Earlier this year, the popular social network Facebook introduced a new initiative designed to help corporations advertise to its users. 

allowed members to “share information [about their actions on]... other websites for distribution to their friends.” Facebook allowed advertisers to select the type of content that would be shared via the social network, including purchase information.

Facebook promised its users they would be able to “decide whether to distribute specific actions from participating sites with their friends.” Unfortunately, reality did not match Facebook’s promises. A few weeks after Beacon launched, influential Forrester analyst and blogger Charlene Li wrote a post, “

,” in which she related her disturbing experience with the new advertising service. She said: Earlier this week, I bought a coffee table on 

. When I next logged into Facebook... [I] saw [information about my purchase on my newsfeed]. I was pretty surprised to see this, because I received no notification while I was on Overstock.com that they had the Facebook Beacon installed on the site. If they had, I would have turned it off.

I used my personal e-mail address to buy the coffee table, so I was puzzled why and how this ‘personal’ activity was being associated with my ‘public’ Facebook profile. Li went on to note that her biggest problem with Facebook Beacon was that she didn’t have control over the information that would be shared with her network. She said “I need to be in control and not get blindsided... I was seriously wigged out, but wouldn’t have been if Overstock had simply told me that they were inserting a Facebook Beacon and given me the opportunity at that time to opt-in to Beacon.”

Although purchasing a coffee table is an innocent activity, in a healthcare context, the situation could potentially carry serious repercussions. For example, what if a Facebook member with bipolar disorder purchases a book about this condition on Amazon.com? Here’s the catch: no one in their immediate network knows that they have this condition and the user does not want to share this information. All of a sudden, because of Beacon, everyone knows. This potentially serious privacy breach could have serious personal and professional repercussions.

Facebook Quenches Beacon Firestorm, but Privacy Concerns Remain

After weeks of user protest and negative press, 

. The company promised that “users will have clear options... to either delete or publish [information about their purchases].” Facebook’s move is welcome; however, the Beacon flap indicates that user privacy can sometimes take a back seat when Web 2.0 companies are racing to maximize their advertising revenue. This should be a major concern for healthcare social media advocates. Many companies are taking privacy concerns very seriously; however, there is a real possibility a company will someday inadvertently release or share private medical information. After all, it has happened before.

In 2002, Eli Lilly and Company agreed to settle Federal Trade Commission (FTC) charges that it had failed to protect information patients submitted on its Prozac.com website. According to the FTC, “A Lilly employee created a new computer program to access Medi-messenger subscribers’ e-mail addresses and sent them an e-mail message announcing the termination of the Medi-messenger service. The 

 included all of the recipients’ e-mail addresses within the ‘To:’ line of the message, thereby unintentionally disclosing to each individual subscriber the e-mail addresses of all 669 Medi-messenger subscribers.” The FTC argued that Lilly violated its own privacy policies and failed to take appropriate steps to protect users’ sensitive information.

Another concern is that many Internet users are not worried that their personal information is floating around in cyberspace. According to a report released in December 2007 by the Pew Internet & American Life Project, 60% of Internet users are “unconcerned about the extent of data available about them online.” However, there are signs this blasé attitude may be partly fueled by ignorance. Privacy advocates say that information Internet users do not believe is online (such as their e-mail addresses, phone numbers, and names of employers) can be found via a simple search engine query.

As social media applications become more ubiquitous and powerful, it is very likely that Americans will continue to use them for health-related purposes. However, a major privacy breach could significantly set back efforts to empower patients, providers, and others using Web 2.0 technologies.

Fard Johnmar is the founder of Envision Solutions, LLC, a full-service healthcare marketing communications consulting firm. Visit 

 to learn more about the company and the services it offers.

Articles

Feature Articles

Earlier this year, the popular social network Facebook introduced a new initiative designed to help corporations advertise to its users.

Social Media Notebook: Will Privacy Be the Achilles' Heel of the Healthcare Social Media Revolution?

Pay-for-performance programs, in which providers are reimbursed at a higher rate if they can demonstrate that they deliver high-quality services, are being introduced in most states as part of an aggressive attempt at controlling healthcare costs without adversely affecting the quality of care. Indeed, many of these programs promise better quality as a result of being able to measure key indicators that are thought to drive clinical outcomes, as well as patients’ perception of the level of care.

At issue, however, is whether these programs can be effectively put in place ahead of the installation of complete electronic health records (EHRs). Many in the industry argue that, without an EHR, it will be impossible to establish controlled processes for the measurement of these indicators in a reliable manner, such that the measurements are truly comparable across providers, because the data necessary for these calculations will only be available after the problem of EHR interoperability has been addressed. Others argue that P4P programs can be established, but they would consist of weak indicators with all the bureaucratic limitations of HEDIS-like calculations, citing similar data-availability issues.

