How does today’s connected, “always on” world translate to your medical practice? Should you be e-mailing your patients? Performing online consults? Telephone consults? What about telemedicine? The 

 defines telemedicine as “the use of medical information exchanged from one place to another via electronic communications to improve patients’ health status. This includes providing direct patient outreach and services and use of the Internet and other technologies for tele-consultations, patient medical education, remote patient monitoring, online medical records, specialist referrals and much more.”  

 that as many as 70% of all doctor visits are for information only or for matters that can be easily handled over the phone. Data shows that more than 36 million Americans have been treated successfully through 

telemedicine, telephone, or e-mail consultations

. In addition, there is also a growing population of patients who can’t travel to the doctor easily, compromising their health and increasing their incidence of medical complications. Therefore, physicians and patients are gradually turning to electronic communication as a supplement to traditional visits. This technological step forward raises concerns about time, cost, liability, privacy, and security, remembering that communications need to be HIPAA compliant. But what if you could set up a system in which patients could receive e-mail and telephone consultations, including diagnosis and treatment for the more minor issues that don’t require office visits? What if for chronic patients you could set up a telemedicine system with secure video visits, with the ability to take vitals, obtain pertinent history, and measure important variables? What would systems that address all these concerns look like? What, if any, are the technical, liability, and ethical issues? “There is a whole move toward consumer-oriented healthcare: Your time, your place, your way,” says Jonathan Weiner, professor of health policy, Johns Hopkins Bloomberg School of Public Health. 

Since a variety of modalities and technologies now make it possible for physicians to exchange information, from brief messages to complete patient records, with each other and with patients—including tools as simple as e-mail and as sophisticated as two-way secure video with biometric patient monitoring&mdash; many physicians are integrating them into their practice. A host of services are becoming available at various levels of service, both to physicians and directly to patients. 

Physician adoption of electronic communication, particularly with their patients, has grown slowly in recent years; an estimated 38% of physicians reported using online communication with their patients in 2008, up from 31% in 2007, and 25% in 2006, according to 

. While the telephone appears to remain the channel of choice for urgent contact, many physicians are discovering that e-mail is a more efficient means for eliminating phone tag and documenting transactions. 

So what services are available? Some physicians have begun to offer patient access via e-mail. Although convenient, e-mail correspondence does raise the concern that a physician won’t be able to respond in a timely fashion to a barrage of messages. Many physician users say this has not been the case and that the bulk of patient correspondence tends to be regarding setting appointments, refilling prescriptions, and transmitting lab results, which would probably have been more time-consuming through traditional methods.  

, the number of physicians who offer online patient consultations might increase in the wake of several developments in 2008: 

 for online evaluation and management services provided by a physician (formerly Category III CPT Code 0074T.

Large medical malpractice insurers will offer premium discounts to physicians who e-mail with patients.

Brad Rostolsky, Esq., healthcare associate, ReedSmith, LLP, Philadelphia, PA, 

 that physicians who use standard e-mail that is not encrypted should take as many practical safeguards as possible in order to minimize liability exposure. Such measures include displaying privacy and security disclaimers at the bottom of every e-mail; requesting patient permission prior to responding any further via e-mail; and limiting medical detail in the messages. It is also a good idea to password-protect e-mail access on all desktop and portable computers, including PDAs and cell phones, which could easily be lost. Consideration should also be given to secure e-mail programs or e-mail encryption programs, wrote Guadagnino. 

These are great steps for the individual physician or practice, but what if patients want access to a more sophisticated assortment of online options and not just their own personal physician, or what if someone doesn’t have their own physician? Several existing services, each fulfilling a different niche, are available. Let’s take a look at a few examples. 

 is an information-only service for patients who can sign up either individually or through their employer if the company they work for has an agreement with eDocAmerica. Once registered, users can obtain answers to their medical questions through Web-based e-mail or call a nurse hotline for a more immediate response. eDocAmerica provides boardcertified physicians who are guaranteed to respond within 24 hours, and there’s no copay for patients who have unlimited access to the service. After completing a simple, onetime registration and brief medical profile, participants submit their questions to an eDocAmerica physician using a unique, selfselected password. The process is online, simple, and secure. Because eDocAmerica is Web-based, participants can access the service anywhere, anytime, making it ideal for anyone who travels and for college students who are away from home. All of the patient’s medical information, questions, and replies remain completely private and confidential. No prescriptions or medical treatment are provided. eDocAmerica isn’t meant to replace the family doctor; it's designed to provide fast and convenient service and access to information on healthcare matters. If a patient does not have access to a computer, he or she may call a nurse hotline for information and speak with a registered nurse who will discuss the medical concern or problem, then provide a recommended course of action, which may range from home care to immediate emergency care.  

Commonly asked questions sent to eDocAmerica by participants include:  

•Do I need to see the doctor for this condition or do I have other options? 

•Where can I find additional reliable information about this issue? 

•What kinds of questions should I ask my doctor when I see him for this particular matter? 

•Can you clarify some of the information my doctor shared at my last visit? 

•What should I watch for when taking this medication? 

•What kind of doctor should I be seeing for this condition?  

In addition to the ability to ask questions to nurses, licensed psychologists, and board-certified physicians, eDocAmerica provides a BMI calculator, a searchable medical library, and a weekly health newsletter. 

 is a slightly different service in that patients can call and get a doctor on the phone immediately and, if necessary, obtain treatment for minor concerns or chronic conditions. Consult A Doctor’s mission is to “improve health and reduce health care costs by creating innovative consumer-driven healthcare solutions for employers and individuals that meet their health care needs of today and tomorrow." They “believe that physician-provided health information economically provided via telephone medical consultations and secure e-mail medical consultations is fundamental to the decline of healthcare expenses.” 

