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Gulf Coast Pain Management
Lynne Carr Columbus, DO
"What's your e-mail address, Doctor?"
If patients aren't already asking this
question, they will be soon. E-mail services that connect doctors and
patients are burgeoning.
By Dorothy L. Pennachio
Senior Editor
Do you exchange e-mail with your patients?
More and more physicians do. Capitated doctors
find it especially efficient because it can avoid needless office
visits. Others find that electronic
communication improves patient education and compliance.
"Face-to-face office visits aren't the only way to provide quality
care," says Charles M. Kilo,
an internist in Portland, OR, and a fellow at the Institute for
Healthcare Improvement.
"If a doctor sees 20 patients in a day, half don't have to come to the
office. They can be taken
care of via phone or e-mail."
Physicians need to restructure the way they take care of patients, Kilo
says. In many practices,
doctors' failure to do so is the reason phones ring off the hook,
paperwork never ends, staff
feels frantic, and waiting rooms jam up.
Online communication can also significantly reduce the cost of care,
according to a recent study
by researchers at Stanford University and the University of California,
Berkeley. Capitated
physicians whose patients used e-mail to communicate with them saved
more than $1
per patient per month when compared with control groups. How? The
doctors received direct
reimbursement from the patients for the care, and there were no office
expenses for the
non office-based encounters.
Don't bank on saving a lot of time, though. It may seem that e-mail
would cut down on the
number of phone calls, but savings depend on how the technology is used.
In fact, researchers
from the University of Michigan Health System recently found that e-mail
didn't save money
or time for the practice that participated in their trial.
Whether you're already communicating electronically with patients or are
just thinking about
doing so, you should consider some issues and services that can help you
determine if it's right
for you.
To protect patients for instance, HIPAA insists that e-mail between
physician and patient be
secure or encrypted, meaning that if a message is sent to someone it
wasn't intended for,
the words will appear garbled.
Fortunately, a growing number of services—some free—offer encryption or
secure messaging
technology for physicians. Among them are:
MDhub.
This free service is considered rather
primitive compared with others, but you may
find it a good way to ease into receiving e-mail from patients. Here's
how MDhub works: Your
patient goes online to the Mdhub site (
http://www.mdhub.com/ ), plugs
in your name
and location, or just your phone number, and writes a message limited to
about 50 words. It's
encrypted and transmitted via fax to your office, where a staffer can
clip it to the patient's file.
If doctors don't use e-mail and need to reply to patients, they do so by
phone or during
an office visit.
Your message center's up and running as long as your name is listed in
one of
The Little Blue Book directories—which contain the names of nearly
every practicing
physician in the country. Ads in the directory pay for the Web site
service. Visit the site
yourself to see if you're included.
Medem.
Sponsored by the AMA and 43 other medical
societies, Medem
( http://www.medem.com/ ) is
used by 84,000 physicians. They refer patients to the site,
and some 9,000 of them also use the secure, fee-based messaging service,
Online Consultation.
"Patients can schedule an appointment, renew a prescription, ask a
general question, or request
an online consultation," says Edward Fotsch, a San Francisco emergency
medicine physician
and CEO of Medem.
IDs and passwords are required. There's no setup cost, but if the
physician charges the patient
for the communication, Medem charges the physician $2.50. Physicians set
their own fees,
typically $20 to $30 per consultation. Follow-up questions on the same
topic and very simple
questions are generally free.
Lynne Carr Columbus, a pain management specialist and anesthesiologist
in Palm Harbor,
FL, uses Medem. "Elderly patients have difficulty coming to my office
for the periodic
monitoring that's required for narcotic pain medications," she says.
"E-mail enables me to
see how they're doing." Columbus says the billing for follow-up online
consultations
(usually $30) helps document the monitoring. She also finds e-mail
convenient for communicating
with the snowbirds who head north during the summer. She even used the
venue when she
was in Budapest recently.
Physicians' Online. Thomas A.
Stevenson, an FP in Grand Rapids, MI, and vice chair
of the American Osteopathic Information Association, is a bit ahead of
his colleagues:
He's using Physicians' Online (
http://www.po.com/ ) while waiting for his group to develop
a policy on electronic communication. The secure server offers a free
e-mail service to doctors;
advertisements that appear at the site pay for it.
Stevenson's staff exchanges e-mails with selected patients regarding
everything from
appointment changes to lab results. "Patients are very receptive," he
says, "and I prefer e-mail
to phone calls, because patients don't tend to go on and on as they do
on the phone."
MyDocOnline.
Some pharmaceutical companies have begun paid e-consultation sites.
MyDocOnline (
http://www.mydoconline.com/ ), a subsidiary of Aventis
Pharmaceuticals,
is one of these. It allows registered patients to access evidence-based
guidelines as well
as communicate by e-mail with their physicians. The service also
provides a type of intranet
for IPAs.
"I'd been looking for a way to replace group meetings or group phone
calls with other doctors
in my IPA," says James E. Barr at Pleasant Run Family Physicians in
Neshanic Station, NJ.
His IPA includes 31 offices and 110 doctors. Barr's office went live
with MyDocOnline first,
in February 2002; since then, five others have also connected.
