Show Me the Money! Patient-Physician E-mail

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

The advent of the Internet and greater adoption of information technology (IT) have created many changes in the healthcare industry. 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—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 California Academy of Family Physicians, “E-mail has tremendous potential benefits 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 February 2007 issue of MDNG, 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.

Why Not?

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 American Medical Association 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.

Financial Woes

Although e-mail can assist with establishing a stronger relationship 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 Medem Inc., “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.”

MDNG 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 Yi Yvonne Zhou, PhD. 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.

Authorized Entry

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 RelayHealth have developed online services that enable physicians and patients to send messages securely. In fact, these services “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, iHealth Services, “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.