The doctor will see you online now

The concept of an online doctor visit has a certain appeal: quick, convenient and efficient, not only for patients but for clinical practice as well.

In theory, at least, these are the advantages. E-visits have been slow to catch on, though, and to date there have been only limited studies examining their effectiveness. That’s why my attention was caught by this study, published in the August issue of the Mayo Clinic Proceedings, that reports on a pilot study on the use of online primary care.

For two years, from November 2007 through October 2009, patients in the family practice department at the Mayo Clinic in Rochester could register for the e-visit service. More than 4,000 patients signed up. During the two years of the pilot project, there were 2,531 online visits, of which 1, 159 were billable. Forty percent of the time, patients were able to have their problem handled without needing to make an office visit. The online service was used most often for questions involving sinusitis, depression and back pain.

These results suggest there’s a viable future in primary care for online consultation, the study’s authors concluded:

The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or from nurse triage and subject to malpractice (protocols) were now documented and billed. Patients showed that they could upload digital images and refill prescriptions as part of the online visits. The timing of visits by patients was generally during office hours. Further study of e-visits, in this era of improving quality while decreasing costs, has merit.

There are some significant caveats, of course. For one thing, the pilot project wasn’t open to any and all patients. According to the study, participants were “identified in face-to-face encounters,” meaning they were specifically selected to join the project. (The study doesn’t indicate what criteria were used, although access to the Internet and a certain comfort level with online communication would certainly have been among them.) For another, most of the participants and most of the e-visit users were Mayo Clinic employees and/or their families, which has the potential for skewing the results even further.

Nevertheless, the study offers some reassurance that e-visits aren’t necessarily the digital bogeyman that so many seem to fear. If the public discussion is any indication, consumers tend to welcome the opportunity to consult their primary care doctor via e-mail and are often willing to pay a little extra for the convenience. Physicians, on the other hand, have been more reluctant. Many of them worry that if patients start asking for e-consultations, it will 1) increase the doctor’s workload; 2) patients will abuse the privilege; and 3) the doctor won’t get paid for it.

Make no mistake, these are all valid concerns. The Mayo Clinic study found, however, that patients for the most part used the e-mail service appropriately. The vast majority of messages were sent during normal business hours, not on evenings and weekends. About 25 percent of the participants only used the e-visit service once during the entire two years of the pilot project.

Nor did physicians appear to be unduly burdened by having to respond to patients’ e-mails. The study’s authors found that clinicians were able to handle most of the e-visits during office hours – and because a highly structured template was used for patients to state their problem and fill in the details, it turned out to be surprisingly efficient. About 40 percent of the time, the patient’s issue could be taken care of without needing to schedule an office visit. The e-consultations even gave physicians a chance to bring up screening and preventive measures. In one case, the authors noted, an e-visit for a refill of a prescription medicine for headaches prompted the doctor to order an overdue colonoscopy, which resulted in the detection of a localized cancer.

As for billing, most of the private insurers were willing to reimburse the $35 that Mayo’s family medicine department charged for an e-visit during this pilot project. Medicare and Medicaid unfortunately did not. Medicare patients had to pay out of pocket for the service, and the cost was written off for patients on Medicaid. On balance, this may have been an acceptable tradeoff, however – the convenience could well have been worth it for older patients. The writeoff for a Medicaid e-visit also was less than what it would have been for a Medicaid office visit, the study’s authors noted. The fact that the private insurers agreed to cover online consultations also suggests that third-party payers might be more receptive to e-care than they’re often given credit for.

Medicine still seems to be wrestling with the proper role of information technology in health care. Are computers helpful in caring for the patient? Do they help make life easier for clinicians? In a companion essay to the study in Mayo Clinic Proceedings, Dr. Warner Slack muses about the benefits and the pitfalls:

With such widespread use of the computer by the general public, there are of course real dangers with misuse and overuse, such as depersonalization, true dehumanization, and breach of privacy, and we must be vigilant. With the computer in medicine, however, the problem is not so much overuse as underuse – or, at least, too little good use.

The goal, he concludes, is “not to replace the physician; the idea is to fill a void.”

If I had the option of an online visit with the doctor, I’d jump at it without a moment’s hesitation. Would I pay out of pocket for it? Yes, I would. Would I do my best to use the service appropriately, i.e. not as my personal online 24-hour medical consulting service or as a cheap substitute for when an office visit is truly necessary? I’m pretty sure I would.

Many of the objections to e-communication with the doctor frankly seem based more on perception than on reality. It’s therefore encouraging to come across studies like this one that suggest online doctor visits, when they’re structured carefully, can indeed be a successful model for delivering some types of care.

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