Physicians Get The Message—Slowly -Though more doctors are communicating with patients via e-mail, online consultations have yet to become routine

When health care organizations train physicians on a new information system, they generally demonstrate its many capabilities.

During training on a new patient portal last year, however, Evanston (Ill.) Northwestern Healthcare also ensured physicians understood the technology’s limitations.

The three-hospital delivery system designed the portal, called ENHFirst, to enable patient access to their medical records, schedule appointments and e-mail physicians. That last feature initially caused some concern for Evanston Northwestern physicians, who were unsure about how far they should go in an “e-visit” with patients, says A.J. Melaragno, director of interactive marketing.

So before the delivery system unveiled the portal to patients last November, system planners set some limitations on how its e-mail function should be used. They determined that physicians should only offer electronic advice to patients with existing medical conditions.

For example, if a patient already had been treated for the flu and wanted to know when to stop taking a prescribed medication—or get a different one—physicians could offer advice via e-mail. Evanston Northwestern also decided it wouldn’t bill patients or payers for the service.

“If we are charging for it, patients are going to expect a diagnosis and some kind of action. But we aren’t at that comfort level with e-visits yet,” Melaragno says. “We can address existing medical conditions via e-mail and if doctors feel uncomfortable with how far it’s going, they ask patients to come in for a visit. It’s a strategic decision because of physician concern.”

Evanston Northwestern physicians conduct some patient business over e-mail, such as explaining test results. But the delivery system’s physicians aren’t alone in their hesitation to conduct full online consultations that involve diagnosing problems listed in an e-mail.

Though the number of physicians who use e-mail to communicate with patients is growing, it hasn’t reached the level many industry experts predicted, says Keith MacDonald, senior research manager at First Consulting Group Inc., Long Beach, Calif.

Organizations typically offer patient/physician e-mail services to differentiate themselves from the competition and to increase patient satisfaction, he says. While they often achieve their goals, such benefits aren’t enough incentive for many physicians to conduct online consultations, MacDonald says.

“For providers, it’s all about saving money and increasing revenue,” he says. “Physicians who are offering online consultations might be saving a little time and money. But when push comes to shove, there’s not enough ‘skin’ in the game for many physicians to want to do this.”

No single method

It’s been difficult to determine how many physicians are e-mailing patients because there are multiple ways to offer online consultations, experts say.

While some health care organizations have purchased software specifically designed for online communication, others, like Evanston Northwestern, have modified existing technology to support it.

The delivery system purchased its portal tool in 2001 as a component of an electronic medical records system from Epic Systems Corp., Madison, Wis. After implementing the records system the next year, it customized the portal to facilitate patient communication.

To send a message to their physician, patients log into the ENHFirst Web portal. Doctors can access the application from the records system. After the physician responds, the site sends a message to the patient’s personal e-mail account asking them to log into the ENHFirst site to retrieve it, Melaragno explains.

Beth Israel Deaconess Medical Center, Boston, also customized a Web portal to serve as a messaging application for its patients and physicians. The hospital, a member of the CareGroup Health System, developed the application in 1999, before most online consultation software vendors were offering such applications.

Beth Israel Deaconess formed a committee comprising I.T. staff, physicians and a patient to help determine how it should handle the new medium, says Danny Sands, M.D., who was on the committee and uses the portal to communicate with about 100 patients.

“We had to develop a lot of policies and procedures because there were no existing best practices at the time,” he says. The committee determined that online consultations conducted via the portal only should be done for patients with pre-existing conditions.

Beth Israel Deaconess’s PatientSite requires patients to log onto a secure Web site to send a message to their physician. Physicians log into the portal from the Internet or the hospital’s homegrown electronic medical records system. After they send a message, the portal sends an e-mail to the patient’s personal e-mail address asking them to log into the PatientSite to retrieve it.

What’s it worth?

Beth Israel Deaconess’s portal went live in September 2000. It’s now used by 250 physicians and 26,000 patients, Sands says. The initiative cost the hospital $2 million.

Determining a return on investment, however, has been difficult. The hospital, like Evanston Northwestern, doesn’t charge patients or payers for online consultations, so PatientSite isn’t bringing in revenue. And some physicians still balk at using the portal, complaining that it’s just another place they have to go to check messages.

