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Online Messaging Opening Clinical Doors
Health Data Management Magazine, May 2006
Davis, like many doctors, used to wrap up such simple cases via a telephone call, giving basic care instructions and writing a prescription or two. When the Internet became commonplace, he started exchanging messages with patients via a secure Web site to treat colds, bumps and bruises quickly and save his patients the hassle of coming in for appointments.
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Patients and insurers weren't charged for the encounters, which means every minute Davis spent on the phone or typing a reply was preventing him from generating revenue for his practice.
"Doctors made a huge mistake when they gave away the phone," he says. "You call a lawyer on the phone and they charge you."
But Davis has found a more profitable and efficient way to remotely communicate with patients. Early this year Winona Health installed "e-visit" online messaging software-from Kansas City, Mo.-based Cerner Corp.-that enables patients to log on to a secure Web site that uses templates and logic-based health questionnaires to document online communications. Not only does the structure of the e-visits enable him to treat patients faster, he is also reimbursed for treating patients covered by HealthPartners, a Minneapolis-based payer organization.
"E-visits offer a second chance for managing patients who don't need to be seen," Davis says.
Physicians and patients have been communicating via the Internet since e-mail addresses starting showing up on business cards. Patients from the get-go have been begging for online messaging-it saves them the time, expense and stress of going to the doctor's office, which means they can get a prescription cold medicine or painkiller that much faster.
Patients treated at Asheville, N.C.-based Carolina Internal Medicine Associates are willing to pay out of their own pocket for an online doctor's visit, says Kenneth Kubitschek, M.D., managing partner at the medical group.
The practice charges $25 to $50 for an online encounter, with the average visit costing $35, he says. That compares with $50 to $75, depending on complexity, that the practice is reimbursed by Medicare for an office appointment. The group is considering an annual fee for online visits, which are conducted using messaging software from MedFusion Inc. and Misys Healthcare Systems, both based in Raleigh, N.C.
"Besides the price advantage, excluding insurance, for patients for avoiding an office visit, there are other advantages as well," Kubitschek says. "These may include no loss of time from work, no gas expense, no hiring of babysitters and no urgent care visit in another town."
Patient satisfaction
Research supports Kubitschek's conclusions. A study of 5,727 Blue Shield of California and ConnectiCare members who communicated online with physicians found that 50% were less likely to miss work due to illness. In addition, 70% of patients rated online messaging "good to excellent" compared with a phone call. That percentage climbed to over 90% for patients who had a physician response to their message by the next business day.
The study was conducted from June 2000 through May 2002 by researchers from the University of California at Berkeley and Stanford University.
Online messaging, however, has generated less enthusiasm among physicians and managed care organizations.
For doctors, the biggest concerns are time and money: While Web messaging has the potential to save them time, many fear they instead will be inundated with messages, which is truly terrifying if they aren't reimbursed for working online.
In addition, there are some legal concerns. Many physicians are wary that exchanging electronic messages may cause them to run afoul of data privacy and security regulations of the Health Insurance Portability and Accountability Act. Also, if a patient says his left arm is tingling and a physician does not immediately reply to tell them to get to the hospital, some doctors worry they could be vulnerable to a malpractice suit.
Payers, for their part, have been reluctant to reimburse for Internet encounters because many aren't convinced online visits will yield significant savings or improve quality. Another factor is that commercial payers typically follow the lead of Medicare, and the federal agency does not reimburse for online encounters, though it is exploring the idea of paying for virtual visits, according to a Medicare spokesperson who asked not be identified.
However, the tide seems to be turning. More sophisticated online messaging software has enabled online encounters to become more structured-and secure-than e-mail exchanges and made it easier and faster for physicians to work online. And a growing number of payers are reimbursing for online visits as they identify financial and clinical benefits.
While physician/patient messaging software has improved, some doctors still are reluctant to open the online door to their practices.
"The greatest source of resistance is fear that there is this latent demand for our time that lurks out there amongst our patients," says Eric Liederman, M.D., director of medical informatics at Kaiser Permanente HealthConnect Northern California. "If we take down the walls and remove the frictions in the system that slows people's access to my time then all this latent demand will be unleashed and there will be a tsunami of time requirements. And then it will be a race between divorce and bankruptcy."