Consult A Doctor is able to reach people in rural and under-served areas, as well as those who have no health insurance and hence no personal physician. Consult A Doctor provides affordable care to individuals and is also partnered with many companies as an employee benefit to cut down on the number of missed work days for doctor visits that could be handled by telephone. Consult A Doctor provides both immediate phone and by-appointment contact with physicians, allowing for an interactive exchange that isn't possible via e-mail. If it is felt to be necessary, medication can be prescribed; however, Consult A Doctor physicians never prescribe controlled substances. This is a great service for travelers who accidentally leave their medication at home, the chronic patient who lives far from his or her doctor, or the patient with an embarrassing problem who would rather speak on the phone. 

Patients' medical records are stored online in a secure HIPAA-compliant format so that the physician has access to all medical records when speaking to the patient. Members of Consult A Doctor also have access to a personal health manager, which includes services like a complete health library, risk assessments, tools to promote healthier lifestyle, a prescription reminder, health alerts, and help with their medical records. A physical exam and lab service is also available. Consult A Doctor is an impressive service, even for those who have a personal physician. Patients may not always want to bother you with questions, especially at 2:00AM, but they can always reach a doctor at Consult A Doctor. 

 is a service that offers live video medical consultations via webcam between patients and a network of physicians who are US-trained and board-certified in many specialties, including internal medicine, family medicine, dermatology, OB/Gyn, neurology, physical medicine, GI medicine, psychiatry, and ophthalmology. The service allows patients the opportunity to interact with physicians from their home, office, hotel, or anywhere they can set up a computer. MDLiveCare is intended for those with non-urgent, healthcare-related matters. The ability to order lab tests and prescribe medications is available. The system also allows for follow-up visits and second opinions. Like the services described above, it saves the time and expense of going to the doctor’s office in person. Video sessions are recorded, allowing physicians to review patient interactions, verify medical information, and provide the basis for re-examination of diagnosis. The site stores patients’ medical records, sends prescriptions digitally to reduce errors, and coordinates lab work through Quest Diagnostics, where all results are appended to patient records. Their goal is to provide complete healthcare to a modern, mobile society, where busy lifestyles can mean that routine medical care is often delayed. Whether patients are busy, housebound, or unable to go to a medical office for any reason, they can see a doctor online, anytime, from the safety and comfort of their office or home. Televideo consultations are conducted in a private, secure, HIPAA-compliant environment, and the service supplies webcams and headsets free of charge to patients. 

 differentiates itself from the above services by providing technology and expertise in creating clinically based solutions for a wide range of patient populations and telehealth organizations. According to American Telecare’s website, recent studies show “proactive monitoring with telehealth technology serves as an extremely useful healthcare delivery tool that improves quality of care for those living with chronic diseases that require close monitoring by their health care provider.” Doctors and nurses can monitor patients who are at home on a regular basis who might not come in for scheduled visits, thereby risking deterioration leading to hospitalization. 

A two-way connection allows healthcare providers and patients to engage in live, secure audio and video encounters through which they can see and hear each other. Through regular telephone lines, the patient and provider engage in live, secure audio and video encounters through which they can see and hear each other. Through regular telephone lines, the patient and provider engage in virtual check-ups, using such medical instruments as telephonic stethoscopes, vital sign equipment, glucose meters, pulse oximeters, and digital scales. The patient goes through an automated collection of data before the doctor visit so that time spent with the doctor can be focused on the checkup. Questions asked by the computerized program are dependent on the answers to previous questions, so each interview is tailored to how the patient is doing on that particular day. The peripheral equipment connects to the patient station, and readings are downloaded to the provider’s central station, where he or she can monitor the patient’s progress, assess their condition(s), and make recommendations in the plan of care. 

The uses for the technology include monitoring patients who have chronic illness who can’t travel easily to the doctor, are on post-operation home care, have diabetes, are obstetric patients on bed rest, or are HIV patients with complicated medication regimens. Physician-to-physician consultation and physician specialist consultation to remote area clinics and offices is also possible. 

Although telemedicine offers benefits, obstacles remain that must be overcome before the technology becomes part of mainstream medicine —one being reimbursement; although Medicare and some insurance companies pay for diagnostic services like teleradiology, most do not yet pay for other consultative telemedicine services. Medical licensing is another potential problem. Because telemedicine can cross state lines, some states could require a state license for an out-of-state doctor whose use of telemedicine crosses into their jurisdiction, even if the doctor’s practice is physically located elsewhere. Medical liability is an issue as well. For example, a remote specialist who does not perform a hands-on examination could be regarded as delivering less-than-adequate care. Or if compressed digital images are not reconstructed well&mdash;causing loss of valuable diagnostic information&mdash;a doctor could possibly face a malpractice suit. These technical problems notwithstanding, telemedicine is here to stay and will only improve. If 20 years ago, someone said you could carry a wireless phone in your hand and talk to anyone in the world, you might have been a bit skeptical; but like cell phones, telemedicine will eventually be accepted too. Taking in the big picture, it is hard to dispute the time and cost savings and the health benefits to patients. 

Dr. Tice is a psychiatrist practicing holistic medicine at Arena Oncology, a private practice in New Hyde Park, NY, and an 

Articles

Feature Articles

How does today’s connected, "always on" world translate to your medical practice?

