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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.

But talking on the phone and answering lengthy text messages often tied up more time than an office appointment. And the remote encounters can create a financial black hole for Davis, a member of Family Medicine of Winona and chief medical information officer for Winona Health in Minnesota, a delivery system with a 99-bed community hospital and three physician practices.

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.