the doctor. The doctor replies,
via the web-based site, and the patient then gets a regular e-mail
telling him to check the site. The Palo Alto Medical Foundation online
in California uses a similar system, says Dr. Bill Black, the medical
director. “We never pass clinical information via e-mail. If your
e-mail is at work, it’s accessible by your employer.” Regular e-mail
can also be accessible to some e-mail service providers. Indeed,
that kind of protection will become necessary later this spring, when
stringent measures to protect confidentiality on electronic medical
communications set forth in HIPAA, federal legislation on patient
privacy, kick in. Already, some insurers are getting on board. In
Massachusetts, Blue Cross Blue Shield and Tufts Health Plan are looking
into it. In California, starting this quarter, the Blue Shield of
California Foundation will pay its doctors for online consults, says
company president, Dr. Jeff Rideout. This decision was prompted by a
recent study sponsored by Blue Shield and ConnectiCare Inc. of
Farmington, CT. It involved 3,000 patients and 300 doctors. The insurers
paid doctors $20 per e-visit, says Rideout. Patients loved it, he says.
In fact, the study found, e-visits actually saved money - $1.92 per
member per month. The Blue
Shield study tested a system developed by the RelayHealth Corp. in
Emeryville, CA. That system, says Dr. Giovanni Colella, the CEO, uses a
”structured interchange,” a kind of questionnaire that the patient
fills out online to explain his current problem to the doctor. All these
communications pass through a secure website. A similar
system is Medem, backed by the American Medical Association and based in
San Francisco. Dr. Edward Fotsch, Medem’s CEO, says that system has
enrolled 85,000 doctors nationwide. Others
dispute whether e-visits will really save money. Among the doubters is
Dr. Steven Katz, associate professor of medicine and health management
policy at the University of Michigan School of Medicine. Katz and his
team found in a randomized study involving about 100 doctors and
thousands of patients, that while e-mail can improve communication, it
doesn’t cut phone calls or office visits. It doesn’t reduce the
number of missed appointments, either. But an equally important finding,
Katz says, is that patients “don’t rain you with
communications...They send courteous messages, health-relevant messages,
non-urgent messages that are totally appropriate.” Moreover,
electronic contact may even be appropriate for sensitive issues like
psychiatric problems or HIV status. Dr. Michael Grodin, a psychiatrist
and director of medical ethics at the Boston University Schools of
Medicine and Public Health, says that e-mail allows some people to bring
up issues they otherwise wouldn’t address: “People will talk about
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