"There are some hurdles, such as getting patients to register. But once
that's done, they easily
log on, just as they would with AOL. The most accepting doctors are ones
who use e-mail in
their personal life," he says.
Can you get paid for electronic consults?
Patients don't mind paying for the convenience of e-mailing their
doctors, says Medem's Fotsch.
"If you add up copays, lost wages, and other expenses involved in office
visits, they actually
save money if they can consult their doctors electronically."
Don't expect to make much—if anything—through third-party payers,
though. "For now,
Medicare and most private health plans don't pay for e-mail consults,"
says Fotsch. "As we
know, plans don't spend a lot of time figuring out new ways to put money
in our pockets."
He says plans will likely begin paying when they can guarantee cost
savings or when
employers start canceling contracts that don't provide for electronic
communication.
The prospect of payment from insurers may sound good, but Fotsch thinks
that doctors
might actually lose money on online consults once health plans
start reimbursing for them.
"They'll want a copay from the patient. The patient will pay that, but
then doctors may have
to try to chase down the health plan to pay a $15 bill ($25 less a $10
copay). The cost to the
doctor's office for kicking out a bill is typically $10 or $15."
Nevertheless, some doctors are trying to convince plans to consider the
idea. "We're working
on a pilot program with Horizon Blue Cross Blue Shield of New Jersey to
see if they'll reimburse
us for Internet visits," says Barr. If the carrier agrees, the
negotiated rate will depend on
complexity and time spent.
Watch out for these pitfalls
If you opt to communicate electronically with your patients, keep
these warnings
and tips in mind:
• Don't write anything on an e-mail that you don't want clipped to the
patient's file, because
that's where it should end up.
• Even though patients are constantly reminded by the messaging centers
never to use e-mail
for any type of medical emergency, remind them often. When they have
serious problems,
they should always call your office or go to an emergency department.
• Make sure your patient resides where you think he does. Practicing
across state lines doesn't
sit well with licensing agencies. "We were operating an asthma service,"
says Craig Skevington,
CEO of Flow Management Technologies, which provides MyHealth.com to
60,000 physicians.
"A patient had been e-mailing with a physician in Colorado, but then he
moved out of state
and never told the physician. Unbeknownst to him, the physician licensed
in Colorado was
practicing medicine in the state of Texas."
Risk management guidelines for online communication with patients can be
found at
www.medem.com/erisk.html
. The rules, developed by the eRisk Working Group for
Healthcare, which includes more than 30 malpractice carriers, medical
societies, representatives
of state medical licensing boards, and Medem, range from how soon a
doctor should respond
to a patient's medical question (no later than the second office day,
the consortium suggests)
to what a patient must do if he loses his password (you give him a new
one only if he comes
to the office). A notable recommendation is to offer e-mail visits only
to existing patients whose
medical history you're familiar with, particularly when a fee is
charged.
See also "E-mail
patients? Don't be nervous. Do be careful," Sept. 3, 2001 for
additional tips
on how to e-mail patients without running afoul of HIPAA regulations.
Some doctors communicate with patients they've never met
The e-mail systems mentioned so far are meant to be used by doctors
for communication
with their own patients, not with strangers. A handful of systems,
termed "online doc-in-a-box"
services, however, don't draw that distinction—and may be treading on
thin ice.
One example is EasyDiagnosis (
http://www.easydiagnosis.com/
), which despite its name,
claims it neither diagnoses nor provides medical advice over the
Internet. Created
by Martin F. Sturman, a Media, PA, internist, the site aims to help
patients figure out for
themselves what might be ailing them and helps to organize diagnostic
strategy. "It's meant
to educate patients so they can go to their own doctors with accurate
information," he says.
Patients who use the site pay a fee of $25 a year.
NetLiveMD (
http://www.netlivemd.com/ )
started as a free service for
FP Dean M. Tomasello's patients, so they could ask questions. But it
grew so large that the
Walworth, WI, physician started charging. Now about 300 people the
doctor has never seen
are the mainstay of his operation. They pay either $25 per e-mailed
question or a $49 annual
membership fee plus $19 per question.
It's HIPAA-compliant, he says, because he and his staff of physicians
don't diagnose, prescribe,
or treat; they just give information specific to the questions they
receive. At the end of each
response, the NetLiveMD physicians supply questions that the patient can
ask his or her own
doctor.
"NetLiveMD empowers the patient so that the patient-physician
interaction works better,"
Tomasello says.
In October, the Illinois Department of Professional Regulation ordered
an online consultation
company owned by Roche Diagnostics, MyDoc.com, to stop prescribing and
treating online
patients. The report cited the "unlicensed practice of medicine . . .
treating patients over the
Internet and prescribing medication to patients over the Internet
without the benefit of
performing a physical examination on the patient."
Dorothy Pennachio.
"What's your e-mail address, Doctor?". Medical Economics
2003;2:66.
Copyright © 2003 and published by Medical Economics Company
at Montvale, NJ 07645-1742. All rights reserved.
More Articles About Gulf Coast Pain Management
Dr.
Lynne Carr Columbus, D.O.
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