Get Connected with Online Physician Consultations

In today’s busy medical practice setting, physicians often fail to communicate everything that patients need or want to know. If verbal instructions are shared, they are readily forgotten. Patient handouts are helpful, but in a 

, 80% of physicians reported doing a “poor” or “very poor” job of distributing handouts during office visits. When patients leave the office with unanswered questions, they naturally turn to the Internet to fill the information gap. 

Google, WebMD, and other online resources off er in-depth health information about virtually every possible medical topic. But casual online searches by patients can quickly lead to misinformation, conflicting recommendations, and a general feeling of being overwhelmed. 

Patients need information from the source they trust most: their own physician. But most doctors don’t offer patient education information online. Most practice websites are focused on providing administrative information and promoting the physicians and their business. And those practices that have taken the time to publish educational content often find it difficult to maintain. 

There are several benefits to having your own patient education resource available online. In a 2007 physician survey distributed by 

48% of respondents stated that having patient education available online reduces phone calls regarding therapy. 

57% stated that offering an online educational resource saves time during patient discharge. 

67% stated that patient education improves patient satisfaction. 

The educational content you provide on your practice website should cover the conditions you treat, procedures you perform, and medications you prescribe. If you have already created patient handouts, you should make them available online. Your website can also be populated with content from third-party sources that you have evaluated and determined are balanced and reliable. These may include: 

• Government agencies (eg, NIH, CDC, NCI, etc) 

• Professional medical societies and associations (AAFP, AAP, ACC, ACAAI), many of which now offer basic information about the conditions their members treat. Some have developed more in-depth patient-resources, such as 

 from the American College of Cardiology. • Patient advocacy organizations (eg, AHA, ALA, ACS). These groups often provide practical information about insurance, employment, school, and other lifestyle issues on their sites. 

To make your patient educational offering particularly robust, you might consider licensing interactive content from a medical publisher, such as the 

, which sells online presentations and videos. 

Or you could try Vivacare, a free patient education service that enables physicians to quickly create their own Web-based patient education library that is preloaded with printable handouts and clinical images. The content can be easily customized to match your specialty and personal approach to care. Topics can be turned on or off, photos can be published, and handouts can be edited or replaced with your own. The library can be integrated into your existing website or serve as the basis of a standalone practice website. 

It benefits you and your patients if you can tell them “to learn more about your diagnosis, visit my website.” Patients and their families benefit by gaining convenient access to health information that reinforces what they learned (or should have learned) in your office. They gain a firm grasp of your qualified opinion before going to anonymous websites for second and third opinions. You can strengthen your voice amidst the online noise and have a useful tool that improves clinical care and increases patient satisfaction. 

Dr. Becker is a pediatrician and President-founder of 

, which provides medical practices with customizable Web-based patient education services.

Tech Sectors


Patients are going online for health information but would prefer to get it from you. Are you there to help them?

Provide Your Patients with an Online Resource You can Both Trust...Your Own!

When I sit with clients to prepare or review their estate planning and asset protection goals, a wide variety of questions and issues arise: What plan is most efficient? How are tax savings created? How do we protect against lawsuit and business risk? Although I have addressed many of these topics in 

, I have compiled answers to several commonly asked questions. 

If I have a will, do I also need a living trust? 

 and should accomplish a variety of objectives; primary among them is specifying who will receive your property and designating a legal guardian for your minor children, if you have any. Potential estate taxes may also be an important consideration. The current law exempts amounts up to $3.5 million in 2009 but only $1 million after 2010. Congress is likely to adopt a new and permanent exemption amount at some point, and the tax provisions of your will should be designed to minimize estate taxes until the law has been settled. 

What a will does not do for you is avoid a probate of your estate. A probate is a public, court-supervised collection of your assets, payment of taxes and other creditors, and then a distribution of the remaining amounts to your beneficiaries. In many states, this can be a time-consuming and expensive process. To avoid this, most estate planning lawyers recommend a living trust in addition to the basic will. Property that has been transferred to the living trust prior to death is not subject to the probate process and passes smoothly and efficiently to the named survivors. All the estate planning objectives of passing property, minimizing taxes, and taking care of family can be accomplished with the living trust, but the additional advantage of probate avoidance almost always makes this the preferred estate planning choice. 

Do I lose any tax benefits if I put my home in a trust? 

The popular tax benefits associated with home ownership are the mortgage interest deduction and the ability to avoid gain on home sale taxes ($250,000 for an individual and $500,000 for a married couple). Clients will often elect to transfer a home into a trust for estate planning purposes and asset protection. But, if they want to keep the tax benefits, we need to draw the trust as a grantor trust (in the form of either a revocable trust or an irrevocable trust) following rules set out in the tax code in order to avoid unintended tax consequences. 

Are retirement plans valuable for asset protection? 

Qualified retirement plans (usually defined benefit plans and 401ks with a non-owner employee) have unlimited protection from most lawsuits and creditors, regardless of the amount. Non-qualified plans like IRAs are protected under many state laws for “reasonable retirements needs” and in bankruptcy for up to $1 million in contributions. Also, all distributions taken from these plans are entitled to the same asset protection rules. However, although a retirement plan is a good overall strategy, you should consider the possible tax consequences before stuffing all of your spare savings into a retirement plan. All distributions from a retirement plan are taxed at ordinary income tax rates, currently as high as 36%. The favorable tax treatment of capital gains and dividends (subject to a maximum 15% tax) is lost when distributed from a retirement plan. Weigh the benefits of the current deduction and deferral against the potentially greater tax rates on distribution when considering any program of retirement plan contributions. 