Winona's Davis, before he implemented the Cerner e-visit software, exchanged "unstructured" messages with patients for five years.
Early on patients weren't limited on the length of messages they could send. That was revised and limited to 1,000 characters after a doctor received a three-page letter via the messaging system, Davis says.
The Cerner software is designed to do more work upfront to provide Davis and his colleagues with more specific information than an unstructured message from a patient.
The software offers patients a choice of different symptoms from which to choose from. The embedded clinical logic of the application then generates more specific questions. For example, if a patient has a cough, the application asks if it is dry or phlegmy, and what color the phlegm is.
Patients also are advised that online messaging should not be used for acute symptoms, like chest pains. If someone logs on with a serious problem they are instructed to either call their doctor or paramedics.
The structured messaging software differs from an unstructured system, which is similar to e-mail. The weakness of unstructured messaging is that patients are not prompted to provide clinically significant details, and when those details are lacking patients and physicians may end up sending messages back and forth until a doctor has the necessary information to provide treatment.
Even with structured messaging systems, some patients veer off course with their correspondence. At the University of California-Davis Health System, physicians sometimes express annoyance about patients using online messaging for reasons other than medical purposes, says Karen L. Mo, M.D. The delivery system uses physician/patient messaging software from Emeryville, Calif.-based RelayHealth Corp.
"It's sometimes a little frustrating when people just use it to be social," Mo says. "I usually give out my personal e-mail for stuff like that. Or I advise that that is not what it is meant for. The main thing is to be clear on your boundaries. Once those are established it enables me to do things much more efficiently. And my patients are very happy to know they can reach me without going through a 'middle man' and they get their exact words to me and I get my exact words to them."
If those boundaries are established, studies have found, physician/patient online messaging can increase productivity rather than diminish it. Liederman, who previously worked at UC-Davis, was a principal researcher on a study released last year that found that physicians using the delivery system's online messaging system averaged 2.54 additional patient visits per day, which translated into an extra $95.34 in revenue.
"There is no uptick in the volume of work with online messaging," Liederman says. "The efficiencies associated with secure messaging make the transaction better for everyone."
The Northwest Physicians Network, a Tacoma, Wash.-based independent physicians organization, has calculated an 8.5 to 1 return on investment with its online messaging system, thanks in part to the technology's ability to streamline the mundane tasks of a typical day at the office- making appointments, refilling prescriptions, providing patients with lab results and automating the physician referral process.
"The system is handling all referrals and moving protected health information from physician to physician for consults," says Rick MacCornack, M.D., director of quality improvement at the network. "It's also handling scheduling and prescription refills. All these workflow enhancers result in cash savings to an independent office."
The group includes 400 providers representing primary care and more than 30 specialties. It is using EMR and messaging software from Malvern, Pa.-based Siemens Medical Solutions.
One seven-physician practice saved $4,000 in administrative costs in the first year of using the messaging system, MacCornack says. The Northwest Physicians Network is having its members turn that savings back into information technology, such as EMRs, he adds.
The technology also enables patients to create a personal health record. Physicians can upload lab results, EKGs, X-rays, MRIs, anything that can be digitized to the system, MacCornack says.
This became helpful when a patient was in Boston and thought he was having a heart attack, MacCornack says. The patient gave his log-on information to the doctor and pulled up a month old EKG to compare with the new one. The doctors in Boston were able to compare the previous one with a current one to show that everything was normal.
Helping out at the office
Online messaging also can help reduce the length of in-office visits, Liederman says. "One of my colleagues tells a story about a patient that had ongoing shoulder pain and in the course of the back and forth they came to the conclusion that he was going to give the guy a steroid injection," he says. "The guy comes in for the injection and the whole thing took three minutes. When people come into the office after sending a secure message the office visit time is cut in half because the history has already been taken."
Physicians at GroupHealth Cooperative of Puget Sound often send patients a message before an appointment to find out if there's anything specific the patient wants to cover while in the office, says Ted Eytan, M.D., medical director of informatics and Web services at the cooperative. GroupHealth is an independent physicians association that operates a health plan. The organization has been using messaging software from Madison, Wis.-based Epic Systems Corp since 2001 and averages 4,000 to 4,500 secure messages a week.
