By Christopher Guadagnino, Ph.D.

Medem CEO Edward Fotsch, M.D.

Published March 2008

Physicians are gradually turning to electronic communication as a supplement to traditional channels – calling, faxing and mailing – for facilitating patient care. 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 fully integrated electronic medical records with online patient portals.

Physician adoption of electronic communication, particularly with their patients, has grown slowly in recent years: an estimated 31 percent of physicians reported using online communication with their patients in the first quarter of 2007, up from 24 percent in 2005, and 19 percent in 2003, according to Manhattan Research surveys. Concerns about time, cost and liability persist, while electronic communication raises a slew of other issues, including privacy and security regulations under HIPAA (the Health Insurance Portability and Accountability Act of 1996), efficiency, care coordination, care documentation, practice marketing potential, and impact on the patient-physician relationship.

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

Technologies are being introduced for hand-held devices that merge the advantages of both modalities – for example, so-called "push e-mail" on personal digital assistants (PDAs), which alerts a physician when another physician has sent a message, facilitating real-time response when warranted, and incorporating message security features that traditional cell phone or "text messaging" carriers do not provide.

National surveys suggest that the majority of online consumers now desire e-mail access to their physician and are willing to pay about $25 for an online consultation, although experience by some physicians calls that willingness into doubt.

A recent Wall Street Journal Online/Harris Interactive Poll found that 62 percent of patients said the ability to talk to a physician electronically would affect their choice of doctors, while a Harris Interactive poll conducted in 2006 found that 74 percent of patients would like to use e-mail to communicate directly with their physicians.

Some physicians have begun to offer patients electronic access to their practice – via e-mail or more highly structured "e-visit" consultations using online patient portals. Those modalities present a variety of opportunities and challenges. They have the potential to enhance patient understanding and compliance with care regimens, overall care coordination, and the patient-physician relationship, while they also raise the concern that a physician won’t be able to respond in a timely fashion to a deluge of patient e-mail, once he or she opens the floodgates of electronic correspondence. Experience by many has demonstrated the opposite: that the bulk of patient correspondence tends to be administrative in nature – e.g., setting appointments, refilling prescriptions and transmitting lab results – which would have taken up considerably more of a practice’s time and resources if handled through phone calls and postal mail – while even inquiries of a clinical nature are often more conveniently handled via e-mail.

Administrative inquiries can be triaged and handled by practice staff, while physicians must decide how to handle electronic correspondence of a clinical nature – patients seeking clarification of treatment plans, asking about follow-up care or requesting medical advice for new symptoms – including when an inquiry should escalate to an office visit.

Whether or not physicians can expect reimbursement for online consultation with patients is a more complex question than meets the eye. Some physicians do not charge for responding to patient e-mail and regard it as no different from what they would have communicated over the phone – except that the asynchronous nature of e-mail saves unreimbursed phone time by making it possible to respond to several patients at the end of the day rather than interrupting workflow during the day.

Many physicians who correspond electronically with patients distinguish between administrative and clinical e-mail inquiries – not charging for the former (typically having a practice staff member handle them), and charging the patient an out-of-pocket fee for an online consultation involving evaluation and management services.

Several vendors are cashing in on the growing business of secure electronic communication among physicians and patients, offering message encryption and user authentication products for e-mail, as well as online consultation portals that invites patients to log onto a secure website to describe their symptoms through an interactive questionnaire, relay it to the physician and permit the physician to respond with medical advice. Vendors tout the ability of physicians to increase their practice revenue by charging for the service, which often consumes less time and overhead expense than a face-to-face office visit.

The number of physicians who offer online patient consultations is still relatively small, but may soon rise rapidly in the wake of several developments this year:

· The establishment of CPT code 99444, a Level I reimbursement code for online evaluation and management services provided by a physician (formerly Category III CPT code 0074T).

· The announcement by Aetna and Cigna that they will reimburse physicians nationwide for online consultations.

· The announcement by large medical malpractice insurers that they will offer premium discounts to physicians who use e-mail to communicate with patients.

Perhaps the most fundamental choice physicians must make when selecting tools to communicate electronically with each other and with patients, is how they will manage the privacy and security of the information exchanged.

