Patients are clamoring for it. Many doctors hate the idea. But the smart money is on the patients to win this one, and it's a biggie: e-mail contact with doctors.
E-mail, to state the obvious, has become part of life: 61% of U.S. adults now use the Internet, and more than half use e-mail on any given day, according to the Pew Internet and American Life Survey.
A Harris Interactive survey last spring showed that nearly 90% of wired folks want to communicate with their physicians online to ask questions, set up appointments, refill prescriptions and get test results.
Moreover, patients say they are willing to pay for e-visits. They figure that even paying for e-mail, they'll come out ahead: To see the doctor, a patient often winds up missing half a day of work.
So why won't doctors just get with the program? Some do, actually, because e-mail is "asynchronous" (the patient and doctor don't have to be online at once) and because the e-mails can go right into the patient's records. E-mail "lets me communicate in a time-insensitive way with perfect documentation," says Dr. David Ives, medical director for the Affiliated Physicians Group, a primary care group that admits patients to Beth Israel Deaconess Medical Center in Boston.
Angela Lawrence, one of his patients, loves it too. Lawrence has HIV.
"I don't have to interrupt his day or take an hour out of my day to get through to him to ask if I should adjust my dosage on this or that," she says.
Still, most doctors resist e-mail because they're worried. They're worried that e-mail will add work to their already rushed days. They are worried that patients will bombard them with dumb questions. They're worried that they might get sued for some e-mistake, a liability nightmare. And they're worried about the "culture" shift that direct access will create (which, of course, is precisely what patients want).
"Doctors are used to controlling interactions with patients," says Dr. Tom Ferguson, a senior research fellow at the Pew project. "With e-mail, they are not in charge."
But, most important, doctors are worried, with good reason, that they won't get paid for their time. Currently, lawyers, accountants and many other professionals turn on the billable-hours clock the minute the phone rings. But doctors do not get a penny for the hours they spend on the phone with patients.
The solution is obvious: Pay doctors to e-mail their patients, either via insurance or directly from patients or some combination of both.
Granted, there are complications. For instance, if e-visits substantially replaced face-to-face visits, doctors could lose out, says Dr. Daniel Sands, clinical director of electronic patient records and communication at Beth Israel Deaconess. "Doctors need to be reimbursed fairly," says Sands. On the other hand, if e-mail with non-urgent cases allows doctors to have more visits with sicker patients whom they can bill at higher rates, doctors could benefit.
A key ingredient for safe patient-doctor electronic communication, Sands adds, is protecting confidentiality, something regular e-mail may not do.
One way is via a secure Web-based site, in which a patient uses a password and ID to get onto the site and from there e-mails the doctor. The doctor replies, via the Web-based site, and the patient then gets a regular e-mail telling him to check the site.
The Palo Alto Medical Foundation in California uses a similar system, says Dr. Bill Black, the medical director. "We never pass clinical information via e-mail. If your e-mail is at work, it's accessible by your employer." Regular e-mail can also be accessible to some e-mail service providers.
Indeed, that kind of protection will become necessary later this spring, when stringent measures to protect confidentiality on electronic medical communication set forth in the federal Health Insurance Portability and Accountability Act, or HIPAA, kick in.
Already, some insurers are getting on board. In Massachusetts, Blue Cross Blue Shield and Tufts Health Plan are looking into it. In California, starting this quarter, the Blue Shield of California Foundation will pay its doctors for online consultations, says company President Jeff Rideout, a physician.
This decision was prompted by a recent study sponsored by Blue Shield and ConnectiCare Inc. of Farmington, Conn. It involved 3,000 patients and 300 doctors. The insurers paid doctors $20 per e-visit, says Rideout. Patients loved it, he says.
In fact, the study found, e-visits actually saved money -- $1.92 per member per month.
The Blue Shield study tested a system developed by Relay Health Corp. in Emeryville, Calif. The system, says Dr. Giovanni Colella, Relay Health chief executive, uses a "structured interchange," a kind of questionnaire that patients fill out online to explain their problems to the doctor. All this communication passes through a secure Web site.
A similar system is Medem, backed by the American Medical Assn. and based in San Francisco. Dr. Edward Fotsch, Medem's chief executive, says the system has enrolled 85,000 doctors nationwide.
Others dispute whether e-visits will save money. Among the doubters is Dr. Steven Katz, associate professor of medicine and health management policy at the University of Michigan School of Medicine.
Katz and his team found, in a randomized study involving about 100 doctors and thousands of patients, that while e-mail can improve communication, it doesn't cut phone calls or office visits. It doesn't reduce the number of missed appointments either.
But an equally important finding, Katz says, is that patients "don't rain you with communications.... They send courteous messages, health-relevant messages, non-urgent messages that are totally appropriate."
Moreover, electronic contact may even be appropriate for sensitive issues such as psychiatric problems or HIV status.
Dr. Michael Grodin, a psychiatrist and director of medical ethics at the Boston University Schools of Medicine and Public Health, says that e-mail allows some people to bring up issues they otherwise wouldn't address.
"People will talk about things in writing that they won't talk about in person."