May 09, 2001 (San Francisco Chronicle) - If more people talk to
their doctors online through so-called Web visits, will it lead to
fewer actual office visits, or just more headaches for doctors?
Answers to those questions will be sought in a study being
conducted by the University of California at Berkeley and backed by
Blue Shield of California and Healinx Corp., an Alameda company that
has created a system for online doctor visits.
The study, which started last month and is expected to take a year
to complete, will involve nearly 200 Blue Shield primary-care
physicians and about 6,000 patients.
Technology has been working its way into the doctor's office in
recent years, with increased attention on creating electronic medical
records and incorporating handheld devices.
Doctors have been using e-mail for years, but now there's a push
by health care organizations to determine whether online technology
can lead to increased productivity and efficiency.
"Health care organizations are investing literally billions in
this new information technology and no one has any idea whether it
works or not," said Paul Gertler, director of the graduate program in
health management at UC Berkeley's Haas School of Business, who is
conducting the Blue Shield/Healinx study.
Gertler said that although Blue Shield and Healinx are paying for
the study, neither company has any control over how UC-Berkeley
conducts the study, or over its results.
The study comes at a time when health organizations are starting
to encourage online communication between patients and doctors.
Kaiser Permanente patients can schedule appointments, refill
prescriptions, consult with a pharmacist and pose questions to advice
nurses online. The Palo Alto Medical Foundation recently began
testing its own Web visit system with about 500 patients and 22 of
the group's primary-care physicians.
And along with the UC Berkeley study, another pilot program
involving the Healinx system is under way. This one involves several
large, self-insured Silicon Valley companies, including Cisco
Systems, Adobe Systems and Oracle. The pilot will involve about 2,000
employees and 100 doctors.
Web visits, such as those created by the Healinx system, are not e-
mail per se. Patients can send free-form encrypted messages, but can
also participate in a structured visit.
That involves answering a series of questions about their
condition that are then transformed into clinical notes and sent to
the doctor via a secure site. The series of questions, designed to
give the doctor as much information up front as possible, is expected
to reduce the necessity of a back-and-forth conversation.
There are many concerns from the patient's standpoint, such as,
will the Web visit start replacing an actual doctor visit? Can the
quality of care be maintained? And then there's the privacy issue:
Will the information be shared -- either with other individuals or
with the insurance companies?
Doctors, on the other hand, may fear that they will be inundated
with messages from so-called cyberchondriacs about every little
sniffle, or that their every move will be monitored by the health
plan. And a huge concern for them could be money -- whether insurance
companies will reimburse them for their online time.
"The study is really designed to formally investigate those
questions -- to determine to physicians and to patients and to
ourselves that this is an effective way of communication," said Dr.
Jeffrey Rideout, chief medical officer for Blue Shield of California.
Rideout said the e-mail program is designed to cover nonurgent
medical problems asked by a doctor's current list of patients, not
new patients. For example, it could be used to help a patient who is
traveling and needs a refill on asthma medication, or someone who is
experiencing minor problems and wants to know if an office visit is
necessary.
Eventually, he said, Web visits may be expanded to monitor people
with chronic but stable conditions. "But the image isn't that we're
trying to substitute complicated clinical care for visits over the
Internet," Rideout said.
OVERWHELMING SUPPORT
Initial market research shows people like the freedom of being
able to communicate with their doctor online, rather than getting
stuck on hold or risking the possibility of missing that all-
important return phone call.
In a Harris Interactive survey conducted in September, patients
overwhelmingly supported using e-mail to improve what little time
they have with their doctor.
For example, 81 percent of the 1,000 surveyed said they would like
e-mail reminders for preventive-care information, and 84 percent said
they would like their doctors to be able to access and monitor their
lab results online.
In contrast to those results, some doctors are still hesitant
about using e-mail to dispense medical advice. A survey released in
February, also by Harris Interactive, shows only about 13 percent of
the 834 physicians interviewed communicate with their patients via e-
mail, a figure that has remained stagnant since 1999.
Katherine Binns, vice president of Harris Interactive, said the
results reflect the increasing pressure on doctors' time. "If this is
presented to them as yet another way to make them more efficient,
they see it as more work -- not necessarily an improvement to their
life," she said.
In the UC Berkeley-Blue Shield study, Gertler, of the Haas School
of Business, said half of the 6,000 patients involved will take part
in the e-visits while the other half will form the control group.
Various factors will be examined between the two groups, including
patient satisfaction, number of office visits, number of online
visits and change in treatment.
Gertler said the lack of hard data on the effectiveness of Web
visits has tempered their being accepted. "Doctors don't want this
because they're afraid unreimbursed Web visits will replace office
visits," he said. "Insurance groups are afraid of the opposite --
that there will be many more visits. . . . This problem is just
stifling adoption."
CASH FACTOR
Doctors participating in the survey will be paid $20 per Web
visit. Blue Shield's Rideout points out doctors are not reimbursed
for the time they spend talking on the phone with their patients.
"Doctors have really not embraced e-mail and the Internet because
they see it as one more thing they have to do," said Dr. Winni
Loesch, a primary-care physician in Sacramento who has agreed to
participate in the survey. "With reimbursement, we might think it's
worth it and try it instead of picking up the phone and talking to a
patient."
Dr. Giovanni Colella, chief executive of Healinx, expects the
survey results to prove that Healinx's Web visits cut down doctor
visits by about 20 percent. And, factoring in the $20 reimbursement
per "visit," he expects the system will save plans and employers
money.
Colella said patients generally do not think the Internet
dehumanizes their interaction with their doctor. "E-mail creates a
sense of intimacy. People are happy to get a personal message through
their e-mail -- it's the doctor, writing to you," he said.
One patient who has agreed to participate in the UC Berkeley
study, Terry Seligman of Mill Valley, has already started to e-mail
her doctor via the Healinx system, but she hasn't yet had a
structured visit using the question-and-answer template.
"We communicated back and forth after my visit about the flu, so I
was able to get that resolved," said Seligman, 54, who owns two small
businesses. "You don't have to worry about being at your desk all day
long waiting for a return (call) from your doctor. You can pick up
your e-mails anywhere or anytime."
Seligman wasn't sure how often she would need to use the Web visit
program. "If something really needs attention, I'm not going to do it
over the Web. I'm going to use the telephone," she said.
Her main concern, she said, was privacy -- specifically whether
her insurance plan would have access to her doctor-patient
communications. But Blue Shield's Rideout insists the plan will not
be reviewing the messages and is only drawing aggregate information
such as utilization rates and turnaround times.
Doctors recognize patients want to talk to them online and they
generally support it, as long as it does not replace the office
visit, said Peter Warren, a spokesman for the California Medical
Association, which represents doctors.
"At the end of every day, every doctor has a pile of patients to
call. If at the end of the day, it's an e-mail message they have to
answer, they can handle it more efficiently," he said.
