A DO Addresses Concerns About Transitioning to Online Communications

Barbara Walters, DO shares her thoughts and experiences as the senior medical director for a medical center that launched its e-consult system in 2001

By Belinda Bombei

A 2006 Harris Interactive poll showed that roughly 80 percent of Americans using the Internet want to use e-mail to communicate with their physicians. Last year, the American Health Information Community (AHIC), a leader in providing innovation and growth to the health care industry, noted that development in information technology and online communication between patients and physicians were two of the most important trends in medicine.

In spite of strong growth in e-prescribing and other technology trends, physician adoption and use of patient online communication has developed more slowly than demand from consumers. In a 2004-2005 Center for Studying Health System Change survey, only 24 percent of physicians said they used e-mail to communicate clinical issues with their patients. This was up from about one in five physicians in 2001. Large clinics and physician groups were much more likely than smaller clinics to use it, according to the latter study.

Nagging questions persist for osteopathic physicians considering the leap to online communication. In an interview with Barbara Walters, DO, these concerns were discussed in relation to what has transpired since her medical center’s 2001 e-consult system launch.

Dr. Walters is an alumnus of MSU-COM (1985) and the senior medical director of Dartmouth-Hitchcock Medical Center, a Lebanon, New Hampshire based nonprofit facility with 300 physicians and 80 associate providers offering 60 percent primary care and 40 percent specialty care.

Concern 1: How to provide a secure online communication that protects the confidentiality of patient information
Information security has been widely noted as a main criticism of the patient e-mail practice. Unlike many traditional e-mail environments that are not encrypted, physicians need a securely encrypted portal to feel comfortable transferring private information and details to patients online. Web portals and electronic records management systems and programs have rapidly developed to meet this need. “Physicians need to purchase a software application with encryption, my groups’ application is embedded in the practice management software, and patients sign on via a secure, password-protected web site,” says Dr. Walters. She recommends that you purchase a software application that fits into your workflow, not trying to adapt workflow to the software and that physicians ask questions about patient portals when shopping for an electronic medical record.

Concern 2: Reimbursement for time online
Among the challenges patient e-mail adoption faces, payment for e-mail consultations is a crucial concern. Back in 2000, many physicians gave away free telephone consultations and the feeling exists that DO’s do not want to go down that road again with online communications. Also, many physicians do not see the gain of investing in often-expensive technology that is needed to provide encrypted e-mail if they might not be paid.

Dartmouth-Hitchcock Medical Center has had success in getting health plans on board. They have agreements in place with Cigna, Harvard Pilgrim Health Care, and Blue Cross Blue Shield of Massachusetts. The key to reimbursement, Dr. Walters believes, is selling the merits of e-consults to payers. Health insurers see a potential for lower cost e-mail consultations as a substitute for more expensive office visits.

There is a CPT code for e-mail and online consultations with patients--0074T--that was issued by the American Medical Association in 2004. According to Dr. Walters, Medicare currently does not provide separate payment for e-mail or online consultations.

But, she feels that even though practices are not paid for routine e-mail, encouraging patients to use e-mail for prescription refills or scheduling is an added convenience and an incentive for them to go online for an e-visit. Plus, online communication is a tool that DO’s can use to differentiate themselves in a convoluted marketplace.

Concern 3: How to incorporate online communication into workflow
Dr. Walters says initially it is difficult for physicians to figure out how to include online communications in workflow because for the vast majority of osteopathic family physicians, online communication integration was not a part of their education and training. Many DO’s are leery that online communication could easily overwhelm the provider and their staff, and the potential that

e-mail could add to their time demands, as patients may not use it as a substitute, but as a way to pose add-on questions or concerns. Dr. Walters has found in her seven years utilizing the patient portal that 90 percent of all communication is centered around the physician. Staff handles the incoming messages and route only official e-visits to the physician. She also states that nurses adore online communication as it virtually eliminates the constant game of phone tag they play with patients when delivering test results.

At Dartmouth-Hitchcock Medical Center, most patient e-mails arrive between 10 a.m. and noon, which is traditionally the most difficult time for patients to get through using the phone. Staff handles the incoming messages, and route only official e-visits to physicians. “We found that clinical messaging was the No. 1 use of e-mail by patients," says Dr. Walters. "That was a big surprise. We thought it would be prescription refills or appointments."

Concern 4: Internet and e-mail use varies among patients
Some patients do not use e-mail and usage rates vary greatly in different areas. Physicians must determine if the use of patient e-mail is beneficial to their practices. "Our patients are very articulate with e-mail," Dr. Walters notes. "We get much better information than we did playing phone tag and using nurses as intermediaries. Currently my home state of New Hampshire is the most wired state in the nation. Online usage transcends young and old; upper, middle and lower class."

A DO must consider time factors and whether e-mail communication would reduce face-to-face and phone demands. The ability to acquire and use e-mail securely is also important. The cost factor may be an indication of why larger practices tend to make greater use of patient e-mail than smaller ones. Other considerations include patient demographics, e-mail access, interest in e-mail communication, and patients’ ability to understand the information they read.

“In the seven years Dartmouth-Hitchcock Medical Center’s e-consult system has operated, I have experienced no detriments,” says Dr. Walters.

“I also believe it is a beneficial risk management tool as things are clearly documented in an online communication.”

Online patient communication is a growing trend for family physicians and clinics as a way to meet their patient base’s growing expectations for physician contact; to differentiate them in the marketplace; and to streamline practice management.

Visit Dartmouth-Hitchcock’s patient portal at dartmouth-hitchcock.org/patientonline where you can give patient online a try by signing on as a guest. Also, communicate with Dr. Walters online with questions you might have about her e-consult experiences at Barbara.Walters@hitchcock.org.

Belinda Bombei is the medical editor and writer for OsteopathicEditor.com and has more than 15 years of experience, including five years of experience editing, writing and designing websites for the osteopathic profession.