“To figure out if the portal was worth it is a tough question,” Sands says. “Patients like this service, so it’s good at attracting and retaining patients to our delivery system. But quantifying that is difficult.” Sands, who practices part time, spends a few minutes a day responding to messages on PatientSite, he estimates. It saves him time because he can answer patient e-mails at his convenience, rather than fielding their calls throughout the day.

“A lot of patients would be calling in their questions anyway,” he says. “But I can answer their e-mails after I put my children to bed, which usually is too late to call patients. This allows me to time shift, so it’s tremendously efficient.”

Another benefit to PatientSite is that it offers free text communication. Sands believes his patients are more comfortable sending messages in free text than they would be with the structured communication offered by many commercial systems specifically designed for online consultations.

Structured communication, however, can better enable provider organizations to bill for online consultations because there’s a detailed record of the dialog, Sands adds.

The desire to get reimbursed for such communication was one of the reasons why Bristol Park Medical Group, Santa Ana, Calif., chose to install an online consultation system from RelayHealth Corp., Emeryville, Calif.

The multispecialty group practice implemented the vendor’s software about two years ago after one of its payers—Blue Shield of California, San Francisco—began offering the system to its physicians. The managed care organization also agreed to reimburse physicians for each online consultation they conducted via the software, becoming one of the first payers to do so.

The Blues plan’s initiative helped Bristol Park Medical Group recoup some of the money it paid about five years ago to begin testing the system, says Medical Director Mark Schafer, M.D., who participated in the practice’s pilot.

Low maintenance

Bristol Park Medical Group pays the vendor $50 a month to use the portal software via the application service provider computing model.

The practice personalized the system by renaming it BPM Docs Online and enabled patients to access it via a link on its Web site.

After patients log into the portal, they can choose from a list of options, such as refilling a prescription, scheduling an appointment or e-mailing a physician. Nearly 3,500 patients use the Web portal to communicate with the practice, Schafer says.

“We now get fewer calls because patients are getting more done online,” he says. “As a result, our average hold time has decreased from five minutes to less than one minute in most offices.”

Bristol Park Medical Group receives $25 from the Blues plan for each online consultation conducted on the site. It also charges patients a copayment for the service depending on their type of coverage. Billing for online consultations is initiated when a patient requests the service on the site.

While Schafer says requiring patients to pay for online consultations doesn’t deter them from e-mailing Bristol Park physicians, recent research came to a different conclusion.

A study published in the May issue of Pediatrics found that parents who communicate with their children’s pediatricians via e-mail would be unwilling to pay for the service. And Melaragno at Evanston Northwestern said an informal survey conducted before the ENHFirst site went live revealed that most of the organization’s patients wouldn’t pay for online consultations.

Only a small percentage of Bristol Park Medical Group’s overall revenue comes from online consultations, Schafer says. But the practice did not implement the service as a way to make money, he adds.

“We went in this direction as a convenience for patients and to help improve our phone hold time,” he says. “The amount of time patients can save outweighs the cost of their copay. The fact that they don’t have to take time off of work to see their doctor is a benefit.”

Rosalind Reshad, a patient of Schafer’s, has been using the service to communicate with him for about two years. Reshad, who lives in Mission Viejo, Calif., but frequently travels, finds it convenient to send e-mails to Schafer for a prescription refill request, referrals and for verification of medical purchases to get reimbursement from her health savings account.

She also used it once to ask Schafer if she could stop taking blood pressure medication after her blood pressure improved. But she hasn’t used the service for a true online consultation, and as a result has never been billed for her requests.

“If I was really sick, I would seek urgent care,” she says. “But I use the service for non-emergencies because it enables me to communicate with Dr. Schafer without having to go to his office. It’s a money and time saver.”

Not perfect

While Bristol Park Medical Group’s consultation portal has many online features, the system doesn’t integrate with the electronic medical charts the practice has created using a document imaging system from Allscripts Healthcare Solutions, Libertyville, Ill. Connecting the systems would be helpful, Schafer contends, because it could offer physicians access to a patient’s medical records while answering their e-mails.

The practice next year plans to implement a “full-blown” electronic medical records system from NextGen Healthcare Information Systems, Horsham, Pa., and hopes to integrate it with the online consultation software.

Such integration is essential to ensure that online communication systems don’t require more work for physicians, says MacDonald, at First Consulting Group.