HIPAA is "technology-neutral," in that it does not require any set form of encryption or information safeguarding, and is "scalable," in that it allows small practices to do what they can afford to do without requiring them to purchase expensive communication security systems, according to Brad Rostolsky, Esq., a health care associate with ReedSmith LLP in Philadelphia. Any physician thinking about using e-mail or other forms of electronic communication for patient care purposes should be "tech-savvy" and decide, after a risk assessment, what best suits their practice. If they decide not to implement any security feature, they should be prepared to justify it, he notes.

For electronic communication, the physician should have an informed consent form signed by each patient specific to the form of communication being used, such as e-mail, says Rostolsky. The form should verify the patient’s e-mail address; should discuss the security risks involved – e.g., that other parties on the patient’s end might have access to their e-mail accounts, and that standard (unencrypted, non-secure) e-mail can be intercepted by unintended parties; should discuss allowable content of the communication; and should include a provision to hold the physician harmless if security is breached.

While there is no private right of action under HIPAA – i.e., a patient can’t sue physicians for breach of HIPAA’s privacy or security provisions – the federal agencies that oversee HIPAA have recently announced plans to step-up their audits and they could conduct an inquiry if a patient filed a complaint, says Rostolsky, although from a cost-benefit standpoint federal investigations seem more likely to focus on hospitals than physician offices, he notes. A patient can also pursue some form of privacy action against a physician under common law, for example, using a physician’s failure to comply with HIPAA as the basis for a negligence lawsuit, alleging that the physician breached the standard of care not to violate the patient’s trust, Rostolsky adds.

Carelessness could also have legal repercussions, and Rostolsky cites a lawsuit settlement that stemmed from a case in which information was sent to the wrong recipient because two patients in the sender’s e-mail address book had the same name and the sender didn’t verify the address field before sending the message. Another lawsuit resulted when a large drug company sent an e-mail about a mental health drug to multiple recipients, but didn’t use the "blind cc" tool to shield the names of the recipients on the list, Rostolsky notes.

Physicians using standard e-mail should take as many practical safeguards as possible to minimize liability exposure, says Rostolsky, such as including a privacy and security disclaimer footer on each e-mail; requesting the patient’s permission before continuing to respond to certain issues by e-mail; limiting the amount of medical detail in the messages; requiring patients to authenticate their inquiries by providing their patient ID number; and password-protecting e-mail access on office and home workstations, as well as on portable devices – such as PDAs and Blackberries – in case they are lost.

Another way to alleviate security or HIPAA compliance concerns is to leave out "protected health information" (PHI) in standard e-mail: data that both personally identifies a patient and reveals a specific diagnosis or condition, says Tracey Glenn, director of practice management consulting at PMSCO Healthcare Consulting in Harrisburg, Pa. For example, a patient could write, "My specific problem is getting worse," to which a physician can reply, "Okay, double your medication," thereby minimizing the release of private information across the Internet, says Glenn. Most physicians that Glenn knows who exchange medical information with patients over e-mail use online consultations through secure channels, she notes.

While standard e-mail works and is offered free of charge by service providers such as Yahoo, Gmail, Comcast and many others, vendors of secure messaging networks are quick to point out its deficiencies. Medem Inc., a physician practice communications network vendor that was founded by the American Medical Association and several national medical specialty societies, warns that standard e-mail:

· Is not encrypted or authenticated.

· Can be used by anyone to access a physician if they simply know the physician’s e-mail address.

· Has no "terms of service" or legal disclaimers to protect physicians.

· Can easily expose patient e-mail addresses and identities to unintended third parties.

· Can breach patient privacy by using employer e-mail networks.

· Offers no charge capture function.

· Has no template or medical records features.

· Is not consistent with HIPAA or medical liability insurance company standards.

Medem CEO Edward Fotsch, M.D. says that traditional e-mail is like sending a postcard in the U.S. mail, in that it can be intercepted and read by others as it travels across the Internet to its intended recipient. An encrypted and confidential e-mail system, by contrast, requires a user ID and password to view both patient and physician messages, which are stored in a secure server environment.

