Unhealthy Communication

At Alliance Medical Group in Pinole, Calif., doctors go online to keep up with medical developments, do research on treatment options and communicate with colleagues. Using wireless hand-held devices, they can access drug-information databases. Alliance patients can visit a Web site, Baydocs.com (baydocs.com¹), which provides links to health information and biographies of the 22 doctors in the family and internal-medicine practice.

But one thing the patients won't find is a way to communicate with their doctors online. Though many in the practice were enthusiastic about using e-mail with patients, so many thorny issues arose that "we decided to put the brakes on it," says James Naughton, an internist and kidney specialist at Alliance.

"We aren't Luddites, and we aren't anti-technology," Dr. Naughton says, but until there are some uniform standards for e-mail and online consultations, and a more secure way of conducting such sessions, "we are actively discouraging" e-mail between patients and doctors.

Desktop Manner

Estimates on how many doctors use e-mail vary. Harris Interactive Inc., a Rochester, N.Y., research firm, estimates that only 13% of doctors communicate with any of their patients via e-mail; a new Deloitte Consulting/Fulcrum Analytics report says 23% of doctors interact with their patients by e-mail. But by either count, doctors remain on the fringes when it comes to e-mail, the standard of communication in most other U.S. businesses.

True, a growing number of doctors are getting onto the Web to find medical information, consult with each other and establish Web sites to guide patients to reliable health data. Their staff may use e-mail to confirm patient appointments or take care of routine prescription refills. But for a number of legal, ethical and financial issues unique to the practice of medicine, doctors have been reluctant to embrace e-mail as a way to make themselves more available to their patients or dispense medical advice.

"I'm not sure whether physicians will ever fully accept doctor-patient e-mail as completely routine," says Alissa Spielberg, a Harvard medical ethicist.

Other experts agree, saying it boils down to two basic problems: liability and compensation. Doctors are afraid of getting sued, and almost as concerned about not getting paid for their time and advice. Though malpractice carriers have been working with the top medical societies to hammer out guidelines for e-mail communications, there is currently no provision in medical-insurance policies for e-mail consultations. And though some health plans are testing payment to doctors, most don't consider e-mail consultations a reimbursable service. Indeed, says Ms. Spielberg, unlike lawyers and other professionals, "doctors have not traditionally billed their patients according to the amount of time spent consulting, analyzing or summarizing patient care."

There are also big cultural barriers. Doctors generally don't spend their day at a desk behind a computer, Ms. Spielberg notes, unlike businesspeople who "are networked all day and are used to responding to e-mail as a matter of course." Moreover, Ms. Spielberg says, e-mail "has a way of creating informal, seemingly intimate connections, [with] a leveling quality to the encounters that may alter the traditional notion of physician authority and power." That might solidify the patient's trust in the doctor and make it easier to ask questions and assert the patient's own views, Ms. Spielberg says, but it also "might contribute to an erosion of authority that might prove unsettling for both doctors and patients."

Despite doctors' wariness about e-mailing patients, many physicians are taking some steps online. There are about a dozen companies now focused on physician-patient "connectivity" that offer such products and services as Web sites for both doctors and patients, messaging, online personal health records and electronic record-keeping systems. Pharmaceutical companies such as Pfizer Inc., Aventis Co. and Schering-Plough Corp. offer Web-based programs with features that allow limited doctor-patient communication. Aventis's MyDocOnline lets patients schedule appointments, refill prescriptions, receive specialist referrals, view laboratory results, get answers to medical and billing questions, verify insurance eligibility and obtain general and specific health information online. Schering-Plough has similar offerings, including Myhealth.com (myhealth.com²), which links patients to the Web sites of participating health-care providers.

A handful of hospital groups have been offering patient e-mail for several years as part of electronic medical record systems. Boston's CareGroup, whose six hospitals include Beth Israel Deaconess, launched its PatientSite more than 10 years ago. Daniel Sands, a CareGroup physician who has been a longtime advocate of doctor-patient e-mail, says PatientSite now has 100 doctors and 5,500 patients using the secure, password-protected site. In April a redesigned version will make it easier for patients to control how their e-mail inbox is set up, will let patients create folders to store messages and lab data, and will let patients know that e-mail has been forwarded to other staffers if the doctor is out, Dr. Sands says.

San Francisco-based Medem Inc., a for-profit joint venture of the top nonprofit medical societies such as the American Medical Association and the American Academy of Pediatrics, has 80,000 doctors in its network, for whom it customizes Web sites, including secure, password-protected messaging systems. It also provides doctors with online access to the medical journals of its 45 member medical societies. Medem soon will roll out a trademarked Online Consultation service that will allow its doctors to advise their existing patients online and bill them via credit card. About 1,000 of Medem's doctors have been participating in a pilot program, and Alliance's Dr. Naughton says his group plans to test the service later this year.

