Using Technology to Skip the Doctor’s Office

By Steve Lohr

The waiting rooms in doctors’ offices rank right up there with bus stations as places to avoid. They are typically filled with cranky people, feeling lousy.

Technology, it seems, can provide at least a partial cure. A study published on Tuesday in the medical journal, Health Affairs found that visits to the doctor’s office can be significantly reduced in practices that use electronic health records and secure e-mail messages between physicians and patients. The study, focusing on the experience of Kaiser Permanente in Hawaii when it implemented electronic health records, secure e-mail and a Web portal, found that patient visits declined 26 percent from 2004 to 2007.

The technology was presented to Kaiser’s 225,000 members in Hawaii as a choice instead of a drive to limit trips to the doctor’s office — but that was certainly the effect. “The level of change exceeded our expectations,” said Dr. Louise Liang, a consultant to Kaiser and co-author of the report. “There are many more efficient ways to provide health care at the same level of quality and service.”

At times, Dr. Liang noted, a face-to-face visit is the “most expensive, least convenient” mode of health care. Clearly, an e-mail exchange can only substitute for certain kinds of care, she added, like adjusting medication regimens for patients with chronic conditions such as diabetes. But they add up.

One benefit, Dr. Liang said, can be that doctors whose offices are less crowded have more time with the patients they do see to treat their problems, without referrals to specialists. She cited separate research that looked at Kaiser’s units in the Pacific Northwest. It found that with more time, primary care doctors reduced referrals by up to 30 percent, especially for dermatology and orthopedics. “It’s all about time,” Dr. Liang said.

True, but Kaiser is also an integrated system, whose physicians are salaried and whose patients are typically insured by Kaiser. In that sort of system, fewer doctor visits make sense for Kaiser physicians and often their patients.

But Kaiser is the exception. In the mainstream fee-for-service marketplace of medicine, primary care physicians are paid by the visit — and not for answering e-mail. There are some experiments in reimbursing online consultations, but they are still just experiments.

Comments are no longer being accepted.

Ricardo Diz March 10, 2009 · 12:52 am

“One benefit, Dr. Liang said, can be that doctors whose offices are less crowded have more time with the patients they do see to treat their problems, without referrals to specialists.”

Won’t Clinics and Hospitals just increase the number of patients per doctor to increase productivity? Even assuming that this is not what management is thinking now, I would expect this to happen in the future…

Ahmet March 10, 2009 · 1:57 am

My experience with this system at Kaiser in San Francisco has been nothing but great. The ability to communicate with my physicians concerning medication, scheduling lab work for upcoming visits, and getting answers to follow up questions has been really valuable. My lab results have been available online within 24 hours. During my office visits my physicians have access to actual MRI, PET/CT scan images and have even shared them with me right on the PC. Hopefully, soon everyone will be able to have access to this kind of technology.

its.kyway March 10, 2009 · 4:15 am

I think that this technology is actually very useful in my opinion.
I agree that often times i find myself waiting for hours to see a doctor, even if i had scheduled an appointment. I don’t blame the doctors because they are busy people who need to take care of tons of people. However, sometimes it just isn’t worth it to wait for hours and spend a good $20-$30 just to have your doctor tell you for 5 minutes how to adjust your medication process or whatnot. Although treatment through e-mail obviously won’t help for serious problems, they can definitely help if you just have a minor injury or symptom that you need clarification about.

Craig in TX March 10, 2009 · 4:22 am

Sounds like the “the mainstream fee-for-service marketplace of medicine” needs changing!

AP March 10, 2009 · 10:03 am

Even though I am a physician who is salaried rather than fee-for-service, my productivity is still measured carefully, largely by patient visits and revenue billed / generated. Emails generate no RVUs for me, and I get no plaudits for avoiding patient visits by using email. How is internal productivity measured for for Kaiser physicians? Do emails count?

Christine in NYC March 10, 2009 · 11:08 am

All the students at my University covered by the University’s health plan go to primary care physicians in our health center. All their records are electronic and the physicians have secure emails capabilities. The system is really great. I can email my physician for prescription refills and ask him simple questions without having to make an appointment. I love it and I am not looking forward to going back to the old way of doing things after I graduate.

