Tap Into Your Inbox

Use E-mail to improve care, boost efficiency - and, sometimes, enhance revenue.

Karen Ilika, MD, is an e-mail pioneer. A gynecologist in Kirkland, Wash., Ilika offers patients e-mail access through a secure Web site. They post their questions online; when a response is ready they receive an e-mail alerting them to go to the site to read her answer. About 350 patients have signed up for the service.

Ilika, who shares office space and support staff with three other gynecologists, gets one or two e-mails a day. If the exchange reaches the level of a clinical consultation, Ilika charges a fee of $30, and she has found patients are willing to pay out of pocket. "It’s a subjective decision. If I think I’ve saved the patient a trip to the office, then there’s a charge for an e-mail consultation," she says.

Surveys show that increasing numbers of patients use e-mail in their everyday lives, and they want to use e-mail to contact their doctors, too, especially for routine administrative questions. A survey released by the Wall Street Journal this spring found that a large majority of online adults would like to use e-mail to schedule appointments, get test results or prescription refills, and ask questions.

E-mail can boost patient satisfaction. A study of pediatrician e-mails in the May issue of Pediatrics found that 98 percent of parents were "very satisfied" with physician e-mails and 80 percent felt that all pediatricians should use e-mail.

Physicians who use e-mail with patients report that such exchanges are more efficient than phone calls, and can create a written record that is easily added to the patient’s chart.

Undoubtedly, though, there are stumbling blocks to widespread physician adoption of e-mail. Physicians’ biggest worries are that they will be inundated with questions, their communications won’t be secure, and perhaps most important, they won’t get paid for them. In fact, that same Pediatrics study found 63 percent of patients thought they should not have to pay for e-mail.

Payments for consults increasing

But as the experiences of Ilika and David Ives, an internal medicine specialist in Boston, show, real progress is being made in overcoming these obstacles. Like Ilika, Ives has been using e-mail with patients for several years, and he is now participating in a pilot project with an insurer that is reimbursing some online patient communications.

Insurers are beginning to pay for "online consultations," which they clearly distinguish from routine e-mails; these are considered similar to phone calls, which are not reimbursed. Consultations, in contrast, are seen as replacing an office visit. During a "Web visit," the patient typically responds to a detailed series of questions, similar to those they’d be asked during an office visit.

Ives, whose practice, Lexington Internal Medicine, is affiliated with Beth Israel Deaconess Medical Center of Boston, is piloting an online consultation program through PatientSite, the hospital’s existing secure Web site. The pilot uses software developed by RelayHealth Corp., of Emeryville, Calif., which includes clinical algorithms that guide established patients through a disease-specific online clinical interview, summarizes their answers, and sends the interview to the physician for a response.

Ives will be paid $30 for each of these online consultations, through a combination of insurance and self-pay. Patients who have coverage from Blue Cross and Blue Shield of Massachusetts, Inc., will pay their usual copayment, while the insurer has agreed to reimburse the difference between the copayment and $30. Other patients will be asked to pay a $30 fee by credit card.

"The key to this service is that when the patient has a simple question, and can pay their usual copayment, they’re much more likely to use an online visit than drive to the office, find parking, and spend half a day seeing the doctor," Ives says.

Other insurers are also experimenting with payment for e-mail. Blue Shield of California is currently testing, and paying for, Web visits using RelayHealth’s structured online clinical consultations. Capitated physicians receive a member copayment equal to the member’s standard office visit, but capped at $10. PPO physicians receive a $25 reimbursement, minus the member copayment.

The California pilot program currently includes nine medical groups and 750 physicians. About 11,000 members are using the process to communicate with their physicians. "So far we’ve gotten very positive momentum," says Sejal Hingrajia, project manager for Blue Shield of California. "Both physicians and members really seem to like the process. We want to look closely at utilization before rolling this out systemwide. We suspect online consultations will cut utilization of office visits, but right now we don’t have enough data to reach significant conclusions either way."

Free e-mail replaces free phone calls

E-mail with patients has come a long way. Technologically, communications are much more secure, and as patients become more comfortable with e-mail, they are beginning to seek help for medical conditions, rather than simply wanting to schedule an appointment.

Five years or so ago, when Ilika practiced in Virginia, e-mail from her patients was routed through a call center, a receptionist, and a nurse before reaching her. "The process took so long I was frustrated, and I began giving my personal e-mail address to specific patients I really wanted to hear from. I got quick, short messages from them that were just what I needed."

These days, she uses a secure Web site provided by Medem, Inc., of San Francisco (www.mygyn.com). Most of the e-mail queries Ilika gets are "things my nurse can handle, such as appointments, prescription refills, or dates of annual exams," she says. Occasionally she receives a clinical question. "In gynecology only a small portion of visits can be replaced by e-mail, because we like to see everybody. But when I get a question from a patient I’ve seen recently who’s just started having hot flashes, or has questions about bone density screening, I can handle those issues via e-mail."

Ilika finds that sometimes patients prefer to come in for a visit, because the charge for e-mail may exceed a patient’s copayment, which ranges from $15 to $30. "But most busy people don’t mind if it costs them an extra $10, because e-mail saves them so much time and is so convenient," she says.