This article will argue that a robust P4P program—with meaningful indicators and an affordable mechanism for auditing and verifying the measurements&mdash;can indeed be established in advance of universal availability of EHR technology. In fact, the greatest barriers to such a program are not rooted in the availability of data, but rather in the adoption of regional data-sharing agreements among all the industry players.

The healthcare industry, which accounts for approximately 15% of the US gross national product, is poised for a radical transformation aimed at reducing the rate of growth of its costs and at increasing the quality and reliability of its services. The industry is universally perceived to have high costs, and the traditional view that high costs correlate with high medical quality are being challenged by a crude but effective first pass at the measurement of healthcare outcomes—which suggests otherwise. Driving this transformation is the work of a coalition of large payers (including the employers and the government), insurers, and providers, and its primary vehicle will be an overhauled payment system for healthcare services.

In order to complete the transformation, the industry must be able to measure the “value” and the cost of the healthcare delivered. These measures must be objectively derived from information in the medical record, and must be comparable across providers. The cost of obtaining the information used in the measures would, ideally, not significantly exceed the costs already incurred in documentation of the medical record, or else the measurement process will itself make

We will start our argument by debunking the idea that the EHR will make the task of creating a robust P4P program much easier. Everyone involved in the measurement of healthcare agrees that coordinating the efforts necessary to create such a program is a difficult task. But how would an EHR simplify this?

Claim #1: EHRs make available all the data that is needed to calculate the P4P measures.

This is patently untrue. Most of the data elements necessary to calculate clinical P4P measures are already available in other electronic systems that are much more common than EHRs. Lab values are available from lab systems and lab vendors. Demographics, procedures, and diagnoses are available from billing and registration systems. Pharmacy data is available within the dispensing industry and from the payers (insurance companies and the government).

Visit-utilization information is available from scheduling and billing systems. While the EHR contains additional clinical information, much of it is in text form (progress notes, for example) and is not readily of use in refining a P4P program.

Claim #2: EHRs will make the data available from a single source

, rather than from disparate systems, therefore making the task easier because all the data for a single individual is tied together under a single ID, whereas separate systems might not share the same identifier for a unique patient. At first glance, this seems to make sense—after all, no one wants to manage the difficult task of matching a lab value to a patient record without an identifier. However, let us remember how the data in the EHR was brought together under a single identifier to begin with: by tackling the difficult question of providing a unique ID to each patient and requiring your lab vendor, for example, to include that identifier in the HL7 transaction that brings back the result. Therefore, an EHR is not necessary in order to ensure a common identifier across data systems of the same provider organization. By contrast, external data that does not carry the unique identifier of a provider organization is equally difficult to integrate, whether one is working with an EHR system or with separate systems. In other words, the industry must solve this problem whether or not we fi rst install EHRs everywhere. Master Patient Index functionality is available in most commercial registration systems, and can also be utilized at the level of Regional Health Information Organizations (RHIOs) in order to overcome this problem.

Claim #3: EHRs contain additional clinical information

 that allows the calculation of measures that are more accurate than those calculated using only “administrative” data. For example, EHRs contain “problem lists” populated by the physicians, which may be a more accurate way of identifying a diabetic than by using the ICD9 diagnosis code in an encounter, which may actually be indicating a “rule-out” of the disease. Additionally, a provider can indicate valid reasons that disqualify a patient from a particular protocol that is used in a measure (for example, allergy to a medication or a “not-medically-necessary” situation such as that of a 95-year-old diabetic with terminal cancer of whom the provider probably won’t require bi-annual glyco-hemoglobin testing).

This is the most valid claim. It appeals to our distrust of early HEDIS-type measures that inaccurately identified diabetics, or the possible individual contraindications to receiving aspirin post myocardial infarction. However, the first concern has been demonstrated to be false by the local successes involving RHIOs or other community registries that collectively pool data from multiple providers and correctly maintain accurate diabetic registries without relying on a problem list. Instead, these systems identify possible diabetics by looking at multiple possible indicators (ICD9, lab values, insulin-type medications) with greater accuracy and then making those lists available to the providers for verification—a process we at Palo Alto Medical Foundation have discovered to be much more accurate than relying on the provider to add the diagnosis to the problem list of an EHR, which shows greater variability across providers who are comfortable or facile with the complexity of a full EHR. The second concern, contraindications or allergies, is real, but hardly a reason to wait years for EHRs to be available universally rather than adding this capability to regional integrators of data.

Having asserted that the EHR does not add much that is not already available, we must propose an alternative mechanism for the support of P4P programs. This approach must maximize the use of available information and leapfrog some of the challenges presented by the lack of a universal patient identifier. It must then perform two distinctly separate but complementary tasks. First, it must gather the data from every available electronic source and perform systematic cleanup functions. Second, it must be able to calculate hundreds of clinical, operational, and financial (efficiency) indicators in a transparent and easily auditable manner. We have been using the term “tactical warehouse” to refer to such systems. Many versions of such systems have arisen from local efforts of large integrated systems, medical groups, RHIOs, or other large collaborative efforts. Although some lack flexibility or a robust architecture, others represent the birth of a new class of healthcare IT that promises to address not only P4P needs, but also the portability of essential elements of our medical records.

