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Eugene Weekly : Coverstory : 5.14.2009

Doctor, Doctor, Email Me the News

Why do physicians resist a basic communication tool?

By Ted Taylor

The doctor who treats you might never tweet you, but you could get an email. Someday.

Twenty computer-savvy people were surveyed at a business meeting in Eugene recently, and by show of hands, not one had ever had an email conversation with his or her doctor. If this question were asked in a larger metropolitan area, it’s likely several hands would go up. National surveys of patients and doctors indicate that somewhere between 8 and 25 percent of doctors email their patients. 

Doctors in the Eugene-Springfield area appear slow to embrace email and other handy medical technologies to supplement office visits and phone calls. 

A typical face-to-face adult visit with a GP, even just to ask a question or say “aaaaaah” to a tongue depressor, can cost $100 to $200 or more. Doctors get a piece of the pie, but every medical practice also supports transcription typists, nurses, technicians, bookkeepers and other various office workers. Can technology help streamline medical care and cut costs?

Some doctors in Lane County have been having email conversations (e-visits) with patients and their families for years, formally or informally, encrypted or not, but most local doctors  avoid email like staphylococcus, and they have their reasons. Are those reasons valid in terms of providing the highest quality patient care at the lowest possible cost? This story examines the arguments and issues, and looks ahead to what’s coming in the field of medical technology for all of us.

 

How e-visits work

PeaceHealth Medical Group is Lane County’s largest physician group with 70 primary care doctors and 60 specialists. The group has a web-based patient interface, but only about 20 of its 130 doctors so far use the messaging feature to communicate with patients. “We’re working on ways to make the messaging feature even easier to use and we hope more physicians will start to participate soon,” says Chuck Broch, PeaceHealth systems analyst.  

The software is called Patient

Connection, and Broch says it’s designed to interface smoothly with the group’s electronic medical records (EMR) system. A “test drive” of the program can be found at www.patientconnection.org or at www.peacehealth.org

The program allows PeaceHealth group patients, at any time of the day or night, to log on using a password and handle routine tasks that would normally require a phone call: request an appointment or referral, see lab results, view medications and inoculations and, if their doctors participate, ask questions and get answers. E-visits, whether handled by doctors or nurses, become part of patients’ medical records.

Doctors and patients in the Kaiser Permanente system in Salem and Portland are now fully web-connected. More than 1.4 million Kaiser patients are now registered nationwide, reducing adult office visits by 7 to 10 percent and cutting phone calls by 14 percent, according to a study published in 2007 in the American Journal of Managed Care.

“Email is more convenient and efficient for both the physician and patient for non-urgent concerns,” says the study. Kaiser is now advertising e-visits through National Public Radio underwriting in an apparent effort to attract new patients.

One of the most sophisticated and user-friendly software programs for e-visits is offered by RelayHealth (www.relayhealth.com). Doctors pay a small fee per month for the service that supports secure electronic communication with patients, scheduling, payments and more. Patients do not get sensitive information sent directly to their home computers. Instead, they get an email notice with a link to a password-protected website where only they can read their messages.

Another pre-packaged, high-end program is offered by MedFusion (www.medfusion.com), offering “secure patient portals” and promising “elevated patient satisfaction.” MedFusion claims to serve 15,000 physicians nationwide. One medical group in our area with more than 100 doctors was quoted a startup cost of $40,000 plus $35 per doctor per month for a basic service. Add-on features such as lab results carry additional fees, with the full package costing the group about $10,000 a month. 

Springfield Family Physicians, a smaller practice with 11 doctors, uses eClinicalWorks, another sophisticated, password-protected system, but only a few of the doctors have embraced the feature that allows direct email conversations with patients, according to office administrator Jane Conley.

 

Why the resistance?

Sharon Meyers is an internal medicine physician at PeaceHealth Medical Group, and the group’s key advocate for PatientConnection. “I have not done a formal survey of why providers don't use PatientConnection,” she says, “but when I’ve asked some of my peers, some say they either don’t have the time or worry that their words may be misconstrued.”

Medical websites and journals list many other reasons why doctors avoid email: They are already overwhelmed with trivial email and spam at home and paperwork at the office; they don’t want their patients to send silly cartoons and medical jokes; they prefer to have their patients phone their office nurses with questions; they don’t want to diminish the personal connections they have with their patients. Some doctors (and patients) are technophobic, can’t type well or are just not at ease with written communication.  

Doctors worry about urgent information getting lost or delayed. They dread getting a single message that asks multiple questions dealing with appointments, medications, insurance and what to do about that irritating butt-crack rash. And some don’t like the idea of not getting paid for medical advice. They already return phone calls for free.

Doctors and medical office managers also worry about legal issues. Confidential information emailed to home computers can be forwarded to people not legally entitled to see it or accessed by others in the home, or home computers can be hacked and messages altered. Most of these issues are addressed in password-protected, web-based systems. 

 

Avoiding the pitfalls

Springfield pediatrician Todd Huffman says he honors requests to use email to communicate with parents. He doesn’t charge for his time, but he sets up-front ground rules.

“Email should never be used to communicate with a physician regarding an acute illness,” he says. “Email is an asynchronous communication tool, not fit for urgent triaging purposes. If a child is ill, and medical advice is to be sought, direct telephone communication with the nurse or doctor is exclusively preferred.”

And while some doctors will refill prescriptions via email or a website, he doesn’t. A request for a non-maintenance refill “triggers questions in the mind of the practitioner regarding the child’s health. Why does Johnny need his inhaler refilled? Why does Emily need her last antibiotic prescription refilled? Such questions are best directed by the physician’s nurse to the parent via telephone.”