Currently Ives’ patients can use PatientSite to check lab results, seek prescription refills, appointments, and referrals, and ask Ives clinical questions, all without charge. Physicians with access to PatientSite can decide how much data their patients can obtain via the site, and Ives has opted for broad access.

Within his own practice, however, one physician uses e-mail but not the Web site, while another doesn’t use e-mail at all. Some physicians are simply uncomfortable with an unfamiliar technology, according to Ives.

"Most are afraid they’ll be overwhelmed if they open the door," he says. "But when they actually try it that never happens. That’s just an urban legend. And the patient satisfaction level is unbelievable. No patient ever says to me, ‘Gee, I’m sorry you’re on e-mail.’ I find I get substantially fewer phone calls than the physician who doesn’t use e-mail. I get fewer requests for lab results, because patients can look them up themselves."

Ives has 2,500 patients using PatientSite. During a typical month, he gets 100 e-mails for prescription refills, 100 for appointments or referrals, and about 400 clinical messages, which equates to about 20 per workday.

"I have to decide whether I feel comfortable managing each problem without seeing the patient," says Ives, "and that depends on the specific question, plus our pre-existing relationship. The big advantage is that I can respond to e-mail at my convenience." He estimates that e-mail has replaced about three-quarters of his telephone work.

John Halamka, an emergency medicine physician at Beth Israel whose titles also include chief information officer for the hospital and for Harvard Medical School, among others, sees an evolution in e-mail among physicians, payers, and patients.

"Generally speaking, patients feel that if phone calls are free, then e-mails should be free, too. But an online consultation that replaces an office visit - that’s different. Patients value the convenience of online communications. Handling a non acute problem remotely saves a lot of time, and that’s especially important for folks who may have a hard time getting around. Is this a widely adopted [philosophy]? No. Is it an emerging trend? Absolutely."

Start slowly, build in safeguards

Physicians such as Ilika and Ives, who answer their own e-mails and conduct online consultations, represent the cutting edge of this practice. But you can start out by using e-mail for routine, nonclinical communications, with an administrator, rather than a physician, responding to messages.

If you’re not ready to set up a secure Web site or don’t have access to one through your group or hospital affiliations, consider using conventional e-mail to communicate with patients on administrative subjects, such as appointment times or billing questions. Just keep in mind, and make sure your patients understand, that without encryption, sending e-mail is like sending a postcard. Anyone can read it.

Among the biggest threats to e-mail confidentiality, Halamka notes, are misaddressed messages, messages inadvertently forwarded to others, and those on computer screens when someone forgot to log off. You need to disclose your privacy and security policies as required by HIPAA, including how you safeguard e-mail exchanges.

Patients of Bluegrass Orthopaedics, in Lexington, Ky., which has eight surgeons, can e-mail nonclinical questions using a form on the practice’s Web site. Administrator Cindy Dunn, RN, estimates she receives about a dozen e-mails per week, usually concerning appointments, medical records, and billing; she expects this number to grow as more patients become familiar with the service.

The Bluegrass Web site (www.bluegrassortho.com) states that the site is not secure, and the e-mail form isn’t designed to convey sensitive information. The practice also posts a warning message next to the e-mail form in red capital letters: "If this is an emergency call 911 immediately!"

Dunn, who also is a consultant for the Medical Group Management Association, advises medical groups that are interested in e-mail to develop a "practice" Web site and test online services by first offering educational materials, online bill-paying, and appointment scheduling.

Start slowly, as her office has, Dunn says. "See how your patients respond. I wouldn’t bring the physicians on board and have them receive e-mails directly until you first have the whole process worked out for nonclinical questions."

When you’re ready to use e-mail for clinical concerns, you should maintain a secure, encrypted Web site, if possible. You send patients an e-mail saying there’s a message waiting for them on the Web site; your responses, and their personal information, never leave the Web site. "This is similar to models used in the financial services industry," Halamka notes.

In addition, Halamka suggests discussing guidelines for appropriate use of e-mail with your patients. You can summarize the main points on a handout, or put them on the back of your business card. Document this discussion, and make it part of the patient’s record.

Halamka recommends that your guidelines for patients say:

• Please include your full name and medical record number in each e-mail.

• Use e-mail to request information and ask nonurgent questions.

• Never rely on e-mail for urgent or sensitive messages.

• Use the telephone or go to the emergency room for emergencies.

• E-mail communications become part of your medical record.

• E-mail messages may be shared with my office staff or with consultants.

• E-mail sent from work can legally be read by your employer, so you may want to consider getting a personal e-mail account.

• If you don’t get an e-mail response within a reasonable period of time, please call the office, since I may be out of town.

Elaine Zablocki is a writer with 18 years of experience focusing on healthcare, contributing to publications such as Group Practice Journal, Managed Healthcare News, and many others. She can be reached at ElaineZ@ezab.net or via editor@physicianspractice.com.

This article originally appeared in the September 2005 issue of Physicians Practice.