The Palo Alto Medical Foundation tactical data warehouse, called Solutions, consists of three engines:

 gathers data from any available source system. It contains data cleansing software that was designed based on the premise that most important measures in healthcare come from relatively few fields (see the “Pareto rule”). It uses extraction technology (not the more complicated live interface) to access data regardless of system brand. It draws data from systems including EHRs, lab systems, registration, billing, general ledger and payroll, etc. And it houses a simple Master Patient Index tool that facilitates the creation of a tree of patient identifi ers that ties a unique patient across source systems. Its output is a clean, simplified EHR-like set of tables containing the fields that are required for most P4P calculations. Lab tests and other elements have been merged such that, for example, all fasting glucose tests are identified by a single code.

applies the definition of each measure to create “metric tables,” which are refreshed weekly, monthly, or quarterly as required by each metric. In the process, this engine generates useful “value-added” tables such as disease rosters and patient activity tables that create a rich, standardized

environment ripe for the easy generation of ad hoc queries.

 catalogs the measures and makes them available to the users singly (for use in products such as dashboards and scorecards), in data series that represent the value of a metric over a period (used in run charts), or in series representing value ranges (for histograms). We maintain more than 150 metrics and their 1,100 variants in a catalog that includes clinical (eg, percent of diabetics with HgA1C <7, by provider), operational (eg, panel size or see-your-own ratios, by provider), and financial (eg, direct cost per practice RVU, by department measures, along with their “roll-ups”) to departmental, site, and organization levels.

The industry would do well to embrace local and regional efforts toward the creation of such systems by pressuring all players (providers, insurers, pharmacies, lab vendors, etc) to enter into HIPAA-compliant data-sharing agreements that would feed these clearinghouse and data aggregation services. Agencies such as AHRQ, NQF, and others, backed by HRSA and CMS, should initiate aggressive certification services that would enable successful tactical warehouse efforts to offer these calculation services, along with data portability services, with a stamp that guarantees that the calculations conform to registered measure defi nition standards.

If we follow that path, we will enable robust P4P programs which, if aggressively funded to motivate change, just might prevent an explosion of costs that are looming once the “Baby Boom” generation hits the Medicare rolls. And by bypassing the EHR, we will get there five years sooner.

Tomas Moran, MS, is Senior Director of Quality and Planning for the Palo Alto Medical Foundation for Health Care, Research and Education, a not-for-profit pioneer in both multispecialty group practice of medicine and outpatient medicine. The foundation is an affiliate of Sutter Health. To learn more about the organization, visit their website at 

Pay-for-performance programs, in which providers are reimbursed at a higher rate if they can demonstrate that they deliver high-quality services, are being introduced in...

Is P4P Possible Without an EHR?

Life insurance can be a key element of an effective estate tax strategy. However, when devising estate plans with clients we often find their current policies accomplish little or nothing in terms of future tax savings. It is not uncommon to find that the actual benefi ts provided by their policies are not at all what the clients thought. Often, people do not review their policies until it’s too late, only to find they may have misunderstood the terms or that their insurance agent may have misrepresented or poorly communicated essential features.

Recently, I was working with a client to develop a strategy to minimize his estate tax liability and preserve his business and savings for his children. We estimated that the total estate would likely grow to $10 million over the next 15 years. He planned to partially cover the potential estate taxes of $4 million with a $2 million “term” life insurance policy he had bought years earlier. These popular policies are intended to pay at face value if the policyholder dies within the period of coverage. Premiums can be fixed for 10-20 years and sometimes can be renewed, with new premiums set by the company at that time. For example, a 20-year policy for $2 million might cost $10,000 per year at age 45. Depending on the policy, you may have the right to renew for another 10 or 15 years, but the premium will be reset by the insurer based on your new age. At 65 or 70, the annual premium might increase to several hundred thousand dollars per year.

Term policies have an important and specific purpose: to replace lost income from a premature death. If you should die before your anticipated retirement date, how much insurance would be necessary to replace for your spouse and children all or a portion of your lost income? If the answer is “a lot,” you are probably a good candidate for term insurance—it’s the best solution because it offers the most insurance for relatively low premiums.

