E-Mail and Medicine

From: Joel M. Eichen (joeleichen_at_yahoo.com)
Date: 03/02/05 

Date: Wed, 02 Mar 2005 07:34:08 -0500

New York Times

March 2, 2005
Digital Rx: Take Two Aspirins and E-Mail Me in the Morning
By MILT FREUDENHEIM
 
Doctors may no longer make house calls, but they are answering patient
e-mail messages - and being paid for it.

In a move to improve efficiency and control costs, health plans and
medical groups around the country are now beginning to pay doctors to
reply by e-mail, just as they pay for office visits. While some
computer-literate doctors have been using e-mail to communicate
informally with patients for years, most have never been paid for that
service.

Brian Settlemoir, 39, an accountant in Folsom, Calif., recently sent
an e-mail message to his doctor at the Creekside Medical Group to ask
if it was time to reduce the dosage of a medicine after his
cholesterol level dropped. The prompt answer was "not yet."

"I'm sitting at work," Mr. Settlemoir said. "I've got e-mail open
anyway. It's much easier than calling and getting voice-mail prompts
and sitting on hold. It's very valuable to me."

Blue Shield of California pays his doctor $25 for each online
exchange, the same as it pays for an office visit. Some insurers pay a
bit less for e-mailing, and patients in some health plans are charged
a $5 or $10 co-payment that is billed to their credit card and relayed
to the doctor.

For doctors, the convenience of online exchanges can be considerable.
They say they can offer advice about postsurgical care, diet, changing
a medication and other topics that can be handled safely and promptly
without an office visit or a frustrating round of telephone tag. And
surveys have shown that e-mail, by reducing the number of daily office
visits, gives physicians more time to spend with patients who need to
be seen face to face.

For patients, e-mail allows them to send their medical questions from
home in the evening, without missing work and spending time in a
doctor's waiting room. In fact, many say exchanges in the more
relaxed, conversational realm of e-mail make them feel closer to their
doctors.

The patients can also use the e-mail connections, which they reach
through secure Web sites, to get X-ray and test results and request
prescription renewals. Doctors are not paid for these services, except
in time saved in the office.

This shift toward online doctor-patient communication is important for
another reason. Physicians and health care technology specialists say
they believe that it could help spur the changeover to electronic
health care information systems, which government officials and
industry leaders say is needed to reduce medical errors and promote
better care. Doctors at the clinics of the University of California,
Davis, grew accustomed to using e-mail for clinical purposes before
the clinics introduced electronic medical records, said Dr. Eric
Liederman, medical director of clinical information systems at Davis.
The messaging "gave them some comfort and facility with using the
computer," he said.

Early research at clinics at the university found that using e-mail
improved the productivity of physicians, decreased overhead costs and
improved access to doctors for patients, including those who still
telephoned. "There was a huge reduction in the number of calls," said
Dr. Liederman, who is a big fan of e-mail exchanges.

Doctors and insurers say online consultations can be especially useful
for patients who have chronic conditions like diabetes, asthma and
heart problems. They have been frequent users and being in touch can
help them to comply with regimens to cope with their diseases.

"Patients love this stuff; I love this stuff; the staff loves this
stuff," said Dr. Barbara Walters, a senior medical director at
Dartmouth-Hitch*** Medical Center in New Hampshire.

One benefit of online messaging - perhaps because it can be done in a
setting less harried than a doctor's office - is that it gives
patients a greater degree of control.

"The intelligence of our patients never ceases to amaze me," Dr.
Walters said. "Patients can describe what's going on with them, if
given the chance and given the time." Since last year, several health
plans - Anthem Blue Cross, Cigna and Harvard Pilgrim - have been
paying Dartmouth-Hitch*** $30 for each online "visit," Dr. Walters
said. In some health plans, a co-payment by the patient reduces the
insurer's share. The medical center gives participating doctors
credits - an e-mail consultation is valued at half an office visit -
that increases their pay.

Blue Cross and Blue Shield plans in California, New York, Florida,
Massachusetts, New Hampshire, Colorado and Tennessee are beginning to
pay doctors similar amounts ($24 to $30, including any co-payment) for
online consultations. Blue Cross of California has made the program
available to 160,000 of its 6 million health plan members. Last month,
Empire Blue Cross and Blue Shield began testing the payment system
with New York doctors at the Columbia University and Weill Cornell
Medical Centers.