Still, not all of Medem's members are taking advantage of the opportunity to connect with patients. In a recent survey of its users, Medem found the majority of physicians use e-mail on a daily basis, but about half of those who are sending e-mails from their offices are primarily sending "professional" e-mail to colleagues. Fewer than 10% of physicians use e-mail to communicate with their patients on a daily or weekly basis, and six in 10 said they "never" e-mail their patients.

Indeed, even though using e-mail could theoretically save doctors from having to see patients for routine questions and follow-up interviews, more than half of the Medem doctors surveyed said they worry that corresponding with their patients via e-mail will dramatically increase their workload without additional compensation. More than half also cited concerns over security and legal liability.

Edward Fotsch, Medem chief executive, says that nearly 90% of the doctors in his company's survey said they were interested in getting paid for online consultations, assuming the service was secure, covered by their malpractice carrier and billable to patients via credit card like other e-commerce. Jupiter Media Metrix, a New York research firm, says 40% of doctors it surveyed expressed interest in communicating via e-mail with patients, with 14% expressing "high interest." But Jupiter also found that doctors might fear "becoming nonreimbursed slaves to their electronic inbox."

Patients seem to want some form of online communication as well. A recent Jupiter consumer survey found that 54% of respondents would be willing to switch to a doctor who lets them use e-mail for scheduling appointments and renewing prescriptions, as well as asking treatment questions and checking lab results.

Dr. Fotsch maintains that online communication between doctor and patient enhances the doctor-patient relationship but will never replace it. A woman who is weighing hormone-replacement therapy after menopause, for example, would benefit after a visit with her doctor from a follow-up e-mail reviewing the pros and cons, perhaps with a Web link to more information. "She can go back, reread what the doctor said, and sit down with her husband and family and talk about it," Dr. Fotsch says.

Doctors, meanwhile, could spend an afternoon a week replying to e-mails "and do what they are paid to do -- think and then advise patients," he adds. "This isn't a vision of changing medicine -- it simply ushers in the option for physicians to dispense information in other than face-to-face visits."

Medem has led some efforts to hammer out guidelines to assuage doctors' fears about e-mail consultations with patients. In October 2000, Medem's medical-society members and a group of more than 30 malpractice carriers representing over 70% of the nation's insured physicians convened an "eRisk Working Group for Healthcare" conference.

High on the agenda: making sure the communications are secure. Many doctors feel standard e-mails can too easily be intercepted, forwarded to others or even sent to the wrong patient. The answer, according to eRisk -- and other health-care experts -- is to use more-secure online messaging services, like Medem's, that offer patients and doctors alike more security and confidentiality.

The eRisk group also warns that e-mail consultations should take place "only within the context of a previously established doctor-patient relationship that includes a face-to-face encounter when clinically appropriate." That guideline is particularly relevant after some doctors connected to an online pharmacy got in hot water with state medical boards for writing Cipro prescriptions to patients they didn't know during the recent anthrax scare.

The eRisk group also created guidelines for how doctors can be reimbursed for online consultations, noting that doctors should clearly inform patients what fees might be charged for an online consultation, and warn them that the charges may not be covered by their health insurance. If the patient doesn't choose to participate in fee-based consultation, the patient should be encouraged to contact the provider's office by phone or other means, the guidelines add.

Online consultations should generally be "substantive and clinical in nature and be specific to the patient's personal health status," the guidelines say, and there shouldn't be any charges for online administrative or routine communications such as appointment scheduling and prescription-refill requests. Doctors should also consider not charging for follow-up questions on the same subject as the original online consultation, according to the guidelines.

Some doctors couldn't charge for such communication even if they wanted to. Some health-maintenance organizations have capitation agreements, which pay a fixed fee for each patient treated regardless of the cost of care. But more health plans are considering reimbursing physicians for e-mail consultations with patients, and there are a number of pilot programs to test the idea.

Last year, Blue Shield of California offered doctors in its network a secure e-mail system designed by Healinx Corp. of Alameda, Calif. Doctors get a $20 fee for e-mail consultations that require medical evaluations and judgments. The University of California at Berkeley is conducting a study to determine how patients use the system and their satisfaction with it. Medem's new online consultation service for the doctors in its Web service this year will include a standardized method for determining fees. But the $20 in the Blue Shield program may not wash with everyone; doctors in Deloitte's survey said they believe a 15-minute e-mail consultation is worth $57.

