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Scott Conard, MD, created TienaHealth after becoming frustrated with rote primary-care medicine that centered too much on diagnosis and treatment and too little on the root causes of disease.

"We educate patients about their condition and the power they have over controlling it, to the degree they have any," says Conard. "We try to make them the quarterback, and we're the coach. They're the ones in the game; it's their body, their life."

It's no surprise, then, that Conard, a fast-talking healthcare visionary, is one of the early adopters of online technology that may alter the paradigm of physician-patient relations in many practices. Conard has enrolled his group of 10 physicians and other providers in MyDocOnline Connect, an Internet-based patient communication service.

By logging into a secure Web site and entering a password and user name, patients can make appointment requests, gain access to lab reports and other medical information, and review their accounts. Most interestingly, they may engage in asynchronous "online doctor visits" with Conard and his physician colleagues.

For the most part, communicating with patients today hasn't much changed from when his father was a primary-care doctor, Conard says. It's mostly done in person at the office, hospital, or nursing home.

Yet with the amount of medical information available, and patients' needs exploding, doctors don't have time to fully discuss everything patients should know during brief in-person encounters. The physician-patient communication conduit, says Conard, ought to be "a big, wide tube ... with communication flowing freely back and forth," but in fact is more akin to a drinking straw. Physicians get precious little information from patients, and patients get a few drops from physicians -- if each side pulls really hard.

MyDocOnline improves the flow both ways. Patients ask more questions and TienaHealth can send information on new treatments, research, and other issues to mass numbers of appropriate patients. Conard can e-mail information to all of his diabetic patients, for instance, instead of sending them an expensive mailing.

TienaHealth allows its patients to enroll in the system for free, but charges them $35 for each online physician visit. Patients pay that out-of-pocket; the encounters aren't covered by any of the practice's payers. During the visits, patients provide information about their current medical condition, their symptoms (if they're having any), and whatever questions they have for the doctor.

During a rare lull at his office, over lunch, or perhaps that night from home, Conard reviews the patient's information, checks his records, and makes recommendations to the patient.

"So whether it's the patient wanting to ask a question, get a [prescription] refill, or if someone isn't sure whether he should come in, he can go to his computer and in a few minutes, I can give him the answer," Conard says. "The patient doesn't have to leave work early; he doesn't have to drive to my office."

Patients can only use the service if they have an established relationship with the practice. If the issues are too complex for electronic communication, the doctor simply advises the patient to make an appointment without charging for the online visit.

TienaHealth has been using the system since late summer. Although practices have been utilizing e-mail with increased frequency for a while now, the concept of online physician consultations -- for a fee -- is fairly new, and the extent to which payers and patients are prepared to accept and pay for such a concept is unclear. Some private payers may even prohibit practices from charging patients directly for such services.

That's why your practice should consider carefully what it hopes to accomplish from online patient communication before diving in. You should also check your contracts first. If used correctly, the technology may increase efficiency, save time, and aid in managing patients with chronic illnesses. But will it work as an effective revenue driver? It's too soon to say.

In TienaHealth's case, the $35 charge is a bit more than the copayment most insured patients would pay for an in-person visit, but Conard is confident that most will consider it a bargain: "When you take the energy, time, time away from work, lost wages, and add that to their copay for a regular visit, plus any deductible, $35 is a good deal for patients; it gives them another option."

Benefits of e-mail

Another well-known provider of physician-patient electronic communication is San Francisco-based Medem, which was founded by a group of medical associations, including the AMA. Some EMR vendors are also providing their clients with secure e-mail communication capability. The concept has piqued the curiosity of many busy practices because it offers hope of solving the problems of poor patient access and endless patient phone calls, while perhaps adding other benefits.

If patients whose medical issues are routine can be handled remotely and asynchronously, the theory goes, practices can reserve their in-person appointment slots for new patients and those who are truly sick. E-mails, unlike phone calls, can be answered when it's convenient for physicians and staff, so fewer phone calls mean staff will have more time to support the doctors.

It's also plausible that e-mail could decrease malpractice exposure. Miscommunication is less likely. Physicians can collect their thoughts before typing a message, and because patients have a written record, they're more likely to understand instructions and follow them. Documentation is easier, too. Practices with electronic medical records (EMR) can easily attach their e-mails to patient charts, meaning physicians won't have to take extra time to document every word uttered to a patient over the phone.

Moreover, adds John Gastright, MD, president of West Ashley Family Medicine in Charleston, S.C., "the e-mail-oriented patients really like it a lot. It's how they communicate in their world."

Indeed, in our Internet-dependent culture, many patients prefer e-mail to the telephone or even to personal contact, so e-mail might serve as a great patient satisfier. About a quarter of physicians already communicate with patients online, according to a recent Harris Interactive poll, and another 9 percent plan to start in coming months. More than half of those doing so said they started primarily because their patients were asking for it.

"E-mail is becoming more and more common, and a more preferred mechanism for folks to communicate, particularly when they're trying to contact someone who's busy," says Steve Ura, vice president and chief technology officer of A4 Health Systems, an EMR provider that is launching a Web site enabling physician-patient communication. "Electronic dialogue between the physicians and patients really makes the best use of everyone's time, and actually allows for better responses to the patient."

Getting paid

But can you get paid for it? That may be the most intriguing question for practices whose physicians and nurses spend hours of uncompensated time on the phone, triaging patients and answering their questions.