If the total value of your estate, including life insurance policy proceeds, exceeds the estate tax exemption, then the balance is taxed at the applicable rate. With tax rates that may be as high as 55% in 2011, a $1 million policy may only net $450,000 for your beneficiaries. To avoid this, a life insurance policy can be held in an irrevocable life insurance trust (ILIT), which can be drawn to own the policy, remove it from your estate, and provide a large, non-taxed fund for your survivors. With an ILIT, your ability to access and manage the policy is substantially restricted, but if tax savings are a concern then the ILIT may be a worthwhile solution. 

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 

Columns

When I sit with clients to prepare or review their estate planning and asset protection goals, a wide variety of questions and issues arise.

Answers to Key Asset Protection Questions

 that focused on former Senate Majority Leader Tom Daschle, whom President-elect Barack Obama tapped to serve as Secretary of Health and Human Services, and his attempts to initiate a dialogue about health reform with the American people. In the initial stages of the effort, the presidential transition team received thousands of comments about health reform on its website, 

. Subsequently, Daschle invited Americans to participate in reform-related town hall meetings over the Christmas holidays. 

Daschle is bullish about the conversation the transition team has initiated. According to the 

, he recently observed that it would have been impossible a few years ago to have nearly 8,500 health reform-related discussions over the holiday season. 

While Daschle’s excitement about the health reform effort is justified, the 

 correctly noted that the transition team’s initiative is reminiscent of another project, The Citizen’s Health Care Working Group. From 2005 to 2006, the Group conducted 84 town meetings and published the results of an online survey of 14,000 Americans. The Group then produced detailed 

 and delivered them to President George Bush and Congress. Despite this, public officials 

If the Working Group spent so much time and effort polling the American people and conducting town hall meetings about reform several years ago, why is Daschle repeating this effort? In addition, Daschle appears to have well-developed ideas about health reform that he may be eager to implement. In his 2008 book, 

Critical: What We Can Do about the Health-Care Crisis

, Daschle suggests that the US government form a Federal Health Board that would make critical decisions about medical care using evidence-based medicine. 

So, if Daschle’s mind is already made up and he has a good understanding of what Americans want in terms of health reform, is the transition team’s effort to generate dialogue and conversation much ado about nothing? Perhaps not. Daschle may be less interested in collecting innovative health reform ideas from the masses than mobilizing a grassroots movement that will support the incoming administration’s health reform plan. 

, Daschle said “lawmakers will be more likely to take up health reform if there is enough pressure from voters.” He added that the health reform meetings will “add to the sense of urgency. ‘It will lead to members of Congress taking note. It will lead to governors taking note. It’s going to lead to a greater degree of commitment on the part of elected people.’” 

Like other members of the incoming Obama administration, Daschle recognizes the power of social media and other online technologies to aggregate grassroots support for candidates and political agendas. He may hope that engaging the public in this manner will generate more support for the administration’s efforts. However, there is no guarantee that the people who have joined Daschle’s nascent health reform movement will back the administration’s plans—especially if they feel that their suggestions have been ignored. 

Clearly, the American people should play a significant role in efforts to reform the US health system. However, in order for this to occur, Daschle and his team will need to demonstrate that they clearly understand what the majority of Americans want and adjust their policy prescriptions appropriately. Otherwise, the grassroots will be loath to climb aboard the Daschle health reform express.   

Reform is a term that means vastly different things to different groups and stakeholders. Do you think the new administration’s health reform priorities, such as they are, have physicians’ best interests in mind? In your opinion, what areas of our healthcare system are in most need of reform? 

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.   

To read more of Fard’s insights on the use of social media and other online technologies in a variety of healthcare applications, visit 

 and type “Fard Johnmar” in the search box to retrieve an archive of columns. 

Late last year, an article was published focuseing on former Senate Majority Leader Tom Daschle, and his attempts to initiate a dialogue about health reform with the American people.

Will We Really Have a Say? Assessing Obama’s Early Online Health Reform Effort

As we begin 2009, I am struck by how radically different the Internet looks and acts today compared to just 10 years ago. One of the biggest changes since 1999 is that there are many new ways to interact with peers and consume realtime information about products and services. 

Today, people are merging their business and personal activities through the Internet. It’s easy to go from a personal banking site, to Google search results, to sites that review and provide uncensored comments about products, healthcare, politics, and just about anything else. E-mail is another area where business and personal activities tend to blur. In the 1990s, business applications like Microsoft Office (with Word, Excel, and Outlook) migrated from the office to the home. Today, Web 2.0 technologies like video sharing, blogging, and social networking are migrating in the opposite direction, from the home to the office. The result is a much less distinct line between work and home life. 

Nowhere does the line between business and personal existence become blurrier than on the message boards of online user groups. These communities have a large and growing influence over everything from purchasing decisions to best practices to discussing personal and professional issues. For example, my EHR website has a user board that is active with a wide array of both business and personal discussions. This uncensored bulletin board for Amazing Charts’ users is a place where folks from around the country and world can meet, ask, inform, and share their opinions. At last check, there are 1,330 “members” who have posted 11,428 messages on 1,347 Topics. 

Looking at some of the more recent posts, the topics range from someone asking how to view a .PDF file using the program to someone comparing Amazing Charts with eClinicalWorks and e-MDs who wants to solicit opinions from users. Yet another person wrote an editorial-style post called “The War on Physicians,” which generated 147 responses in just one week. 

