Doctoring via e-mail: Will it fly? Physicians worry about pay, time

By Carol M. Ostrom
Seattle Times staff reporter

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	E-mail this article Print this article Search archive Related stories A sampling of an actual e-mail exchange between a patient and her doctor

In 1883, an editorial in The Lancet, a respected medical journal, warned physicians about succumbing to that new-fangled contraption — the telephone.

If patients can converse with their doctors "for a penny," the editorial darkly predicted, "they will be apt to abuse the privilege. ... " Forty years later, the journal was still worrying about how to protect busy doctors from the telephone's "too common incivilities."

Fast forward 80 years and arrive at e-mail.

Doctors, it turns out, are still worrying about the same things they were with the telephone: how to get paid for using e-mail and how to find the time.

Despite many doctors' distaste for this latest intrusive technology, however, more and more patients are communicating with their doctors by e-mail.

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According to a 2002 Harris Poll analysis, about 90 percent of adults already online (about 66 percent of all adults) want that access, and nearly 40 percent say they're willing to pay for it. Patients say it's efficient and less hassle than an office visit or playing phone tag for things like adjusting medications or reviewing test results.

Perhaps more important, many patients — and some doctors, too — believe that more continuous attention to their health care, rather than the current system of sporadic drive-through office visits, would improve not only their attitude, but their health.

'It's so easy'

Terry Chiafalo, 57, works in a Seattle real-estate office, where it's very difficult for her to be stuck waiting on the telephone to talk with a receptionist, nurse or doctor, repeating the reason for her visit over and over. So when Group Health Cooperative invited patients to begin communicating with their doctors via e-mail, she jumped at the chance.

"It's so easy to do a little e-mail to your doctor. ... 'This is what's happening with this medication. ... I like it, I don't like it.' Typically, I've gotten a response within two hours."

Chiafalo, who has fibromyalgia, also uses Group Health's secure Internet site to see her lab-test results, make appointments and refill prescriptions. "It is such a wonderful, timesaving, frustration-free tool to better your health care," says Chiafalo.

Her doctor, Matt Handley, also Group Health's medical director of informatics, calls himself a "true believer." These days, a third of his contacts with patients are "virtual." Well over half his patients are signed up, says Handley, who believes his ability to converse with patients this way helps deliver good care. "If I practiced anywhere else, I couldn't do half as good a job for my patients," he says.

Tips for sending e-mail to your doctor • Even e-mail takes time. Don't use it for emergencies because it may take a day or two to receive a reply. • Consider privacy. Use a secure messaging system to ensure confidentiality. • Be descriptive. More detail helps your doctor better understand your situation. • Ask questions. It's easy to hit reply. It's better than phone tag. • Be informed. A member of your doctor's staff who has permission to access medical records may see your message. Source: Group Health Cooperative

In a recent pilot project at the University of Washington's General Internal Medicine Clinic at Roosevelt, Dr. Harold Goldberg tested a model allowing patients with adult-onset diabetes to "co-manage" their disease from home. The patients used e-mail and had access to their own electronic medical record (including lab-test results and blood-sugar readings in graphic display) and reminders for screening tests, exercises and other health-management tools.

One of the pilot's test patients, Helen Berglund, 66, a real-estate appraiser who suffered from being overweight and related sleeping problems, said she found the model very helpful. Although she told the researchers she'd had trouble losing weight, in part because she lives with a Greek man who likes to bake baklava, the online management aids helped her lose 20 pounds and get her blood sugar under control.

From e-mailing for appointments or prescription renewals to the graphs that helped her relate her diet and stress levels to her blood-sugar control, the system was more efficient than the traditional system, she says, and "put me in another level of awareness of my whole personal diet management."

Who pays?

So if e-mail communication between doctors and patients and access to online records and health-management tools is such a great deal for patients, why isn't everyone doing it?