What you probably won’t get from term insurance is any actual money paid out. Remember, these are low-cost policies until you get older, at which point the premiums often skyrocket. Hardly anybody renews or keeps them in force for the rest of their life. It’s too expensive to maintain a term policy as you reach age 65 and older. Term insurance effectively covers the risk of lost income for a set number of years, but it doesn’t build wealth for the future. When we looked closely at my client’s policy, we discovered that it had fixed premiums until age 70, at which point he could renew, but the increased annual premiums would make the policy effectively unaffordable. We could see that unless he died before age 70, there wasn’t going to be any insurance to accomplish his goals. That was certainly not what he intended or understood when he bought the policy. He knew that his business would increase in value and he needed a source of funds to pay estate taxes without selling the business, so he had purchased the policy the agent recommended and didn’t look too closely at the details.

Life insurance can be a key element of an effective estate tax strategy. However, when devising estate plans with clients we often find their current policies accomplish little or nothing in terms of future tax savings. It is not uncommon to find that the actual benefits provided by their policies are not at all what the clients thought. Often, people do not review their policies until it’s too late, only to find they may have misunderstood the terms or that their insurance agent may have misrepresented or poorly communicated essential features.

Because your current term policy probably will be insufficient if you anticipate paying sizeable estate taxes or you want to leave money to your family, you’ll need a “permanent” life insurance policy that lasts for your lifetime. There are many varieties of these policies, but they are often described as “Whole Life” or “Universal Life.” In addition to paying the specified death benefit, these policies also work like savings accounts, building cash value that you can borrow against or redeem. They also get a big tax break because the earnings on the savings are not subject to income tax at any time.

Term policies and permanent policies meet important but different financial needs. Term life insurance efficiently and inexpensively protects against the risk of lost income for a specific number of years. Permanent policies are designed to last for a lifetime; they effectively guarantee that a specified amount of wealth is accumulated for whatever family, charitable, or estate tax needs you might consider. The caveat is that there are huge differences in benefits and costs among all of the available plans. We will cover some of these differences and dangers in future columns but for now, as always, we advise you to talk to your knowledgeable advisors about the real benefits and costs of any insurance plan you are considering.

Robert J. Mintz, JD, is an attorney and the author of the book Asset Protection for Physicians and High-Risk Business Owners. To receive a complimentary copy of the book, call 800-223-4291 or visit 

Life insurance can be a key element of an effective estate tax strategy. However, when devising estate plans with clients we often find their current policies accomplish little or nothing in terms...

Covering Your Assets: When Is it Too Late for Asset Protection?

In case you hadn’t noticed, CompUSA, the largest computer specialty retailer in the country, closed more than half of its domestic stores back in February. I wasn’t that surprised, given how empty my local CompUSA always seems to be, how they never seem to have the computer I want in stock, and how the salespeople push extended warranties (on which they make commission). In fact, I would say that nearly all brick-and-mortar computer retailers fail at providing that truly excellent customer experience for which we always hope, but which is oh-so-elusive. For me, the ultimate customer experience is to walk into a clean, large, well-lighted store with lots of hardware and software on display and in stock; speak to someone knowledgeable; and then walk out the door with my new purchase. Unfortunately, I have rarely had that experience and you probably haven’t, either.

Mom-and-pop computer shops are great if you want a custom-built computer. But they tend to have quirky store hours (and occasionally quirky staff ), and you may have to wait a week or two to take delivery of your (often non-brand-name) computer. These stores also tend to be limited in their display items and available stock of merchandise.

At the other end of the spectrum are the big-box electronics stores (like Best Buy and Circuit City), which have taken over as the principal merchants of computers in malls and stand-alone stores across America. Because they tend to have large product demonstration and display areas, they are ideal for browsing computer equipment. However, there are several factors that often detract from the overall shopping experience at these stores.

- You can often save 10% or more off the brick-and-mortar store price by shopping online, assuming you know exactly what you want—just type the product name into a shopping-specific search engine like 

. Always do your homework and ensure the merchant you are buying from has a good customer satisfaction rating.

 - Let’s face it, your average salesperson doesn’t know much about computers. Even worse are the salespeople who think they do, but provide only incorrect information. It’s hard to be confident about your purchase when you realize you know more about the product than the person from whom you are about to buy it.

 - Is there anything worse than really wanting something, driving 20 minutes to the store, spending another 10 minutes waiting for someone to help you, only to find out that the item is out of stock?

 - One of the biggest scams in retail. In November 2006, Consumer Reports launched a public awareness campaign to educate shoppers about the often misleading information surrounding extended warranties. According to this trusted watchdog, stores are pushing extended warranties like never before because they are revenue drivers. But the dirty little secret retailers don’t want you to know is that most products don’t break down often enough to make warranties worthwhile. When repairs are necessary, they are usually affordable, and, in many cases, cost less than the warranty. Besides, many electronics retailers don’t even provide technical service or support themselves—they just ship the goods back to the manufacturer.

I still visit the big-name computer stores, but only to play with products in their demonstration areas and figure out what I really want. Then I go home and order it online. This not only saves me money, it also lets me avoid the dreaded extended warranty sales pitch.