For example, data encryption software known as HealthyEmail, offered by ZixCorp, allows physicians to send secure e-mail from their existing e-mail address to any other party, including patients, other doctors, payors and hospitals, says Peter Wilensky, vice president of corporate communications and government relations. Messages arrive unaltered and are password-protected, allowing them to be opened only by the intended recipient, while physicians have the choice to send unencrypted e-mail to recipients who request it, he notes.

A large share of ZixCorp’s e-mail encryption business is marketed to insurance companies and hospitals, says Wilensky, whereby HIPAA-compliant content filters scan all e-mails and attachments for protected health information, prompting the sender to encrypt the message if PHI is detected.

Whether or not electronic communication is encrypted or secure, physicians should guard against getting lulled by the casual nature of e-mail which, unlike a conversation or phone call, is not erased from a computer’s hard drive when deleted and is potentially discoverable in litigation, says Fotsch, who warns physicians not to write indiscrete comments that could be damaging when read aloud in a courtroom.

While some physicians still prefer the immediacy of the telephone, secure electronic messaging tools are beginning to supplement phone calls and beepers to facilitate communication among physicians.

"The majority of our partners check e-mail only once a day, or less. For a real-time patient care issue, it’s still better to pick up the phone or see them personally," says Anthony V. Coletta, M.D., a general surgeon based at Bryn Mawr Hospital in Montgomery Co. Pa., and part of an 18-surgeon practice. "About four of us carry PDA phones with text messaging and use them regularly to arrange for consults," he says.

Most PDAs run on the same networks as standard Internet e-mail, while offering even less security because their transmissions are wireless, warns Ed Shay, Esq., a partner in the Philadelphia office of Post & Schell, in Philadelphia. Achieving data security and privacy usually requires purchasing a commercial subscription service from an application service provider – a company that hosts a secure Web-based server which warehouses and transmits messages securely, he notes. Health systems often host secure electronic communication through their own servers, which have a "firewall" preventing unauthorized external access to the messages, and some may have secure wireless messaging capabilities, adds Shay.

A wireless "managed exchange hosting" service offered by LongCall Technologies, LLC allows secure e-mail with wireless access from handheld devices including Treos and Blackberries, according to the company’s CEO Edward Fein, M.D., who is also chief medical informatics officer and president of the medical staff of Saint Peter’s University Hospital in New Brunswick, NJ. The system – a commercial enterprise run by Fein – uses a secure server instead of the open Internet to transmit and store messages, and uses the "push-e-mail" concept, alerting recipients of incoming messages with a ring tone or vibration on their handheld device, facilitating immediate replies to inquires, as well as storage and retrieval of messages, says Fein. E-mails are instantly received and automatically displayed on the screen pager-style, while most modern answering services can send messages directly to the company’s servers, he notes. "A simple question can be answered in seconds," and typically involves an interaction of a few sentences – a patient status update or query, or a response to a consult, says Fein.

The system is useful to large group practices as well as solo practitioners, allowing physicians who are out of the office to send e-mails to their staff and forward messages to other members of a group, while also allowing specialists and primary care physicians to keep in touch with each other instantly, Fein adds. The system is superior to a paging system, which only allows for a one-way transfer of information, whereas the LongCall system touts the ability for "instantaneous collaboration" between physicians for any case discussion. The system is also superior to traditional text messaging, which is limited to 150 characters, does not use encryption or secure servers for transmission, and does not allow messages to be retrieved through a personal computer, Fein says.

About 200 physicians are currently using LongCall’s service, primarily staff members of St. Peter’s and Robert Wood Johnson University Hospital, says Fein.

Given the migration of primary care physicians out of the hospital setting, department and section meetings are becoming dramatically de-emphasized, and hospitals are seeking ways to preserve physician-to-physician communication, says Mark Van Kooy, M.D., chief medical information officer of Virtua Health in Marlton, NJ. To any of its 700 active medical staff members who have a PDA, Virtua offers free software enabling access to the health system’s secure electronic medical record system, including inpatients’ lab work, prescriptions, history and physical, and transcribed consultation notes. About 100 physicians are using the service, Van Kooy notes.