One of the group's physicians handles more than 50% of his patient encounters online. Overall, the cooperative conducts about 15% of patient encounters through the secure messaging system, Eytan says.
Online messaging is evolving into an effective way for physicians to point and click through the routine patient encounters-treating common ailments and long-time patients who have frequent yet easily treatable complaints. In addition, some physicians are using the technology to keep in touch with patients with chronic diseases or check up on those who have conditions that need to be monitored but not necessarily via office visits.
Blue Shield of Massachusetts, for example, is sponsoring a pilot program that enables patients with problematic skin conditions to send digital photos to dermatologists so the doctors can track their condition on a weekly or even daily basis.
Messaging also is evolving into an effective cost-savings technology for payers, in part because payers reimbursing for online encounters are paying less.
Blue Shield of Massachusetts in October 2003 started offering more than 200 physicians access to RelayHealth messaging software. The software is used for more than 100 online physician/patient encounters per month. But the Blues plan typically pays physicians about $30 for a virtual visit, including a $5 to $10 patient copay, which is about half of what it reimburses for an office visit.
"It's a less intensive visit," says Vin Plourde, vice president of provider services at the Blues plan. "Physicians can do more Web visits in an hour than brief in-office visits. They can work through one of the Web visits in about seven minutes." Only about a third of the physicians using the online messaging system apply for reimbursement. Plourde adds. "Most physicians view it as a value-added service."
Many payers that are reimbursing for online physician/patient encounters are, like Blue Shield of Massachusetts, paying about half of what they typically pay for an office visit, says Mark Bard, president at New York-based Manhattan Research.
Putting it together
While online messaging systems can streamline care delivery and lead to savings for providers and payers alike, the technology also has the potential to create its own workflow problems.
Getting all staff members on board often is the first challenge. "When you bring in anything new you run into technology issues and people don't always have time to learn it," says Craig Lanway, CIO at San Ramon, Calif.-based Hill Physicians Medical Group Inc. "Sometimes the staffs are not very technology literate either."
Hill Physicians, which operates a health plan, has more than 3,000 physician members and is affiliated with 20 hospitals in northern California. Some of the physician practices in the group weren't equipped with high-speed Internet access to check messages. In addition, some office staffs had a hard time adjusting their workflows to use the technology, Lanway adds.
In addition to staff resistance, a lack of integration sometimes can make online messaging systems feel more like a burden than a benefit. Winona Health, before it implemented e-visit software, used a Web-based messaging system from Cerner that required physicians to log into a standalone Web site to check for messages, says Davis, the chief medical information officer.
Physicians didn't check often for online messages because to do so required them to continuously log into the messaging site.
The new e-visit system integrates with the delivery system's electronic medical records system, also from Cerner. When a physician logs into the EMR, they are shown a list of patient messages they've received. When they click on a message, the patient's EMR comes up on screen.
Some doctors are taking await and see approach to online messaging as they sort through a growing list of new technology options.
Blue Shield of Massachusetts, for example, has a number of technology initiatives underway, including ones for EMR adoption, deploying a regional health information organization and providing physicians with electronic prescribing technology, says Plourde, the vice president of provider services at the plan.
"There are a lot of new technologies out there and I don't think everything has sorted itself out," Plourde says.
Online messaging also has to be sold to patients, and while the majority are eager to go online with physicians, explaining the ins and outs of online communications can be a tough sell.
Winona Health, for example, learned how to get patients to not sign up, Davis says.
After deploying the system the delivery system took out newspaper ads and told patients to go online and register to use it.
But after registering online the patients would have to go to a clinic and show a driver's license or state ID to validate the account. This extra step took too much time and effort and only 700 of the 3,000 patients that originally registered followed through with the validation.
The caused Winona to change the way they register and validate patients. "Now, we're getting people registered when they're in the office," Davis says.
Sidebar
Microsoft tests virtual visits
Software giant Microsoft Corp., Redmond, Wash., launched a pilot program in January to see if it can reduce health care costs by paying for online physician/patient encounters for its 100,000 U.S. employees.