Kaiser Permanente, the nation's largest nonprofit managed care
company, has tested patient-physician messaging in the Pacific
Northwest and is starting the program this year in Hawaii and Colorado
as part of Kaiser's $3 billion information technology program.
Kaiser's salaried doctors get credits for messaging, adding to their
pay.

System providers say overuse by doctors and fraud have not been
problems. RelayHealth, a secure electronic system used by the Blue
Cross and Blue Shield plans, for example, provides monthly user
reports with names of doctors and patients.

Doctors who use the medical messaging services are advised to limit
their replies to appropriate topics, and, under standard rules, the
doctors reply only to patients who have already been examined in the
office.

The records could even be useful in fending off medical malpractice
lawsuits, according to Eric Zimmerman, a senior vice president of
RelayHealth, based in Emeryville, Calif., because allegations based on
undocumented telephone calls are often hard to rebut. "Good
communications with patients is protective," said Frank A. Sloan, an
economist at Duke University who has studied malpractice suits. "This
kind of interaction is helpful."

Many of the health plans promoting Internet consultations are also
introducing electronic systems that keep track of a patient's medical
records and send prescriptions to the pharmacy. For doctors in small
private practices who have hesitated to invest in computerized
systems, the e-mail exchanges are often a first step into the growing
world of health care information technology.

Online consulting is "one of the biggest changes to come to health
care since the beginning of the electronic medical record itself,"
said Judith R. Faulkner, chief executive of Epic Systems, a health
information technology company based in Madison, Wis., that is working
with Kaiser.

The federal Centers for Medicare and Medicaid Systems is sponsoring a
study of disease management programs, including payments for online
consultations, to help the government decide whether the benefits
would justify the cost to Medicare.

Dr. David J. Brailer, the government's health information technology
coordinator, said online communications between patients and
physicians were "one of 12 strategies to achieve President Bush's goal
of widespread adoption of technology" in health care. But he said more
experience was needed before asking Medicare to pay for those
exchanges.

A bill introduced in the House on Feb. 11 by Charles A. Gonzalez, a
Democrat from Texas, and John M. McHugh, a Republican from New York,
for the first time included a provision to authorize Medicare to make
"bonus payments" to doctors for e-mail consultations.

To comply with federal privacy requirements, medical information
technology companies like RelayHealth, Epic and IDX, which is based in
South Burlington, Vt., make secure software allowing only the doctor
and his staff access to a patient's medical records, including the
e-mail exchanges.

Doctors can connect with the secure systems over the Internet from
home computers or laptops if they wish, but overnight messages are
typically answered the next day.

Some employers are embracing medical e-mailing as a way to help
maintain workers' productivity. "Why do I have to leave my office to
check out my sore throat?" asked Dr. Jeff Rideout, corporate medical
director of Cisco Systems, the big Silicon Valley technology company.

Cisco is paying the Palo Alto Medical Foundation for a one-year trial
with the first 500 employees to sign up to see if providing online
answers to medical questions eliminates unnecessary appointments for
employees. The company's health costs have been rising at 10 percent a
year, eroding overall productivity gains, Dr. Rideout said.

Sixty-nine of the foundation's 300 primary care doctors are online in
a system provided by Epic. Dr. Paul Tang, the Palo Alto group's chief
medical information officer, said it charged $60 a year for patients
using the service.

Dr. Tang said most users were people with chronic diseases who were
willing to pay for better access to their doctors. But other medical
groups said they would prefer that insurers pay for e-mail
consultations so there would be no barriers for patients.

The American Medical Association has issued a temporary identification
number for online visits in the association's "current procedural
terminology" code that doctors and hospitals use in sending bills. But
Robert Mills, a spokesman, said the association was waiting for more
data on how clinical messaging was being used before issuing code
numbers like those for office examinations and follow-up visits that
payers refer to in their schedules of fees. "All consumer surveys in
the last several years show patients want to be able to communicate
through e-mail or messaging," said Dr. Thomas Handler, research
director at the Gartner Group, the technology consulting firm. "The
problem was, reimbursements for the doctors weren't there."

That is changing quickly. One pleased consumer, Dona Gapp, a
schoolteacher in New York, who is expecting her first child in April,
said she used e-mail to ask Dr. Richard U. Levine, her obstetrician at
the Columbia University Medical Center, if certain vitamins and
nonprescription medicines were safe for her.

"It was much easier to have access by e-mail," she said. "When I had a
chance to call, it was after 5 o'clock and he was not there." He
replied to her e-mail within hours, she said.