Pediatric practices face a unique set of other issues in dealing with the complexities of today’s families. Are non-custodial parents legally entitled to web access to their children’s medical records? How can a doctor know if an email from parent Jane Jones is really from Jane Jones? Can doctors be sued for email breaches of privacy? 

An extensive but somewhat outdated discussion of email communication between pediatricians and their patients and parents can be found in a clinical report from the American Academy of Pediatrics, published in Pediatrics July 2004.

Geriatrics has its own challenges and opportunities. In cases involving dementia and dying, multiple family members across the country and even around the world may want electronic access day and night. A website with updated patient information can provide assurance, enable informed end-of-life decisions, and avoid many disrupting phone calls for doctors and nursing staff.

 

The role of insurance companies

The efficiencies offered by the new medical technologies can save time and money for patients and insurance companies, but with the exception of Kaiser Permanente and a few others, most insurers are lagging behind in paying for e-visits with doctors and/or encouraging clients to embrace the new medical records technologies.

Kaiser doctors, patients, medical records and insurance are all under one system, making it easier to coordinate. Other doctors’ offices deal with multiple insurance companies and different policies even within the same companies.

Regence BlueCross BlueShield is one of Oregon’s largest health insurance providers. “We don’t have a policy regarding e-visits as yet,” says Samantha Meese, a spokesperson for Regence. “But we are supporting several projects related to e-health in general. Last year, for example, we conducted a small electronic medical records pilot program in LaGrande that connected one hospital, one lab and 12 practices that included more than 40 physicians. Providers who fully embraced it reported high satisfaction and improved efficiency in their practices.”

Regence does provide one-way web-based communication. Patients can log on to myRegence.com and provide comments about their doctors’ services. And doctor profiles are available to view.

BlueCross BlueShield of Massachusetts ran a pilot program back in 2004 that paid for e-visits. Some 200 physicians participated in a plan that paid doctors $19 for each web conversation with a patient. The patients were billed a $5 co-pay. “E-visits can be more time-efficient than office visits, or even than returning patients’ phone calls. There’s no phone tag,” according to a story in Information Week, May 31, 2004.

 

Taking it slowly

The Pacific Women’s Center in Eugene is just a year into electronic medical records, and the clinic is taking its time getting used to a paperless environment. Web-based conversations between doctors and patients could be years away.

“I anticipate that over the next couple of years, as we become more familiar with it and as our comfort zone is there, that we will open up to more of the Internet online functions that electronic medical records offers us,” says clinic administrator Betsy Hill.

The Eugene-based Oregon Medical Group has about 110 physicians under its umbrella and is currently looking at several “off-the-shelf” programs that would facilitate secure, web-based doctor-patient communication, and enable patients to see lab results, pay bills and request prescription refills. “It’s a significant capital investment,” says OMG Chief Operating Officer Josh Kimball, “but we think it’s going to be an advantage for us.”

Conley at Springfield Family Physicians has worked at other practices that have implemented e-visits, and she’s confident the technology will catch on over time. “It’s a new concept for doctors,” she says. “I think it’s a fabulous thing, but our physicians have yet to catch the vision of how it helps both parties. I absolutely believe we will be using it more in the future.”

 

Educating patients

“Email is wonderfully useful for general questions,” says Huffman. “What do I think about the supposed link between vaccines and autism? What infant formula is best to give my baby if my breast milk is drying up? What books would I recommend to help deal with sibling rivalry, or an adolescent’s first menstrual period?” 

The PatientConnection program, says Broch, lists patients’ medications, and “each of the medications is linked to a knowledgebase that provides further information about that medication, including the benefits, side effects and possible alternatives.”

What happened to PeaceHealth’s free phone program, Ask a Nurse? The hotline was discontinued in the summer of 2005 and has been replaced with several educational websites that have links at www.peacehealth.org The links offer a “Healthwise Knowledgebase” and frequently asked questions regarding children’s health, women’s health and seniors’ health. A link is also provided to the Health Information Library, staffed by “trained medical librarians” who respond to emailed requests for information. 

 

Looking ahead

High on President Obama’s agenda is getting our nation’s medical records off the shelves and into usable electronic databases. The reasons are many: better patient care through improved accuracy and accessibility, enhanced sharing of medical information, reduced health care costs through new efficiencies and hundreds of thousands of new jobs. 

As slow as local doctors’ offices are in adopting and embracing the new technologies, no one we talked to for this story sees e-visits as just a fad. The service will become ubiquitous. And at some point, if not already, patients may be choosing their doctors and even their insurance companies based on how well their medical issues and questions can be addressed not only face-to-face but also from the privacy of their own computers.



Questions for our readers

• What are your stories regarding communication between doctors and patients? 

• What do you see coming in the next 20 years?

• Who actually owns medical records, and do patients and their families have a right to see them? 

• What effect would single-payer health insurance have on the ability to streamline and modernize our nation’s electronic medical records system? 

• What are your experiences in dealing online with Medicare, Medicaid, the VA medical system and the Bureau of Indian Affairs? 

• The Coburg Veterinarian Clinic (www.coburgvet.com) welcomes email inquires from both pet owners and the public, as does Oregon Dental Care. Are there other medical practitioners who do the same? Chiropractors, physical therapists, massage therapists, acupuncturists?

Email (naturally) to editor at eugeneweekly dot com