Ed March 10, 2009 · 11:18 am

Another Kaiser patient chiming in: the system at Kaiser is great. Broke my arm this winter and have been seeing an orthopedic surgeon the past two months. I stop for an x-ray just before the visit and by the time I walk over to his office (just down the hall) he’s already called up the image, reviewed, and is ready to discuss my progress.

I know that the system improves patient-doctor communications in other ways. I have had my Kaiser doctors call ME to see how I am doing, at home, in the evenings, on the weekends.

Warren Churgin March 10, 2009 · 11:22 am

From a physician’s point of view, and especially as a primary care physician, pretty much all I have to sell is my expertise. Since, legally, a physician cannot bill for time spent on the phone or emails, I make my patients come in to see me for a visit. This is the only way that I can stay in business. Medical offices are so over regulated, and have very high overheads due to malpractice insurance and staffing costs, etc. I cannot give my skills away for free.

William Osler March 10, 2009 · 11:24 am

The most amazing thing to me is that Obama administration is talking about spending vast amounts of money to develop an electronic medical record system when there has already been one up and running for YEARS in the federal system. The VA has had a electronic medical record system which has already been tested by time. While it is not perfect, it is, in my experience, a wonderful system to use when compared to paper charting. The feds could save much needed money and just use what it already has.

DP in OrangeCal March 10, 2009 · 11:45 am

The health insurance company only pay for office visit and the medical board will ding the physician for not following the standard of care within the community if something goes wrong. The scenario above begs the question: Why should the physician provides service to get LESS compensation with MORE medico-legal risks?

Darryl Mitteldorf, LCSW March 10, 2009 · 12:34 pm

Cancer support groups seem to be leading the way, with online sites like //www.cancermatch.org and //www.outwithcancer.org
Seems like hospitals and doctors should be using the online systems already in place.

Jeremy Engdahl-Johnson March 10, 2009 · 12:56 pm

Closed systems like Kaiser, Group Health in Washington State, and the Veterans Administration, among others, do have an advantage since they have already integrated the payer and provider functions, making the potential benefit of electronic health records that much greater.
The benefits are also significant for non-integrated systems, though the implementation barriers are seemingly more daunting– perhaps that’s why overall adoption of electronic health records nationwide is still well below 20%. Will the potential service and efficiency improvements be enough of an incentive for hospitals, clinics, and small practices to implement these record systems?
So far this has not been the case. It will be interesting to see if efforts by Medicare, Medicaid, and state and local government are successful in bringing about more sweeping technology adoption throughout the provider community. More information at //www.healthcaretownhall.com/?s=closed+system

miked March 10, 2009 · 1:10 pm

In response to William, the VA system is good, but has many limitations. There are companies that sell variations. Technology has changed in the more than 20 years since VISTA (the VA system) was designed. Some times its easier to design a new product than to adapt the old to fit.

TSM March 10, 2009 · 1:13 pm

I have two experiences with electronic records. The first is with the VA, and it works great!! They also use Nurse Practitioners as your first level of contact who then refer you to specialists. These are HIGHLY trained (PhD level) nurses who don’t seem to have the attitude of some doctors. Everyone in the system can bring up your history and prescribe or question you accordingly. I think it works great and recommend it as a national system. They also provided my a complete printed copy of my records when I transfered to a private practice physician who seemed mystified when I gave them to her.

My second experience is as a volunteer in a research study at a major medical school. They enter all data into a file and anyone involved in the study can see my history at any time. No paper records and it’s very easy to see changes in history over time in things like weight, blood pressure, heart function, etc. They do not share data from one study to another, but I would endorse that in order to reduce the costs of research.

benzeo March 10, 2009 · 1:48 pm

I am a family medicine physician and have had experiance with several systems.
E-records (EMRs) are often over complicated and slow simple record keeping, they remind me of MS software, written by computer geeks, not users.
Medical email can reduce office visits, but like phone calls to patients, is an unpaid service. The doctor is not paid anything for this encounter and insurance companies are not keen on starting reimbursement this new service. I always found this unrealistic, would my lawyer carry on a professional consolation over the phone without billing?