This form of interaction—not only between company and customer, but also between customers themselves&mdash;is an example of the real-time feedback and dialog one can generate nowadays because of the broadband connectivity made possible by the Internet. Students who use MySpace and FaceBook are graduating from medical schools with a strong sense of this online community, as well as the skills to leverage message boards to explore life and work problems and discover new products and services that can enhance their lives personally and professionally. 

Bulletin boards, message boards, forums, and blogs—no matter what the name&mdash;offer a way to compare notes with and get opinions from people who are concerned with similar issues and problems. There are community websites for just about everything imaginable. There are boards discussing the car you drive, the software you use, the foods you eat, the activities you enjoy, even the sexual fantasies you imagine (see my other website AfraidToAsk.com’s bulletin board). And although by their very nature they are biased to the opinions of those contributing, they provide a refreshingly candid and non-commercial forum for discussion. One can only imagine what it will be like in 2019… 

How have new interactive online technologies affected the practice of medicine? Are online patient communities a good thing, or are you concerned about their growing infl uence? What about message boards, forums and other online communities for physicians? Do you participate in any of them? If so, do you discuss clinical topics and other professional matters, or do you tend to talk more about nonmedical subjects? 

Dr. Bertman is Physician Editor-in-Chief of 

. He is also a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts. com, a leading developer of electronic health record (EHR) software. He also is the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

As we begin 2009, I am struck by how radically different the Internet looks and acts today compared to just 10 years ago.

Influential Online Communities

Healthcare consumers may be the driving force behind Health 2.0, but are they really in control? And who knows what the final destination will be?

According to the bloggers and physicians interviewed for this article, mapping the progress of Health 2.0 depends on your view of the forces powering the movement. In my opinion, patients are without question the fuel for the machine. Without tech-savvy, proactive patients rooting around for information in online health communities, there is no market for entrepreneurs, hospitals, insurance companies, and other healthcare organizations to build, expand upon, and innovate with existing Health 2.0 networks and technologies. 

The very idea of “innovation” is the point of contention. Are patients and doctors, with the creation of each new startup, writing the manual on Health 2.0 from which all future research and development will be drawn? Or are companies such as Microsoft and Google synthesizing research with their knowledge of social networking and massive technological power to create the tools that users will rely on to drive their online healthcare experience in the future? 

Those in the field offer a mixed bag of responses, but in the end suggest that no one—not patients, doctors, nor businesses&mdash;is taking definitive steps to assume the industry’s Health 2.0 leadership role. John Norris, a researcher who focuses on healthcare support groups in virtual worlds and developer of john-norris.net, believes that effective, patient-driven Health 2.0 initiatives suffer from a lack of resources and an authoritative knowledge base, and companies are often too cautious with both their initial investment and decisions to get involved in earnest. 

Overly cautious business involvement with Health 2.0 can be attributed to a host of causes. A lot of the promise of Health 2.0 stems from its electronic existence, giving individuals oceans of information to sample and share together for the betterment of personal healthcare. But as you’ve read in these pages and in other medical news and literature since the turn of the century, the many debates over the efficacy of the Internet and medicine, EHRs, PHRs, and everything in between, remain largely unresolved. What these debates ultimately boil down to is money. The models that show how to make wildly profitable enterprises out of EHRs and Health 2.0 do not yet exist. But when the model is perfected, investments will pay off , and the debates will end. 

, says that he believes industry will ultimately push the evolution of Health 2.0. “Healthcare companies see Health 2.0 as a way to save money on customer service; entangle themselves into long-term relationships with customers; gain new customers; and create new revenue streams,” he explains. “The growth is driven more by the industry now than the users.” 

Elmer Bernstam, associate professor, Health Information Sciences and Internal Medicine, University of Texas School of Health Information Sciences at Houston, disagrees. “Healthcare is not currently structured around information technologies,” Bernstam says. “For example, procedures and in-person consultations are generally reimbursed. Although there has been some success in getting paid for online activities (eg, virtual visits), as far as I know, these are the exception rather than the rule. Unless something changes, I think that Health 2.0 will continue to be a user-driven phenomenon.”  

Bertalan Meskó, a medical student at the University of Debrecen, Hungary, and author of the blog 

, thinks that might not be such a bad thing. Meskó envisions Health 2.0 as an entity that should remain first and foremost the domain of patients and physicians and fears that if pharmaceutical and medical device companies recognize the power of Health 2.0 tools, their presence will erode the ability of patients and physicians to be strong voices in the online community. 

“That’s what we try to avoid by informing patients and doctors about the possible implications of Web 2.0,” Meskó says. “I’m quite confident regarding the future of Health 2.0, as I realize the so-called e-patients will lead the way here. E-patients will change the way medicine is practiced and healthcare is delivered. Medical professionals also have to realize they must meet the expectations of e-patients.” 

While no clear Health 2.0 leadership has emerged, physicians and patients remain the main drivers and focus of the movement. Unfortunately, despite its benefits to these groups, they face a problem with Health 2.0’s medium, the Internet. The expansive size of the Internet is a status quo problem, but that does not change the fact that it negatively affects the patient—physician relationship. 

“Web 2.0 creates infinite possibilities for social interaction and discussion in healthcare, but it also creates an enormous amount of ‘info-noise’ in medicine,” says Dean Giustini, biomedical branch librarian, University of British Columbia. “While it is true that the blogosphere has changed the way that citizens share their ideas and opinions, how many people doing health-related research on the Web understand the difference between hard, cold facts in medicine and mere opinion? Not many.” 