"Doctors for a long time have vented a certain frustration that lawyers are able to charge by the minute whenever they answer the telephone" but physicians can't, notes Nicholas Bonvicino, MD, senior medical director of Horizon Blue Cross Blue Shield of New Jersey, which this year has experimented with reimbursing physicians for online visits. As a general surgeon who spent years working in a group dominated by primary-care physicians, he sympathizes. "Doctors forever have asked, 'Isn't our time as valuable as a lawyer's?' So the e-consultations could be seen as a way to get paid for these things."

That's just how Medem CEO Edward Fotsch, MD, sees it. His company enables secure patient messaging for appointment and prescription refill requests, administrative questions, and online consultations. Some 10,000 physicians use Medem's e-mail service.

"Our experience so far has been that physicians set incredibly low fees for their online consultations; the average is $25," he says. "Most attorneys and accountants don't answer the phone for $25. ... And 50 percent of e-mail inquiries to physicians on our network are answered, then not charged for. How many questions do you pose to your attorney and not get charged for? The bottom line is that all physicians have are their brains and their time, and if you're going to take up a fair chunk of both of those, they need to be compensated."

But it's not clear yet how serious the prospect of charging for e-mail consultations is. Bonvicino, for one, has become more skeptical about the idea since January, when Horizon began its pilot project with two rural practices. The insurer agreed to reimburse the practices for online visits on two conditions: the issues tackled during the visit would have to be, in the doctors' judgment, medically justifiable as reimbursable encounters, and the patients would have to pay their normal copayments.

Horizon did not want to open a whole new cost center for itself by reimbursing doctors for things it currently considers part of what it already pays them - including answering patients' mundane if time-consuming questions about medication dosage, doctors' instructions, and so forth.

"The question for us," says Bonvicino, "was would we be reimbursing for something that otherwise we wouldn't be paying for at all? Or would we be reimbursing for a service that's legitimate but less complicated, and therefore we'd see a cost savings by having it performed online? In other words, would e-mail replace an office visit, or would it replace a phone call?"

Horizon will be collecting data until the end of the year. But early results are mixed. For one thing, many patients balked at the idea of paying a copayment -- they must provide a credit card number to enroll -- to get the kind of information online that they were accustomed to getting for free over the phone. And doctors didn't like having to tell their staffs to refrain from providing such information, says Bonvicino.

Why not just drop the copayment for online users? Because doing so would amount to discriminating against non-computer users, and would also defeat the purpose of copayments, which is to spread costs around while encouraging patients to be more judicious about their use of the healthcare system.

Fotsch rejects the idea that e-mail is a mechanism for physicians to charge patients for services patients are currently used to getting for free: "What they're used to doing is calling the office and getting a recording, or the opportunity to wait on hold. They rarely get to the doctor; they usually speak to a nurse if they speak to anyone. And then they usually get a couple of minutes on whatever the issue is, and if it can't be handled simply, they're told: 'You sound awfully concerned; maybe you'd better come in.'"

Although he says that insurance reimbursement for e-mail consultations is probably not in the near-term offing -- "Insurers aren't looking for new things to pay doctors for" -- Fotsch argues that patients will pay for online consultations out-of-pocket, provided it's presented as an additional service rather than as a replacement. In the Harris poll, 40 percent of patients said they'd pay $120 a year to communicate online with their physicians.

Common uses

For now, however, many practices are using e-mail strictly to add efficiency to their practices, reduce call volume, and satisfy busy, tech-oriented patients. Those benefits alone are worth it to those practices.

"The biggest [patient inquiry] that we get via e-mail is for prescription refills," says Gastright. "And that's OK because it reduces staff time. Otherwise, the patient calls in for the refill, the receptionist answers the phone, transfers the patient to the nurse, the nurse writes the information down, checks with the doctor, the doctor approves the refill. But if the patient e-mails the doctor directly, there's no voice interaction -- and the e-mails go into our EMR, documenting the communication occurred."

When the e-mail is linked to a practice's EMR, the physician can simply review the patient's chart and easily approve the refill with a few clicks, says Gastright. Patients also e-mail with other questions they'd normally call about. The practice doesn't charge patients for answering these queries, but Gastright says the time e-mail saves him is worth it regardless.

Family physician Paul Ehrmann's group, Family Health Care Center of Royal Oak, Mich., has been e-mailing patients for some time now, and recently began using a secure Web-based messaging system provided by MedAxxis, its practice management software vendor, allowing it to expand and refine its communication with patients.

The service from MedAxxis does not cost the practice any additional money, and Ehrmann says he wouldn't be comfortable charging patients a fee. "I've heard about that trend, but I see it as just part of the normal routine of providing care," he says. "Unless it gets really out of hand, I don't think it will be necessary. It's hard to know where to draw the line -- what do you charge for and what don't you? And I don't want to risk getting into contentious issues with patients about that."

Besides, it's difficult, if not impossible, to diagnose most conditions over e-mail, in Ehrmann's opinion. He once had a patient with acute appendicitis e-mail him her symptoms, not realizing how serious it was. "Sometimes, patients misinterpret things," he says.

It goes almost without saying that practices should use secure e-mail systems if they're going to use e-mail at all. A Web-based service like MyDocOnline or Medem that requires user names and passwords are safe bets, as are services provided by your EMR vendor. Whatever service you use, make sure it complies with all HIPAA security and privacy regulations.

"My feeling is that physicians and their clinical staff should be looking to use e-mail as frequently as their patients are willing to do so," says Ura. "There are fewer interruptions throughout the day and you can provide more thoughtful responses. We just think it's a better way all around."

Bob Keaveney, associate editor for Physicians Practice, can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the October 2003 issue of Physicians Practice.