– benzeno

KP Internist March 10, 2009 · 1:53 pm

I am a KP internist in northern California and I agree with the findings published in the study. Having easy access does increase productivity of primary care providers. The comments earlier about how this system is only effective in a “closed” system like KP is true. It only makes sense if there is complete integration. So, why doesn’t every system operating in this country become integrated like KP? Our competitors have spent decades trying to differentiate themselves from our system and now they have to play catch up to get to the same quality that we can deliver. If you are a patient who lives in an area where a fully integrated system exists, give it a try. You will have a very hard time returning to the “fee-for-service”, “every man for himself” health care systems out there.

John March 10, 2009 · 6:12 pm

Hawaii Medical Service Association (Blue Cross Blue Shield) has just rolled out Virtual (Online Care) Doctor visits. These are done via webcams and other software. I think that’s worth checking out as well.

//www.hmsa.com

Housedoc March 10, 2009 · 9:41 pm

For the majority of doctors and patients, who don’t have email capabilities via electronic medical records, //www.housedoc.us provides an easy to use on-line portal for communications between doctors and patients, that’s also free and HIPAA compliant. Its more convenient and time efficient than using the phone. Its an example of how technology can help improve health care.

Norman March 10, 2009 · 11:59 pm

The nice thing about using an on line system such as housedoc.us is that depending on the type of service, physicians have the option of charging a fee, by credit card, for their time and expertise. Routine messages to secretaries, etc, are free. That way the physician can taylor the service to their practice, without having to worry about permissions, compliance, etc.

Paul Grundy March 11, 2009 · 8:31 am

The single most import part of healing is the RELATIONSHIP it is the very foundation that healthcare of value starts with — has to start with. To carry that one step further this relationship has to support the longitudinal comprehensive care of our patient built on a strong base of primary care and prevention. Smart healthcare can support that relationship by improving communication via email via portal internet. It can allow expanded communication with a patient; it can empower the doctor not to forget to ask an important question be it about the patient’s person life or a key fact to the healing process. Smart healthcare can send little reminders of care compassion and yes importantly express a doctor’s investment in a person who needs a healer and healing. A smart healthcare system can help with compassion remind the patient of the important things that would otherwise be missed in a busy doctors life like e-reminders of a visit, or that mammogram that was forgotten to be completed.

Scot Silverstein March 11, 2009 · 12:12 pm

What is the morbidity and mortality of this service?

Examining only the positives without looking at the negatives is what gets pharma in trouble, after all.

George March 11, 2009 · 1:17 pm

In a recent survey, posted on Sermo, an on line physicians’ community, 17 of 30 responders said that they would consider exchanging email with their patients only if it can be done securely, and they were able to charge the patient for their services. 13 said that they wouldn’t do it under any circustances.

Dr Van Nostrand March 13, 2009 · 3:06 am

We need some type of “informed consent” for the doctor to fully understand the implications of starting an EMR, just as there is informed consent for the patient.

An example:
Benefits – increased productivity, written proof of a patient encounter, keyword searchable
Risk – start-up costs, loss of income, lack of “user friendliness,” medicolegal liability, incompatibility with the hundreds of other EMR’s out on the market, HIPPA
Alternatives – a federally-sponsered CPRS (the EMR program used in the VA system), version 2.0.

CPRS is a good start, but one way to think of it is a disorganized (but legible) office chart, multiple volumes thick (because of rampant cutting and pasting duplicate vital signs, labs, etc), but keyword searchable (sort of).

Tony March 13, 2009 · 11:03 am

My provider recently went to electronic records. I can now correspond with him or his office to get answers to minor questions, to point out areas of possible interest, to set up appointments, to renew prescriptions, to see lab results. I imagine this system, once installed, would save any practice a great deal of money in overhead, as well as improving communication between doctor and patient. As for practising medicine without a fee, I would not dream of having the doctor try to evaluate a problem strictly by e-mail, but follow-up of a visit, for which there is normally no charge, can easily be done that way and is more economical than another visit or phone call. I think the system is great!

EHR Geek March 13, 2009 · 11:23 am

The level of change exceeded our expectations,” said Dr. Louise Liang, a consultant to Kaiser and co-author of the report. “

Dr. Liang is the former head of KP’s entire EHR program. So while the study is very interesting, the NY Times should have noted this possible conflict so the readers can understand the full context of the source of the information.