The extent to which physicians utilize Health 2.0 tools compared with patients is debatable. The 

 estimates that between 75% and 80% of Internet users have looked for health information online, while Harris Interactive estimates that 66% of all adults have done so. 

Jupiter Research’s US Online Physician Executive Survey, 2007

 indicates that an estimated 89% of physicians reported searching the Internet for clinical information. For better or worse, however, the consensus seems to be that patient behavior is shaping Health 2.0. 

Norris feels that “organizations with resources will be able to create more valuable areas within virtual worlds” but “nimble, nonauthoritative- seeking groups may always be in the lead.” This is a concern for Bernstam, because coupled with a “tremendous unmet consumer need for health information” are few, if any, controls over poor and inaccurate health information online. While Bernstam concedes that there is evidence of self-correction in online communities, “there is also evidence that consumers do not discriminate based on information quality.” 

Dr. Henry Potts, lecturer, Centre for Health Informatics and Multiprofessional Education, Royal Free & University College Medical School, University College London and principal investigator on the 

Survey of Doctors’ Experience of Patients Using the Internet

, “the volume of material seemed to matter more than traditional fears about the accuracy of information.” More interestingly, Potts discusses the idea that “both patients and healthcare professionals are feeling swamped, yet perhaps both sides have yet to recognize that this is a common problem.” 

If Health 2.0 is about social networking and information sharing, chief among other things, and some 80% of Internet users and 89% of physicians are searching the Internet for health information, then that lack of recognition of a “common problem” raises questions about what exactly patients and physicians are doing with the information for which they are searching. Perhaps it’s a gross assumption that the average patient, simply because he or she searches for medical information online, knows or even cares to know about Health 2.0. “I think patients are much less aware of this notion of Health 2.0,” says Potts. “They may well be participating in behaviors or online activities that we would label as Health 2.0 but without reflecting on what they’re doing in that way. Patients are also generally part-time, in a sense. They’re off living their lives, which may or may not entail a variety of Web 2.0 activities, and only sometimes being a patient. Healthcare professionals are full-time, immersed in these issues. I think they’re much more involved.” 

By the same token, it is Meskó’s experience that many doctors would not be able (even unwilling) to hold up their end of the conversation even if a patient broached the subject. “Hungarian doctors always tell me they don’t have time for these Web things,” Meskó recalls. “This is quite ironic. When I tell them I have at least 180 medical blogs, websites, and journals in my RSS feed reader, they don’t believe me. For me, it means it will still take a few more years and a lot of additional work to persuade them to use these tools and to help them understand the main concept of Web 2.0.” 

This incident highlights one area in which Meskó believes progress in Health 2.0 has stalled: education. “Nowadays, there are more and more medical community sites, but where these fields should improve a lot is education. We must educate not just doctors but patients about how to use these tools. I hope the 

 community, and Webicina.com take important steps in that direction.” 

In his own experience, Potts believes that the government response to Health 2.0 has been the weakest. “In the UK, the Department of Health is still pushing ‘Health 1.0’ solutions without success.” 

Benjamin Hughes, a researcher in the Department of Information Systems at ESADE, Ramon Llull University, is critical of Health 2.0 for making “no progress in measuring its impact on patient outcomes.” Bernstam, however, sees that as the starting point for real progress. “Perhaps the biggest developments have centered on personal health records that have been offered by a variety of companies, such as Google,” says Bernstam. “This may shift the health information economy, giving the consumer greater control over their health information. They may be able to benefit from it in new ways, like getting paid for allowing researchers to mine their information. This can change the way that we do research from the current format (learning from very few clinical encounters) to a future model (learning from many clinical encounters, and capturing and learning from experience that is currently lost).” 

As for now, Bernstam feels that consumers lack an effective means for dealing with information. “Consumers have plenty of information, but that does not necessarily allow them to make better decisions. In some cases, they are not able to make sense of the information.” 

That won’t occur, predicts UBC’s Giustini, unless “thinkers in Health 2.0 can come up with good reasons for patients to abandon their most-visited social media tools for specific niche tools in Health 2.0,” adding that good foundational articles on the topic are also needed. Stoltz sides with Giustini, predicting the failure of large, patient-driven communities and the rise of niche verticals “serving very specific groups of people with rare and/or difficult conditions, improving outcomes via patient-to-patient and patient-to- provider communications.” 

In June 2008, Dr. Luo, Physician Editor-in-Chief of 

 many of the people and companies driving the development of Health 2.0 innovation. The drivers identified in that article all work toward the goal of better patient care. If these resources are all pointed in the same general direction, there is the potential for interaction and even convergence of different tools and areas of practice. 

Potts anticipates the possible interaction between 

, healthcare organizations, and governments. “If Google Health takes off in a big way, will they be in a position of creating de facto standards, irrespective of government or the big HMOs?” Potts tempers that thought with the possibility that “different national systems for organizing healthcare may trump such attempts.” 

-type section to the likes of WebMD, in tandem with research techniques that would allow patients to better understand their condition and situation, would be a potent resource. 

Bernstam’s stance aligns with that of Norris, citing the proliferation of data in electronic form for research purposes. “The increasing availability of clinical data in electronically readable form can potentially have enormous consequences,” Bernstam explains. “I already mentioned the PHR example, which can fundamentally change the way that we learn new scientific and medical information and evaluate providers. Health 2.0 has the potential to help us extract useful knowledge from the deluge of electronically readable information.” 