The program started with 4,000 Microsoft workers and family members in the Redmond area, says Tom McPherson, senior benefits manager at the company, which is self-insured.
The online visits are conducted with physicians from Seattle-based Virginia Mason Medical Center. Microsoft chose seven clinics around its headquarters and a variety of different specialists, including pediatricians. Microsoft has Seattle-based Premera Blue Shield administering the benefits for the program and is using Emeryville, Calif.-based RelayHealth's messaging system.
Cost was the key consideration, McPherson says. "We wanted to determine if we could reduce the escalating cost of in-office visits for non-urgent care," he says. "We need to understand from the pilot population whether they received quality care and what their satisfaction level is compared with an in-office visit."
Microsoft is reimbursing physicians $30 for an online visit, compared with between $60 and $70 for an in-office visit, McPherson says. "If we can see a reduction in in-office visits then we'll see a reduction in those costs," he says.
An added benefit is that employees do not have to miss half a day of work to go to a doctor's office. It takes an employee about 10 minutes to fill out an online medical form, McPherson notes. Physicians typically answer a message within a business day.
Employees in the pilot also can make appointments, create personal health records, request prescription renewals and receive event reminders. Later this year participants will be able to have new prescriptions refilled at a pharmacy of choice and review test results online.
As of late March, 150 online visits had been logged, says Marnee Iseman, vice president at Virginia Mason. Though there's not much data available yet, project leaders have found that12% of employees are using the system on the weekends, and appointment requests are the most frequently sent message.
"It's replacing the phone," says Iseman. "For someone who is busy and on the road it's a super effective means of communicating."
Sidebar
Going online for another opinionAn executive at an electronics firm was golfing in Florida and got knocked unconscious after accidentally being hit in the head with a seven iron by another player. His friends convinced him to go a local emergency department even though he said he felt fine.
After several tests, including a CT scan, doctors told the man he had lesions on his brain, unrelated to the golfing accident, and recommended radiation treatments.
The man wanted a second opinion, but didn't have many options around his home in rural Florida. That's when he found the e-Cleveland Clinic.
While most online doctor's visits are for non-acute symptoms, the e-Cleveland Clinic is offering patients a way to get a second opinion without the time and expense of traveling across the country, says C. Martin Harris, M.D., chief information officer and chairman of the information technology division at Cleveland Clinic in Ohio.
The clinic already had been in the second opinion business, but putting its services online made the process smoother.
"We were performing the function on a day-to-day basis with a sub-optimal system, people calling on the phone, e-mailing, faxing and hoping one of our physicians would be able to render a second opinion," Harris says. "It wasn't adequate."
Many of the patients who have sought treatment via e-Cleveland Clinic haven't been sick before and haven't had much interaction with the health care industry. "These are people who have relatively little experience with their health and suddenly are told they have a life-altering condition," Harris says.
To get a second opinion via the e-clinic, a patient goes online and completes a medical history. Depending on the problem the patient is sent a specific list of questions regarding their diagnosis. They also are told what additional information, such as lab reports or images, needs to be sent to the clinic for examination. In addition, patients are given an opportunity to write specific questions they would like the doctor to answer.
Online consultations eliminate problems that frequently crop up during the second opinion process, Harris says.
"A number of times someone has flown across the country and within five seconds we find out they don't have the proper information," Harris says. "Or they schedule an appointment with an inappropriate physician."
During each phase of the online consultation, the patient receives online messages about steps completed and what still needs to be done. Between 36 and 40 hours after all the necessary information is received, the physician and patient talk on the phone and a second opinion is given, Harris says.
The e-Cleveland Clinic has performed thousands of online consultations. Harris says. A major benefit for patients from online consultations is cost: the average price of an online second opinion is $600, compared with an in-person average price tag of $3,500, including transportation, hotel, meals and time off work.
Managed care companies don't directly reimburse the e-Cleveland Clinic for second opinions. Patients pay upfront and can request reimbursement from their health insurer, Harris says. About 50% of patients do end up getting reimbursed, he adds.
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