Apple Stores are the exception to the rule, a model for what the computer retail experience should be for everyone. Although they also try to push extended warranties, unlike other tech stores, the Apple “genius” staff is usually quite knowledgeable, and the range of products on display and in stock is often impressive.

Dr. Bertman is Physician Editor-in-Chief of 

. He is also a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of Electronic Health Record (EHR) software. He also is the founder and president of 

, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI

In case you hadn't noticed, CompUSA, the largest computer specialty retailer in the country, closed more than half of its domestic stores back in February. I wasn't that surprised, given how empty...

Tech Talk: Thinking Outside the (Big) Box When Buying a Computer

1) Perform Billing and Coding Electronically

The introduction of information technology into the healthcare field has resulted in reduced costs associated with business-to-business communications, most notably in the “accounts payable” and “accounts receivable” departments, which are accustomed to labor- and paper-intensive processes that can be eliminated by using electronic systems. The potential to free up office space and allow the staff to focus more of their time on patient care is another reason why no office should manually perform these tasks. Plus, office expenses such as payroll, employee benefits, paid vacations, and sick time can all be significantly decreased by computerizing administrative processes.

In order to keep your practice running efficiently, you’ve got to make sure that the absence of one or two staff members does not cause a major interruption in productivity. It’s important for members of your staff to be able to multitask and be prepared to perform additional duties other than their primary tasks. This is beneficial in several ways: you always have the necessary skill-set in the office; staff members understand their importance to the team and the entire workflow process; they can see how their position and contributions affect others in the office; and you can reallocate resources to necessary areas of the practice as workload needs change.

The first thing that should be done when it comes to telephone billing within your office is to identify what business plan is most suitable for your needs. There are so many companies and plans out there that chances are you can find a way to decrease costs in this area. Incremental billing should be examined; some companies will charge for a full minute on a call that may last only 10 seconds. However, many carriers off er six-second incremental billing, which can save up to 10% on your long-distance calling. Another thing to consider is setting up a toll-free 800 number for customer service or if you need to tie multiple locations together seamlessly. An 800 number is an effective way to route all calls from one source as opposed to providing several phone numbers to patients.

Advanced Benefi ciary Notifi cations (ABNs), which have been part of the Medicare program for many years, are intended to provide the beneficiary with sufficient information to make an informed consumer decision as to whether or not to proceed with a service knowing that payment may not be covered by Medicare. ABNs are an easy way to ensure that you are properly compensated for your services, and failing to adhere to them could ultimately result in the loss of revenue for your practice. If you fail to provide an ABN prior to rendering a service, you will be unable to bill the Medicare beneficiary. Make sure to take this precautionary step, and you will avoid unnecessary pitfalls.

Keeping tabs on your explanation of benefits is extremely important to improving your practice’s billing and collection processes. Take the time to review them on a regular basis, looking for things like timeliness of payments, the accuracy of payments (do this by comparing contracted rates to amount reimbursed), and amounts paid in full, indicating that your practice charges are too low. Catching even small errors or discrepancies could end up saving you a bundle in the long run.

6) Take Advantage of Automatic Remittance Posting

Although having your remittance payments posted automatically is an additional cost you will have to incur, the benefits will outweigh this cost, as it will save your employees a great deal of time and will consequently increase staff productivity—no more paper handling, filing, copying, adjusting data entry errors, or additional processing costs. Staff time saved by automatically posting remittance payments can then be spent following up with payers, filing appeals, or whatever other tasks

It is important for any practice to communicate billing procedures to its patients. This includes time-of-service payments, authorizations, cancellation policies, and any other routine collection policies. Finalize your policies, print them all on a one-page document, and ask your patients to read and sign it. Taking these steps to inform your patients of what to expect in terms of compensation will help ensure there are no issues when it comes to payment.

8) Collect Co-payments and Coinsurance at Time of Service

Do not underestimate the value of this step. Collecting these fees at the time of service will save your practice the cost associated with billing the patient and the time it takes to send and collect the paperwork involved. Th e fact of the matter is that the likelihood of collecting fees from a patient is reduced the second the patient exits the office without paying. This is a simple step that should be acceptable for everyone; therefore, there is no reason not to follow this policy.

Every practice receives calls pertaining to patients’ statements and number of payments that have been received; cut down on these phone calls by providing easy-to-read patient statements on a regular basis. This will not only reduce the time it takes to receive appropriate payment, but will also allow your staff to operate more efficiently by cutting down the time it takes to field so many phone calls.