How far away these possible developments are is tough to predict, but as both Potts and Bernstam emphasize, humans tend to overestimate progress in the short term and underestimate progress in the long term. Hughes believes that Health 2.0 is still “very marginal” within healthcare but that real progress will seemingly come all at once. “We are looking for the tipping point, where we have enough Internet-savvy patients and doctors who want to use the tools and some infrastructure that deals with issues of data security and privacy.” 

Stoltz believes that changes affecting Health 2.0 will come about as a result of federal funding, as he lacks faith in the idea of widespread PHR creation. “Federal support for health IT will drive a shift from paper-based to digital records,” Stoltz explains. “This will reduce medical errors and inefficiencies somewhat and will mainly happen within institutions. I’m not convinced patients will create their own medical records online.” 

Stoltz also sees government and market pressure coming to bear on insurance companies, which will be forced to develop successful Health 2.0 management tools and practices for patients who consume the most care resources (diabetics, asthmatics, etc). 

Finally, Stoltz posits that real benefits to consumers will come in the form of comprehensive healthcare reform rather than Health 2.0 initiatives. “The major savings in healthcare will come from insuring most of the 47 million who don’t have it, spreading routine care and preventing high-cost, late-in-thegame interventions and ER visits. Other savings and improvements will be incremental.” 

Giustini, while expressing his belief that the United States must overhaul its health insurance system, counters that a “universal healthcare system can benefit from the exceptional information-sharing possibilities generated by Health 2.0. Our healthcare system can learn a great deal from the United States’ private system and the important role that innovation plays in improving patient care.”

Bradley Schmidt is a freelance healthcare journalist.

 - Our interviewees identified these resources as making the biggest strides in Health 2.0

 - “Do a web search on most any illness or drug and the relevant Wikipedia page is going to be near the top of the search results. Wikipedia isn’t trying to be a Health 2.0 application, yet it is influencing patients through a Web 2.0 model.” —Henry Potts 

“Group Health in Seattle is integrating technology into clinical practice better than most. So is Harvard’s Brigham and Women’s Hospital. These successes will encourage wider adoption once tools are identified and improved outcomes are demonstrated.” —Craig Stoltz

 - “CureTogether is a good example of convergence of separate Health 2.0 fields.” — Bertalan Meskó

 - “PatientsLikeMe has become a unique tool for medical research in the past few years.” —Bertalan Meskó

 - “I think wikis have been making strides in Health 2.0. Take a look at the new wikis. Dean Giustini created a health librarians wiki that has been used by not only health library classes, but also some practitioners. Giustini has encouraged other health professionals to add and create their own information niches based on their expertise. This is a new publishing paradigm—one that is not unlike when the Gutenberg press first came out. It’s a small change but with large implications, particularly in the years to come.” &mdash; Allan Cho, Program Services Librarian, Irving K. Barber Learning Centre, University of British Columbia

Cover Story

Where Do We Go from Here? A Health 2.0 Progress Report

Done right, the benefits of a practice portal extend beyond just dollars and cents.   

Awhile back, you decided your practice needed to have a presence on the Web—a portal through which you could provide valuable information to your patients. You contracted with a website developer to launch such a site and populated it with items like the practice’s office hours, contact information, services provided, nice pictures of your building, and some biographical information on your staff. The problem, however, is that you did this five years ago, and little has been updated on the site since. 

Don’t laugh; this happens more frequently than you would imagine, and many practices omit a very important ingredient from their website. “The real benefits of the Web derive from interactivity,” says Michael Uretz, executive director of the 

, an information technology consulting firm. “When you develop a website, the mantra is, always give patients a reason to keep coming back.” Doing so will enable you to answer affirmatively on many fronts when pondering the question, “Is it worth it to have a practice portal?” 

For some physicians, launching a Web portal arises out of a natural need or desire to extend the reach of their practice, and make communication and healthcare delivery more efficient and effective for both patients and physicians. For example, Katherine Gregory, MD, San Francisco Gynecology, had been e-mailing patients since she began practicing straight out of residency in 1995. The problem was that she was doing so through her AOL account, which was definitely not HIPAA-compliant.

“I had to find a Web portal that was compliant,” says Gregory, who subsequently subscribed to the 

Medem Group’s iHealth physician—patient online communication service

. Her main goal was to preserve e-mail communication as an option for her patients, but she quickly found that other features of the service, including the online scheduling of appointments, were extremely beneficial to her working-women patient population. “They can’t play phone tag,” she notes. “They can’t break away from their day any more than I can. Communicating online is very efficient for everybody.” 

For J. Allen Meadows, MD, Alabama Allergy and Asthma Clinic PC, having a practice portal was a logical and efficient way to reach current and potential patients. “It was obvious to me that the clientele of patients I was looking for—young patients who have incomes they can spend on things like allergy testing and allergy shots&mdash;would be people who used the Internet,” says Meadows, who also subscribes to Medem’s iHealth service. “And quite frankly, I have patients who said that they selected my practice over others because of the website.” 

At Fort Collins, CO-based Front Range Center for Brain and Spine, the decision to sign on with Sage Software for its 

 was a matter of remaining competitive and meeting patient demand for secure, efficient, electronic communication. For the past year, the practice has been utilizing the portal for patient communication but will shortly add a feature called Instant Medical History, an online questionnaire that patients can fill out prior to coming in for an appointment. The demographic information and medical history is then downloaded directly into the practice management system. Says Nancy Timmons, practice administrator for the four-physician provider, “We’re very excited, because we believe it’s going to save a lot of entry time on our side and provide real specific information from the patient.” 