Back to the telephone: Docs are still worrying about how to get paid, and — even more than in the old days — how to find time. As it is now, insurers pay only for face-to-face visits, with rare exceptions.

When Goldberg, the lead investigator on the University of Washington pilot, first approached the clinic about taking part in a larger, randomized trial to test the intriguing findings of the pilot, the answer was swift: "Their medical director said his physicians were simply too busy and overworked to take on the responsibility of responding to patient e-mails and glucose data from home," Goldberg recalled.

So the study, funded by the Robert Wood Johnson Foundation, will tap nurse-practitioners and a clinical pharmacist to e-interact with patients. One part will enroll diabetic patients at the UW's Roosevelt clinic and the other disadvantaged African-American diabetics at Harborview Medical Center, where Goldberg is an internist.

At Seattle's Polyclinic, four doctors who are participating in the clinic's "Partnership in Health" program have signed up to use e-mail to communicate with patients. They're charging patients from $20 to $25 per month for that service, along with a newsletter, lectures and other services designed to help improve care for chronic illnesses. That way, the doctors say, they can cut their patient load enough to make time for the e-mail correspondence with patients.

Without that extra fee, says Dr. Jon Younger, one of those doctors, he wouldn't use e-mail with patients. "It takes time — my time and staff time. Because there's no ability to charge for phone time or e-mail time, it means it really does substitute for a chargeable kind of encounter. That's one of the reasons why docs have been reluctant to do a lot of care over the phone."

Because e-communicating with patients doesn't cut office visits enough to pare staff costs, there isn't a savings, he says. "It's basically just adding another pile on my desk."

In Whatcom County, four doctors with the Family Care Network, a group of family practitioners, are piloting e-mail communication with about 200 patients. "It's a great way to maintain contact when testing and consultation are going on," according to Dr. David Lynch, who says more doctors plan to join the "InTouch" program next year. The doctors charge $10 per person per month for unlimited access, or $25 for a single virtual "visit."

Unlike most providers, Group Health doesn't have to figure out how to pay for e-mail communication with patients. Because it's both a health provider and an insurer, if it can save doctors' time and help keep patients healthy, it's ahead.

Safety concerns

Besides the money and time issues, some doctors say e-mail communication with patients can be downright dangerous.

Dr. Hugh Maloney recalls that about four years ago Minor & James Medical opened an e-mail service for patients and doctors.

"We quickly had to shut it off," says Maloney, who is now chief of the University of Washington Physicians Network Kent-Des Moines clinic. "We were inundated with long, voluminous e-mails that were interspersed with critical stuff. 'My toe hurts ... I couldn't sleep last night ... I have chest pain. Boy, that chest pain really hurts,' " Maloney remembers.

It was an example, he says, of "not having established what the ground rules were."

Because e-mail is what techies call "asynchronous communication," you, the patient, can say something to your doctor now, but your doctor may not hear it until tomorrow and may respond to you the day after that, which could put you in danger if you need urgent care.

The strength of that approach: You can send the e-mail when you have a moment, and read the response when you have time and/or the privacy you need.

The weaknesses: A query sent off into cyberspace may not reach its intended target for some time, and the same is true for the response. Doctors who use e-mail say they try to make it very clear to patients that it must not be used for any health emergency that requires immediate attention.

In addition, Maloney, like many other docs, worries about not having that face-to-face interaction.

"Encouraging e-mail and Internet disconnected communication is against the intimate nature of the doctor-patient relationship," Maloney says. "I like the relationship. I like the talk, the banter, providing the service. I like my patients. It's hard to do all that through e-mail, through a Web site."

Nuances like tone of voice or facial expressions can be important clues to a patient's health, he says. "You're never going to get that on an e-mail."

Younger, too, worries about some of the subtle things. E-mail is good for times when he starts a patient on a new medication, for example. "I'll say, why don't you e-mail me in a week and let me know how you're doing?"