Dig up all those old invoices pertaining to your office supplies and try to highlight the office supplies that make up 75% of your total costs. Focus on the top 25%, as those are the items you will always need to have on hand. Once you’ve established this, contact three vendors, explain to them that you are shopping for an affordable way to purchase whatever items you need, and then get bids on them. Compare the prices you were given to online and mail-order companies, and see where you can get the best deal. If you do decide to go with an online or mail-order company, be sure to check for important details like minimum order requirements, freight charges, and return freight charges in the event supplies need to be returned. Although this task will require some due diligence on your part, it is a one-time procedure that can significantly reduce expenditures in the long term. Many thanks to 

Looking to improve your bottom line? Of course you are. Who isn't? The introduction of information technology into the healthcare field has resulted in... 

10 Ways to Enhance Revenue

The advent of the Internet and greater adoption of information technology (IT) have created 

. Although many physicians still “don’t necessarily see the value of IT”, the days of paper records and communicating with patients by telephone may soon be numbered as practices replace those technologies with electronic medical records (EMRs) and e-mail.

Communication is the foundation of the physician—patient relationship. Because the majority of communication between the physician and patient is synchronous—speaking one-on-one in the office or on the telephone&mdash;it can be frustrating for both parties when this process is disrupted by time constraints, playing “phone tag,” missed appointments, and other interference. One solution to this would be to make greater use of e-mail, an asynchronous mode of communication that many of us already rely heavily on to interact with friends, colleagues, and business associates. According to an executive summary published by the 

 to enhance communications, streamline office processes, improve documentation, and save money in the form of decreased office visits.”

We briefly discussed the use of e-mail as a tool to connect physicians and patients in the cover story of the 

, outlining how it can (and will) change the physician—patient relationship. In this article, we will investigate this topic further, with special emphasis on reimbursement challenges and secure messaging services.

If physicians have access to e-mail, and patients have access to e-mail, why wouldn’t e-mail communication between the two work? The 

 defines physician—patient e-mailing as “computer-based communication between physicians and patients within a professional relationship, in which the physician has taken on an explicit measure of responsibility for the patient’s care.” Although public opinion polls consistently show that an overwhelming number of patients (74% per a 2006 Harris Interactive poll) want to communicate with their physicians via e-mail, the numbers haven’t yet influenced physicians (25% per a 2006 Manhattan Research survey) to satisfy consumer demand. The number one reason for physicians’ reticence when it comes to e-mail is inadequate reimbursement, followed closely by concerns over time commitment, liability, and confidentiality.

Although e-mail can assist with establishing 

 between physicians and patients by allowing for “follow-up patient care and clarification of advice provided in a professional office setting,” many physicians are concerned that making greater use of this technology to communicate with patients will decrease practice revenue because it takes away precious time that could be better spent conducting office-based consults. According to Edward Fotsch, MD, CEO of 

, “The biggest challenge is that physicians are as busy as can be, practices are stretched thin, and payments are [decreasing], so they have to do more work in less time.” This is where the e-mail reimbursement challenge comes into focus.

Many physicians feel that if they take the time to answer patients’ e-mails, they should receive some sort of payment, be it from insurance companies or the patients themselves. Although some private and public payers offer financial compensation to physicians for e-mail communications, many are doing so only through small-scale pilot programs. Most payers have so far elected not to reimburse providers for e-mail communications with patients. “The good news is that payers in both the public and the private arenas are really beginning to open up to the idea of reimbursing physicians, or at least not penalizing them,” says Bill Crounse, MD, Director of 

Worldwide Health for Microsoft Corporation

. “Many payer organizations that have contract language forbidding physicians from charging patients for e-mail have loosened up the language.”

editorial board member Daniel Sands, MD, MPH, Senior Medical Informatics Director for Internet Business Solutions at Cisco Systems, and co-author of the “

Guidelines for the Clinical Use of Electronic Mail With Patients

,” says, “I think physicians need to determine whether this is something worth charging their patients for, because, in reality, the volume of messages is really quite small, and the amount of time it takes to respond to these messages doesn’t take very long.” In fact, 

Kaiser Permanente’s KP HealthConnect study

 found that many physicians overestimate the number of patient e-mails they would receive on a daily basis. “Each doctor averaged about two messages per day,” said study co-author 

. So, it may be worth forgoing concerns about compensation and seeking comfort in the realization that online communication allows for a more efficient physician—patient relationship with increased opportunity for communication.

As with all information passed via the Internet, data security and confidentiality is a major stumbling block with physician—patient e-mail. However, within the last 10 years, companies such as Medem and 

 have developed online services that enable physicians and patients to send messages securely. In fact, 

 “allow physicians to bill patients for e-mail exchanges, taking a small fee for enabling the transaction via a credit card. Most doctors who do this charge $25 to $30 per online consultation.” We spoke to Dr. Fotsch to learn more about Medem’s online portal, 

, “the first and only suite of fully integrated Web-based

physician-patient communication services that are proven to effectively engage patients in better managing their health.”