Vanderbilt University Medical Center took a different approach to the practice portal. William Stead, MD, Departments of Medicine and Biomedical Informatics, says that the traditional approach is to automate a practice, then create an EMR as a byproduct. The problems inherent in that approach, he says, are that the portal doesn’t easily accommodate information from outside the practice, and it doesn’t easily deal with the constant growth/merger/de-merger of healthcare enterprises. Instead, Vanderbilt used informatics techniques to create an EHR from existing data for every patient seen in its hospitals or outpatient clinics, and then built a physician portal on top of it. 

“It took us about four months and cost less than $500,000 to create the electronic health records,” Stead says. “That contrasts with what would be a two- to four-year, $6—10 million project that no one ever finishes.” 

The rollout of portal capabilities was done in stages. The portal was initially used to alert physicians to any new information about their patients, and to support intrapractice group communication, something that Stead says saved 20—30% of physician time. “If you think about stuff that comes into your inbox; if you set it aside, it costs you a lot more time to deal with it later than if you can deal with it in real time,” Stead says. “In essence, that’s what this lets physicians do.” 

The stages that followed included enabling patients to schedule appointments, send messages to any provider who was taking care of them by way of practice staff , and directly access their lab data. For the latter feature, the medical center made sure to use consumer-level- language explanations of all labs to avoid any confusion patients might experience when viewing test results. 

“If we took the approach of first automating the whole practice in order to have the data, you’d have to use a big-bang approach and do everything at once,” Stead explains. “That approach has a huge training barrier, initial slow down in productivity barrier, and unforeseen consequences when you begin to insert technology in the practice. By breaking it up, we encountered almost no barriers.” 

On the surface, then, it would be easy to think that having a practice portal is more about being patient-centered rather than simple dollars and cents. But Gregory and Meadows agree that both elements determine a practice portal’s worth. For Gregory, answering 15 e-mails in less than 10 minutes is much more efficient than taking three or four times as long to field the same number of phone calls. Staff time is also maximized by not having to spend as much time on the phone to schedule patient appointments. 

“When a woman wants to know the results of her pap smear, I can e-mail back one or two sentences, and she’s happy,” says Gregory. “But in a phone conversation, it’s just inappropriate for me to say, ‘It’s normal. Bye.’ There’s always something else in the conversation. And even if you’re adding just two minutes per phone call, time is worth something.” 

Meadows sends out a patient newsletter via broadcast e-mail. In years when influenza immunizations were hard to come by, patients wanted to be notified quickly when flu shots might be available. An e-mail newsletter alerting patients of the vaccine’s availability was not only fast, it was equitable, in that all patients were alerted at the same time. “And it saved me and my staff time and money not having to call patients, or having patients calling the office and asking about the availability of the flu shots,” Meadows says. “Having our patients register on the website and sending them an e-mail is very beneficial. Just putting up a website isn’t going to save you money if it’s not alive and active and has things on it that patients want.” 

Stead agrees, adding that money is a factor when determining a portal’s worth, but it’s also about the quality of the patient—physician interaction and the degree of the engagement of the patient in their own care. “Making the patient a full partner in their decision making, tracking, and care is a key element to improving people’s health.” 

Timmons says that rather than being a question of dollars and cents, the practice’s portal fosters office efficiency and patient communication. “Are we cutting down on phone calls? Is it enabling a process to be done faster? Those are the things I look at.” 

Gregory says that many of her colleagues are resistant to corresponding via e-mail with patients because they’re afraid of unleashing a deluge of junk e-mail. But, she notes, that hasn’t been her experience. 

“I think the misconception is that every patient who e-mails is going to send this very complicated question,” says Gregory. “I think it’s the change that’s difficult, and I think the newer generation of physicians is going to feel as I do; that communicating via e-mail is natural for them. But it’s a huge challenge for older physicians.” 

Meadows echoes those thoughts. He explains that one of the features Medem has on the portal is the ability to perform online consultations. Many patients have told Meadows that they selected his practice because of that availability, but when it comes to actually conducting an online consultation, he performs fewer than one per week. A contributing factor could be that, at present time, Meadows charges patients for online consultations, but they can phone the office for free. In the near future, however, the practice will begin charging patients $25 to speak with a registered nurse on the phone. “I’m interested in seeing what happens when I level the playing field economically,” he says. 

Security is an issue, but Stead says that if a practice uses secure messaging instead of e-mail, all traffic is encrypted and stored behind firewalls. And as long as the portal is designed so that e-mail messaging is initially received by practice staff and then entered into an EMR for the physician to view, risk is effectively managed. “If you design your portal so that any patient can message any doctor directly, you have a huge risk of chaos,” he says. 

Vanderbilt’s physician portal has been so well received that the medical center created a company called 

 through which to market the technology. One of the first customers is 

, a Cooperstown, NY-based provider with 25 health centers, 10 school-based health centers, and four hospitals. Asked why it’s important to implement ICA’s physician health portal, Henry Weil, MD, Bassett’s medical director of informatics, says that it’s simply the right thing to do. 

“It’s a driver of quality care for patients,” Weil says, “and it’s an attractant to physicians. They can leave work after a lab is drawn, go home and have dinner with their family, and take care of the lab after dinner. So, if you want to take good care of patients, you have to have good doctors. And if you want to have good doctors in this day and age, you’d better have systems that mitigate some of the problems of modern healthcare.” 

Adds Gregory, “In the next five to 10 years, this is going to be the way people do things. Physicians don’t like change, but to me, it’s a no-brainer for the practicing physician because you’re saving yourself time and making your life easier.” 

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, Pa.