A significant barrier to hospitals exchanging electronic health information with multiple physician practices in the community is making the various medical record systems "interoperable" – permitting them to interface with each other while preserving the integrity of the data. Main Line Health, a five-hospital health system in the Philadelphia region, launched a "health information exchange" pilot project last month to permit its health institutions and affiliated physician practices (many of which use different electronic medical record systems) to perform real-time exchange of lab results, radiology reports and transcribed reports, thereby replacing cumbersome and less efficient channels such as faxes, phone calls, and postal mail, according to Harm Scherpbier, M.D., Main Line Health’s chief medical information officer.

Using a third-party "connectivity intermediary," MobileMD, and with an initial goal of one-way traffic – sending data from a hospital to physician offices – Scherpbier says the health system hopes the exchange will eventually permit community physicians to order hospital tests electronically from their practices. A significant way to improve quality of care, he says, is to replace physicians’ handwritten orders – often hand-carried to the lab by patients – with direct electronic order entry and communication of results among clinicians.

Physicians who exchange e-mail and perform online consultations with patients tout the higher level of care they are providing and the efficiency benefits their practices are enjoying. When, or whether, to charge patients for the service varies. Most do not charge for administrative transactions, such as fielding prescription refill and lab result requests, while some charge for evaluation and management services. Some physicians charge for neither, and report that the freedom from having to spend time conveying similar information to patients over the telephone – which is also unreimbursed – pays for itself in office efficiency.

There is compelling evidence that inviting electronic communication with patients does not result in deluge of patient e-mail, and that it enhances the efficiency of a physician’s office practice. A recent Kaiser Permanente study of patients who used the medical group’s secure e-mail system between 2002 and 2005 to access their physicians found that they phoned their physicians nearly 14 percent less than did patients not using the system, while each doctor averaged about two e-mail messages per day.

A two-year study of a pediatric rheumatologist’s e-mail and telephone interactions with 121 patient families, published in last October’s Pediatrics, found that the physician received an average of 1.2 e-mails per day, while answering patient questions by e-mail was 57 percent faster than using the telephone. Families responding to a survey about the service agreed that patient-physician e-mail increased access to the physician and improved the quality of care.

Specialists can also benefit from the efficiency and care coordination potential of e-mail exchange with patients. Coletta puts his e-mail address on his card and says he exchanges e-mail with a small number of his surgical patients who have long-term, complicated problems. At the end of an office visit, he invites patients to e-mail him with additional questions, asking them to organize and enumerate their questions to facilitate an efficient and organized response from him. "If it’s a long list of questions, I’ll print it out and put it in the patient’s chart," says Coletta.

"The main hook for the patient is the ability to communicate with the practice, not the physician," as some 80 percent of the volume of electronic communication with patients involves appointment scheduling, prescription refills, billing questions and lab test results, says Fotsch. "Most of the time you call your physician practice it is for one of these purposes. Nobody expects to talk to the physician, and the physician doesn’t get paid to do so – we’ve established that as an expectation in the health care system," says Fotsch.

Physicians benefit from handling administrative matters electronically because it gets their office staff off the phone and allows them to focus on patients in the exam room, while an online presence can also be used to market the practice to new patients or to improve payor mix – as the typical online patient is better educated and insured, adds Fotsch.

"To me, the enemy is the telephone. I have to pay real money to real people to answer patient questions, and there is value to my practice in getting rid of the phone calls," says Louis Spikol, M.D., who is part of a two-physician family practice in Whitehall, Pa. which is owned by Lehigh Valley Hospital. Having used a secure e-mail and online consultation service by the vendor RelayHealth for about five years, Spikol says his practice receives from 10 to 20 patient e-mails a week, about a quarter of which are inquiries requiring clinical advice, from a pool of about 500 patients who use e-mail.

While the system is equipped to bill patients an out-of-pocket charge for an online "webVisit" for clinical questions, Spikol does not charge for it, and instead reaps value in the ability to monitor chronically ill patients – for example, having diabetic patients report their blood sugar levels and care management activities, while reducing his practice’s phone time in handling administrative inquiries – the bulk of the communication. By asking patients to submit history of present illness data in advance of an office visit, Spikol says he can spend more time attending to his patients’ advanced medical needs during office visits, which may entail higher level billing than time would otherwise have permitted.