According to Fotsch, Medem’s relationship with the AMA and other medical societies has “increased physician awareness” of iHealth Services, several EMR vendors and health plans have integrated their systems into the service, and Medem’s collaboration with Microsoft and several Internet search engines has increased traffic on physician websites that were set up with iHealth Services.

Dr. Crounse also expressed his opinion about online messaging services, explaining that although using secure, online portals may be beneficial, “a lot of the secure e-mail services, quite frankly, tend to be still a little cumbersome, and I think, too costly to be widely deployed in healthcare. The good news is that with every passing year, I’m seeing improved security and options… in e-mail and messaging. 

The advent of the Internet and greater adoption of information technology (IT) have created many changes in the healthcare industry.

Show Me the Money! Patient-Physician E-mail

Rombach says the combination allows for better patient care and brings coding in line with the work physicians actually perform, so there’s no more guessing when it comes to coding. “We’re getting paid for what we actually do,” she says. It was hard with the old system to make sure the practice filled out all fields of the complicated HCFA-1500 claim form because there were so many disparate identifiers for patients, providers, and health plans. “Trying to make sure you had a clean claim, that was really a problem,” Rombach says. With an integrated practice management and EHR system, “You can basically see how the claim is going to be captured,” according to Rombach.

Girish Kumar Navani, president of Westborough, MA, vendor 

 says that integration is an issue of managing one system versus having to manage two. “You save money on maintenance,” he says. “That’s the obvious one.” For a three-physician practice, eClinicalWorks charges about $3,000 more to get the entire system as opposed to just the EHR, a relatively small sum considering that an EHR alone could run $30,000 or more per physician depending on the features and services purchased.

Although the real advantages to an integrated system are related to workflow, there are also several less-obvious benefits, including ease of use for everyone in the office. For example, if a patient moves or changes phone numbers, updates made in the practice management system automatically are reflected in the EHR, so there’s no double data entry—and no chance of having conflicting information. At check-in, the doctor can see that the patient has arrived, as well as any new information provided by the patient. At check-out, the front desk can see, for example, that the physician wants the patient to return in two weeks, so it’s easy to schedule the follow-up visit and to remind the patient in advance of the next visit.

, a four-physician family practice in Winter Park, FL, added appointment reminders to its eClinicalWorks system in 2005, their no-show rate has dropped by 50%. Because the system automatically captures charges as the physician documents the encounter, the back office can get to work on sending out the bill right away. Insurance companies often need to see progress notes to justify charges. “You can open up the chart right when you’re on the claim and print it,” Navani says.

The integrated system definitely has improved revenue and cash flow for Family Physicians of Madison County. “My claims go out clean,” Rombach says, “and I have an exceptional A/R.” Only 29% of total accounts receivable are more than 30 days old, and of those patients with insurance, only 15% billed charges are considered past due. Some payers have timeliness-of-claim rules, essentially setting a statute of limitations on claims. If something turns up months after the fact, too bad. “They have people who get paid to throw claims in the trash,” says Rombach. “It’s important for me to know that I have a patient’s proper insurance information.”

Better systems equal better billing and better care

More significantly, thanks to their integrated system, physicians at Family Physicians of Madison County are spending more time on patient care, and the medical assistants are no longer hunting down lab results. “I need fewer staff to actually take care of the patient,” Rombach says. “It works toward well-rounded patient care.”

“Those are things that are costly to practices,” adds Jennifer Sirkawa, financial product marketing manager for 

 in Tampa, FL. The experience has been similar for Block & Nation since that practice migrated from an old practice management system and paper records three years ago to an integrated eClinicalWorks system. “Having the combination software definitely is better,” says one of the doctors, Bradley Block, MD. Previously, one staffer spent 75% of her time simply inputting data for superbills. “Vaccines and other ancillary charges were occasionally falling through the cracks,” Block reports.

A glance through a random stack of paper charts convinced Block that he and his partners were losing at least $400 per physician per month in unbilled ancillary services, which works out to $14,400 annually for the three physicians who were there prior to the EHR. Add to this fact that the part-time billing person was costing the practice close to $15,000 a year to handle mostly redundant tasks, and all of a sudden the EHR doesn’t seem so expensive. “That goes a

long way toward paying for the system,” Block says.

The doctors perform minor procedures in the office, such as skin biopsies. In looking over a paper chart that happened to be out on a desk, Block noticed that the practice never billed for a biopsy because someone pulled the abnormal result from the chart to call the patient and the record of the biopsy never made it to the superbill. By the time he discovered this, it was too late to submit a claim, so Block and his partners had to eat the cost. “Now, when I click on my EKG

or urinalysis, when I’m done with the visit, all the billing is ready,” Block says. “There’s no delay inputting the data… and we’re not losing charges.”