The eRisk group also recommends that any records from the online consultation have to be included in the patient's medical record. Ms. Spielberg of Harvard notes that traditionally any document about a health-care interaction becomes a part of a patient's permanent medical record, such as summary notes doctors and their staff make about office visits and phone conversations. But a patient's own words rarely appear in that medical record -- only the doctor's version of what the patient said. E-mail thus would provide the first "running log of patient-physician communication" and the patient's own words.

"These very interactions themselves will be recorded verbatim, serving as a transcript of the encounter," Ms. Spielberg notes. That could help both patient and doctor go back and recall what was said, but e-mails would have to be properly stored and archived, and protected from access by outsiders. Technically, they could also be subject to discovery in a potential legal proceeding, she says.

Michael G. Lloyd, senior risk-management consultant at Seattle-based Physicians Insurance, says the notion that doctors don't use e-mail because of liability issues is "largely a specious argument." Though there may be some liability and confidentiality issues specific to e-mail, in general, he says, they are the same issues associated with any form of clinical communication, such as phone calls.

Mr. Lloyd says his company, a nonprofit medical-malpractice insurance company that provides coverage for physicians, dentists and hospitals throughout the Pacific Northwest, sees "many more malpractice claims associated with the delivery of health care via phone, yet no one is arguing that physicians should not use the phone, or only speak via encrypted phone lines." He says he tells doctors who are considering the use of e-mail that they should take reasonable measures to protect privacy and confidentiality, and make sure that e-mail is documented in the patient's chart when appropriate.

In Mr. Lloyd's view, the main barriers to widespread use of clinical e-mail are ease of use, time constraints and lack of reimbursement. Doctors tend to use e-mail more if they are in practices "where the amount of time spent providing medical services and practice income are not strongly correlated," he says. Mr. Lloyd predicts that if insurers started to pay physicians $20 per clinical e-mail, "the use of e-mail would skyrocket."

In a large group practice, which might be connected to several managed-care plans, e-mail could be used as a form of "triage," says Ms. Spielberg of Harvard -- to filter patient problems and help determine how physicians could best schedule their time. The practice's e-mail could be answered either by a nurse practitioner or a covering physician who rotates taking "e-mail duty," much like current on-call coverage arrangements, she adds. As for doctors who open themselves up to personal messages and compose their own responses, they "might ultimately create an environment in which their patients are actually more comfortable with the current trend of shorter visits if they know they can interact with their doctor even after the visit."

In Practice

For all the questions that remain to be resolved, some doctors are making online communication with patients a part of their practice -- and finding their own way through the thorny issues of privacy and billing.

Judy Mates, a San Francisco obstetrics and gynecology specialist, set up her own Web site via Medem about two years ago. Typically, she says, a patient will contact her to follow up after an exam, and she seldom gives advice to patients she has never seen. But once a patient sent her an e-mail asking for a change in her prescription because the phones were busy; Dr. Mates checked her chart and changed it as soon as she saw the message, "which was sooner than if she had left me a message on my voice mail."

Dr. Mates says that she cautions her patients that "sending an e-mail message to me is like sending me a postcard: The message may be read by many people along the way... so be cautious." She has secure messaging, but says many of her patients opt not to use it because e-mail is simpler.

Dr. Mates says she doesn't charge her patients for e-mail or for accessing health information on her Web site. "As long as the information is valid, I hope there is no malpractice problem," she says. "I am happy that they can get the information I would like them to have so readily. I hope they appreciate the fact that they have another avenue of access to their doctor, too."

Another gynecologist, Joe Heyman, recently set up a private practice in Amesbury, Mass., after splitting off from a larger group. Using the Medem network, he set up a Web site and a billing system, and communicates frequently with patients via the secure messaging feature.

Dr. Heyman provides a chatty, direct primer for patients who log onto his Web site, assuring them that they can log on without sacrificing their privacy, and that "messages to and from me are encrypted so that they can be read on this site only."

The site also notifies patients that any message having to do with a medical condition "will probably be saved in your medical record," warns them not to leave messages about conditions that need immediate attention, and provides a phone number for emergencies. "If I have never physically seen you as a patient, we do not have a legal relationship," the site says. "My advice and opinions online must be taken in that context. There is more to helping patients than can be gathered through e-mail. I must reserve the right to refuse online communications with any patient who ignores these policies or uses this communication in a way that I believe is not conducive to good care or is irresponsible. I may not be able to give a medical opinion when communication is electronic instead of hands-on."

At age 60, Dr. Heyman says, using the Web to communicate with patients makes him feel on the cusp of new technology. Moreover, with only himself and one medical assistant in his practice, he says he must be the "lowest-overhead, highest-tech doctor in Massachusetts."

-- Ms. Landro is an assistant managing editor of The Wall Street Journal in New York.

Write to Laura Landro at  laura.landro@wsj.com ⁴

Updated February 11, 2002 11:59 p.m. EST

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