“If you want to implement an online consultation system, you have to integrate it with other systems,” he says. “You don’t want to have physicians using one tool to prescribe a medication and another to communicate with patients. It’s complicated, but you have to get them working in concert or else it will be a productivity and workflow issue.”

Some physicians and health care organizations, however, don’t want to invest a lot of money developing or implementing an online consultation system and integrating it with other applications. As a result, they are taking a simpler approach—using basic e-mail—to communicate with patients.

“There are a few physicians who are doing this informally with select patients,” says Rosemarie Nelson, a consultant at the Medical Group Management Association, Englewood, Colo. “It’s not a policy, but they use their organization’s e-mail software to communicate with long-term patients or those with chronic diseases.”

The Tampa, Fla.-based H. Lee Moffitt Cancer Center & Research Institute might change its policies to allow e-mail communication with patients after it ensures its e-mail system truly is secure, says Donald Wasylyna, the institute’s security officer.

The provider organization is implementing technology from Dallas-based Zix Corp. to secure outbound e-mails that contain protected health information. It expected to finish rolling out the security software on its Microsoft Outlook e-mail application last month.

Moffitt also is using technology from CipherTrust Inc., Alpharetta, Ga., to secure the application for incoming correspondence.

Moffitt implemented the technology to help comply with the privacy and security rules of the Health Insurance Portability and Accountability Act.

Byproduct

Enabling its 1,500 physicians to use e-mail to communicate with patients could be a byproduct of the initiative, Wasylyna says.

“We haven’t made a conscious decision to endorse or spearhead online communication with patients,” he says. “But we foresee our policies changing after we have ensured our system is secure.”

Some of Moffitt’s physicians and patients already have asked the organization to support online communication. Before Moffitt will sanction it, however, the practice will form a committee to create policies and procedures on how online consultation should be handled, he adds.•

Sidebar

Experts: E-mail generates few revenue opportunities

Santa Ana, Calif.-based Bristol Park Medical Group is able to bill one of its payer organizations when a patient requests an online consultation. The 11-location group practice is one of the few lucky ones that have been able to turn e-mail communication into a revenue opportunity.

The practice receives a small amount of revenue for online consultations from Blue Shield of California, San Francisco, says medical director Mark Schafer, M.D. The payer two years ago announced it would reimburse physicians for online consultations they conduct using software from RelayHealth Corp., Emeryville, Calif.

A few other payer organizations have followed suit. Managed care organizations that now reimburse for online consultation include:

• Blue Cross Blue Shield of Massachusetts, Boston

• Blue Cross Blue Shield of Tennessee, Chattanooga

• Empire Blue Cross Blue Shield, New York

• Group Health Inc., New York

• Blue Cross and Blue Shield of Florida, Jacksonville Some of these organizations, however, have limited their generosity to providers who are using commercial online consultation software, such as RelayHealth.

That has left health care organizations such as Boston-based Beth Israel Deaconess Medical Center high and dry. The hospital, a member of the CareGroup Health System, developed its patient communication Web portal in house.

As a result, the homegrown system isn’t eligible for reimbursement from Blue Cross Blue Shield of Massachusetts, says Danny Sands, M.D., who uses the organization’s PatientSite Web portal to communicate with patients.

The inability to bill for the service could deter physicians and health care organizations from offering online consultations, says Keith MacDonald, senior research manager at First Consulting Group Inc., Long Beach, Calif.

“Payer reimbursement will be a driver for increased adoption of online consultation,” he says. “If it’s not paid for by payers, it’s not going to increase a practice’s revenue.”

If Evanston (Ill.) Northwestern Healthcare ever decided to enable its physicians to conduct full online consultations with patients, the delivery system would have to determine a way to financially entice physicians to do so, says A.J. Melaragno, director of interactive marketing. While Evanston Northwestern’s physicians use e-mail to communicate with patients, the delivery system doesn’t permit full online consultations.

No payer organizations in Evanston Northwestern’s area offer reimbursement for online consultations, so the provider organization would have to determine another way to derive revenue from the service if it decides to allow it, he adds.

“I’ve seen organizations charge for online consultations via a yearly membership fee,” he says. “Or it could be done via a more simple method, such as a copay. But if we didn’t offer something, we’d just be taking money out of physicians’ pockets.” •