Any concern that using online communication with patients might reduce the number of patients seen in the office – and thereby decrease practice reimbursement – has not been borne out, according to Robert Eidus, M.D., a solo family physician in Cranford, NJ who has been using e-mail with patients for five years, and also offers e-visits for $30. "Patients who are satisfied with the ability to reach me by e-mail have spread the word to friends as a feature they like about our practice," he says, noting that his office’s phone greeting invites requests via e-mail. As the only physician in New Jersey participating in the American Academy of Family Physicians’ TransforMED medical home pilot program, Eidus says his practice offers open access to patients without an appointment, which may translate into fewer patients paying for an online consultation when they can have an office visit at the same cost.

Vendors of secure online communication services like Medem and RelayHealth offer formalized templates for handling clinical questions through an online consultation, which invite patients to choose from a menu of non-emergent symptoms – such as allergy, arthritis, back problems, chronic pain, coughing, rash – and answer a series of questions related to that specific condition.

Patients with administrative inquiries are not charged, while software algorithms flag clinical requests based on key words – such as specific symptoms or medical conditions – and offer the patient an online consultation with the physicians using the formalized questionnaire template, says Ken Tarkoff, vice president and general manager of RelayHealth, which currently has about 15,000 subscribing physicians. Roughly 60 percent of patient inquiries to their physician through RelayHealth are administrative in nature, and 40 percent are clinical, he notes.

Online consultations are designed for ongoing care to established patients for known diagnoses, and the physician uses his or her judgement and knowledge of a patient’s condition and cognitive abilities to decide if and when the patient should be seen in the office, says Fotsch, who notes that about 12,000 physicians are using Medem’s online interface with patients.

Most physicians are not reimbursed by health plans for online consultations with patients, and decide on their own whether to charge patients out-of-pocket for the service – typically around $25 or $30 – which vendors tout as a way to boost a practice’s income. But the allure of added reimbursement does not appear to have played a major role in spurring physicians to adopt the technology. In practices that offer it, less than five percent of patients typically use it, notes Fotsch. That may change, as new sources of reimbursement to physicians are beginning to emerge, as well as lower liability costs.

Some physicians report that charging patients for online clinical consultations can cause a cultural disruption in their practices. Spikol, who says he is satisfied with the added efficiency and quality of care afforded by online consultation with his patients, also notes his concern that patients might object to being charged for something that they thought was a routine inquiry.

Reluctance by patients to use an online visit that would incur a cost – rather than an e-mail or a phone call to obtain the same advice at no charge – was one of the downfalls of an e-visit pilot program five years ago by Horizon Blue Cross Blue Shield of New Jersey that reimbursed physicians for e-visits and charged patients a copay via credit or debit card, according to James Barr, M.D., who is part of a three-physician family practice in Neshanic Station NJ that participated in the pilot program. Patients were using the secure e-mail that was intended for administrative inquiries for health-related concerns, and it was difficult to distinguish what was reimbursable, says Barr. A Horizon spokesperson says the pilot program was discontinued due to lack of interest on the part of its members, and that the insurer is reconsidering its policy due to the growth in Internet usage.

The e-visit system could work well today if structured properly, Barr believes, and he says the key is to clearly inform the patient that the physician will require an office visit – or an e-visit – for evaluation and management services, which will not be given free of charge over the phone. "An office regularly offering free advice over the phone will have a more difficult time changing the culture needed for reimbursable e-visits to work," says Barr.

Two major insurers have begun to pay physicians for e-visit services, while a large medical liability insurer has begun to offer premium discounts to physicians who correspond electronically with patients.

Aetna members, as of Jan. 1, are covered for secure, online physician-to-patient consultations in all states where Aetna’s participating physicians in primary care and 30 specialties are also enrolled in the RelayHealth service. The physician reimbursement rate is $30 and the patient’s financial responsibility for a webVisit is the same as it is for an office visit, with required copays or deductibles charged online, according to Bill Fried, M.D., Aetna’s medical director in the Mid-Atlantic region. Fried says reimbursing for the interaction legitimizes the transaction, improves patients’ access to their physicians, averts miscommunication, compliments office visits and improves overall quality of care. A physician is expected to reply to a patient’s webVisit inquiry within eight business hours, he adds.