The office is operating much more efficiently, too. Within eight months of the eClinicalWorks installation, the practice reduced its labor costs by $5,500 a month by shrinking its front-office staff from four to three and cutting back to four medical assistants from the previous five. The biller who was wasting time on data entry was reassigned to more productive work. Multiple users can view the same information simultaneously, so the referral specialist doesn’t have to wait for the chart to be told to prepare a referral letter and make an appointment. In the first 15 months with the integrated software, Block & Nation saved $7,000 on office supplies, and the reduction in paper use also has cut copying and mailing expenses, Block reports. Records go out on CDs rather than in thick envelopes. 

Accounts receivable on insurance-paid claims older than 90 days rarely tops $1,000, since the practice doesn’t have to wait for staff to enter charges manually or hold bills until there are enough from each payer to send out “batch” claims. The old practice management software didn’t even produce HIPAA-compliant transactions, so there were additional delays and expenses to send the claims through a clearinghouse for conversion. Now, the practice collects insurance

reimbursements in half the time it previously did.

Above all, with integrated EHR systems, workflow simply is smoother, making for safer care and a better experience for patients, physicians, and staffers alike. “It’s quieter in the office,” Block reports. “Now we don’t hear ‘chart up’ every two minutes,” he says. “I can track data faster on the computer,” Block notes. “Here, on one screen, I’ve got three years worth of data.” And that record will only get richer with time. With one particular patient, he clicked on the page showing the man’s vitals and noticed that the patient’s weight had been trending up for the previous three years. That basic historical information in hand, Block started asking questions and was able to determine in a matter of minutes that the 40-something man had been suffering from erectile dysfunction.

Without easy access to historical information, it might have been impossible to get the patient to talk about such a sensitive topic in the short amount of time the doctor had with him. For patients with chronic conditions like diabetes or an enlarged prostate, being able to view trends in lab results is invaluable. Intergy, the

Sage product, includes a health management module to help the physicians with disease management, reminding doctors, for example, to schedule regular eye and foot exams for diabetics. Physicians can set the frequency of reminders based on guidelines, and the practice can document if a patient declined the test and

include a reason. Patients might skip the eye exam because their insurance excludes vision care.

Version 4 of Intergy, set for release later this winter, will improve upon this, according to Sirkawa. “Health management will be tied to practice management,”

she says. The computer will remind the front office if a patient is overdue for a check-up, physical, or test, leading to more revenue and better care without burdening the physicians.

Rombach, the Illinois practice manager, knows that time is money, and having the problem list visible to the physician right away saves both. “When the patient is in the room, those are dollars ticking away,” Rombach says.

It also is a matter of patient safety for Family Physicians of Madison County, since there is no draw station on site; patients have to go to nearby 

 and Laboratory Corporation of America facilities for most testing. Fortunately, the practice’s EHR is connected to both companies, so the lab gets the diagnosis code immediately and is ready whenever the patient arrives, and results get electronically reported back to the practice and into the patient’s record. This way, the practice knows the patient has actually gone to the lab for the test—and has the information to act upon.

Th ere are some things that are not fully electronic, however. When Block & Nation switched to the integrated system in 2004, direct ePrescribing into pharmacy information systems was not widely available in central Florida—and federal law still prohibits prescriptions for narcotics and other controlled substances without a paper trail&mdash;so the practice opted for an electronic fax system. Even that smoothed the workflow. “We used to have lines of nurses at the fax machines,”

Block says. Now, all faxes come into and go out of a computer, and the fax system is linked to the e-mail network embedded in the EHR, so it’s easy to rout messages to the proper people.

Block says he frequently sends messages to nurses to request patient-specific information such as test results from local hospitals. “A couple of minutes later, I get a knock on my door to know the report is in,” he says. Sometimes there is no knock on the door, because the system includes a virtual private network (VPN) for secure, remote access. “I can do work from home if I want to,” Block says. He no longer stays at the office until 9:30pm some nights to go over paper files, and he can pull up patient information from his home computer when he’s on call at 

This winter, Block’s practice may add a secure portal to what right now is a rudimentary website, potentially giving patients the ability to request refills, schedule routine physicals, and view test results over the Internet. Reimbursable Web visits for existing patients may be a component of that. Block says patients also will be able to update personal information such as addresses, phone numbers, and insurance data. An add-on program called 

 from Columbia, SC-based Primetime Medical Software will give patients the option of entering medication lists, allergies, and symptoms from home rather than filling out the

dreaded clipboard each time they come to the office.

Patients benefit from the convenience factor, while office staff and clinicians can be sure they have the most current information for safety’s sake. “I get paged all day long,” Block says. He expects the portal to reduce the number of times nurses have to ask him to sign off on results before calling patients, potentially reducing overtime expenses and taking some of the stress off weary nurses. “We get better flow and better patient satisfaction.”

Neil Versel is a freelance healthcare journalist.

There are some unfortunate realities of today's healthcare system that work against providers, particularly smaller physician practices. 

January 2008