But even some of the simpler things, like a discussion of symptoms for a chronic illness, require at least an ear-to-ear visit, he thinks. "Often I'll get an e-mail query, and I'll respond by phone. I still feel more comfortable with the give and take of the phone conversation."

In general, he says, he's still very conservative about what he will discuss in e-mail. "I heavily restrict the kind of medical give and take I'm willing to have over e-mail," he says. "It's not at this point replacing a patient visit."

Privacy an issue

Another big issue — related to money — is ensuring privacy. New federal privacy rules that went into effect in April carry hefty fines for wrongly disclosing patient information, and medical-malpractice insurers have warned doctors about the legal risks.

Critics warn doctors that sending an e-mail to a patient through a nonsecure system is tantamount to sending a postcard — there's nothing secure about it.

Late last year, the eRisk Working Group for Healthcare announced guidelines for doctor-patient e-mail, including encrypted security systems, informed consent, clear guidelines about emergency subject matter and having systems to integrate e-mail correspondence into the patient's medical record.

For many clinics and practices, the costs involved in building that kind of system were overwhelming. "In our health-care financing system, there is nothing built in to allow that kind of infrastructure to be created," says Maloney. Clinics that went ahead, like The Polyclinic, often buy the services of a secure system, such as MyDocOnLine.com or Medem, a communication network founded by the American Medical Association and six national medical societies.

Patients say some systems work better than others; while some require patients to fill out lengthy forms, for example, others are as simple as ... well, simple as e-mail.

The future

So what does the future hold? Clearly, patients want what Goldberg calls "e-health," e-mail plus electronic access to records, scheduling, prescription refills and tools to help patients and doctors co-manage health problems. But as of the beginning of 2002, only about 6 percent had been able to use e-mail to contact their doctors or other providers, according to a national survey reported in the Journal of the American Medical Association in May.

Some doctors, like Goldberg, are exploring e-health alternatives because they believe the current system isn't working for many patients, particularly patients with chronic illnesses.

Take diabetics, for example: Only about 44 percent of adults in this country are adequately treated, he says. "That's not acceptable."

Such percentages mean that other approaches must be evaluated, Goldberg believes. Will the solution be e-health? "I'm not one of those wide-eyed believers that e-health will solve all our problems," he says, but fact is, there hasn't been much evidence either way.

As for insurers reimbursing for the service, "we are seeing some plans looking into it," says Mohit Ghose, spokesman for the American Association of Health Plans/Health Insurance Association of America, which represents the health-care insurance industry. Although it's a slow process, new technologies proven to work have in the past been incorporated into billing and reimbursement systems, he says.

But there are privacy and safety concerns, he says, as well as practical questions about how e-mailing would be billed and reimbursed. "If I talk to the doctor over e-mail, is it I get charged a $20 co-pay, or does the doctor bill the insurance company?" he asks. Should e-mails be measured by length or time it takes to do? "How do you time someone's typing speed?" he asks, only partly in jest.

The American Medical Association, which creates the "CPT" codes used in medical billing, is now considering an application for a code designation for an "e-mail consultation." "We think there will be movement on that, probably in the next year," says Jason Best, spokesman for Medem, the applicant, which provides secure e-mail for patient communication for about 1,000 doctors in the state, and about 90,000 nationally.

Having a code doesn't mean that insurers will reimburse, but it's a step toward that end.

Premera Blue Cross, one of the state's largest insurers, is exploring reimbursement criteria raised by e-mail and other types of virtual office visits in a pilot test of "tele-medicine" conferences in Alaska, said spokesman Scott Forslund. "It's something we're definitely looking at," he said.

For many doctors, an important issue is e-mail's efficacy. "You can't say yet that e-mail consultation improves outcomes," Ghose notes.

That's where Goldberg is heading, he says: to answer fundamental questions about electronic communication in health.

"The first question for a scientist like me is: Does it work? Does it help make patients better?"

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com

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