If the physician determines than an office visit is needed in addition to the webVisit, the patient is responsible for both copays, although the physician can waive the fee for a webVisit in such situations, and both Aetna and RelayHealth will monitor how such situations are being handled. If the physician elects to waive the fee for a webVisit, Aetna will make no payment for that interaction.

In about one-third of webVisit transactions through RelayHealth, a physician asks the patient to come in for an office visit and does not charge the patient for the webVisit, says Tarkoff. The physician often decides to escalate to an office visit because the patient reports multiple symptoms, he adds.

This year, Cigna has also started reimbursing physicians nationwide for RelayHealth webVisits with patients who are covered by self-insured employers – the lion’s share of Cigna’s business, says Joseph Mondy, Cigna’s assistant vice president of IT communication. Cigna will pay $25 for a typical online consultation. "We expect exponential growth of this service over time," he adds.

Pa.’s Blues plans do not currently cover online consultations, although Capital Blue Cross says it is currently under consideration, given that a projected shortage of primary care physicians for the coming years makes it important to consider various methods to ensure continued access to care, according to spokesperson Joe Butera.

E-visits put physicians in a potentially powerful marketplace position, according to Fotsch: "Physicians can do inexpensively and quickly what health plans and employers are desperate to do: contact patients to remind them about follow-up care and compliance." The credibility of the information – and the likelihood that patients will act on it – are far greater when it comes from their doctor than from their insurance company, he adds.

Achieving online connectivity with their members for prevention and disease management may spur further evolution of health plan incentives to physicians, says Fotsch. Connectivity vendors can supply health plans with the names of patients who are connected online with their physician, providing health plans a targeted way to push information out to their member network – for example, urging a 50-year-old patient to get a colonoscopy, or enroll in a smoking cessation program. Medem has signed up four health plans for such an arrangement and expects 12 more to sign on soon, Fotsch says. The next step, he believes, is for health plans to pay physicians – perhaps $5 or $10 per patient – to be the source of that information, increasing the message’s credibility to, and compliance by, patients. "Pure economic incentives between the health plan and the physician are now aligned in this model – making patients healthier by hooking them up to appropriate care," says Fotsch.

Electronic communication with patients can also lower a physician’s risk of being sued for malpractice, and medical malpractice insurance carriers are beginning to promote it for several reasons, says Fotsch. They like paper trails, which pre-empt the ability for a plaintiff attorney to say, "My client didn’t know the risks." Physician-patient electronic communication is a "differentiator" that portrays a "model physician" who offers advanced services to his or her patients. Physicians can e-mail educational materials to patients and set up automated notification systems for same-day transmission of FDA recalls or warnings, enhancing patient safety. Patients who communicate online with their physician also have higher levels of satisfaction, and a lower likelihood of suing.

Northwest Physicians Insurance Company (NPIC), one of the largest medical liability carriers in Oregon and Idaho, recently began offering physicians annual premium reductions – ranging from $375 to $2,250, depending on specialty – for connecting with their patients using iHealth, an online service offered by Medem that includes a practice web site for physicians, an integrated secure e-mail and online personal health records for patients. The service also includes automated patient education and safety messages for patients, including same-day patient notification if their medicines are subject to FDA recall or warnings, while the company believes that online communication will improve patient-practice communication, leading to a more informed and educated patient and contributing to reduced professional liability for the physician.

Fotsch believes that such programs will spur physician uptake of online communication with patients, and he notes that NPIC and Medem are collaborating to expand the program to health plans and hospitals. He says the iHealth service is being made available to physicians at a discount as part of the initiative and costs physicians less than a dollar per day for the practice web site and the interactive features.

Two of Ohio’s largest medical liability carriers – OHIC Insurance Company and The Doctors Company, are collaborating with the largest Ohio-based health insurer – Medical Mutual of Ohio – to encourage physicians to use secure online communication with patients through the iHealth system. The collaboration includes physician outreach and education including incentives, continuing medical education programs, seminars and case studies.

The Doctors Company, which insures over 32,000 physicians across the U.S., is encouraging all of its insured physicians nationwide to utilize iHealth, although no specific incentives have been announced.