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Time to Take the “E” in Evidence-Based and Turn It into E-Visits

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Friends, the question, as we hurtle into the middle of the second decade of the 21st century, is no longer, should we be developing e-visit programs for our patients and communities, but rather, how we can harness the tremendous potential embedded in a variety of technologies to move forward to provide the care that patients need—at a time when technology can help us to better bring patients what they want and need, when they want and need it.

Is there still a great deal of resistance among some physicians towards electronic visits and virtual care programs? Sure there is. But, check out the research:  a study done at UPMC, where we launched an e-visit program in 2009, showed that e-visits are clinically comparable to in-person visits, and indeed, that in terms of effectiveness, they are similar. A group of researchers led by Ateev Mehrotra, M.D., and including myself, published a research letter in the Archives of Internal Medicine (published online on Nov. 19, 2012; print version JAMA Internal Medicine Jan. 14, 2013), found that “Patients appear generally satisfied with e-visits,” and what’s more, “The fraction of patients with any follow-up was similar” to those requiring follow-up for an in-person visit. As we noted, “Follow-up rates are a rough proxy for misdiagnosis or treatment failure, and the lack of difference will therefore be reassuring to patients and physicians. Among e-visit users,” we found, “Half will use an e-visit when they have a subsequent illness in the next year.”  That feels like a trend to me.

All of this tends to validate the strategic decision that we made some time ago at UPMC, to make e-visits a normal part of the panoply of care delivery offerings in our organization. We offer our patients a patient portal, MyUPMC, and when patients sign into MyUPMC, they see a drop-down bar that says, “What would you like to do? Renew a prescription, communicate securely with your doctor, get treated online?” And if they choose to submit a request for an online/AnywhereCare visit, they are led through a series of questions to ensure appropriateness of the e-visit. Our own physicians designed the algorithm for this. And it’s working for all of our patients, including in some cases for first encounters. Indeed, we changed our protocol last November from e-visits being permitted only as follow-ups to in-person visits, to allowing them for a range of first encounters.

And what we’ve been finding is satisfaction among patients, and relief among physicians. The fears that most doctors, even some UPMC doctors, had about being flooded by patient electronic messages, turned out to be unfounded.

So, for example, if you’ve got sinusitis or a cold, or sunburn or a urinary tract infection, or herpes zoster, we’ll render care to you for $38. You have to be 18 years old or older, otherwise, it has to be for a proxy who’s an adult, for 3-17 year olds. And we provide the opportunity via the Virtual Care Collaborator, a secure audiovisual communication tool developed by UPMC’s Technology Development Center (think Skype on Steroids). So as long as the consumer’s computer can capture images/video, we’ll do the image/video capture, and that will facilitate electronic care for you as a patient.

Meanwhile, back to the study led by Dr. Mehrotra that I referenced earlier. What we found was this: for UTIs and sinusitis, when you compared office visits and e-visits, the clinical outcomes were virtually the same. Not surprisingly, in an e-visit, we gave more antibiotics. And, in the office visits, it cost more because we did more testing, which wasn’t surprising, given that there is a stronger natural impetus towards more robust testing in that environment. The e-visit in effect had more antibiotic usage, but in aggregate, the e-visits still cost less. And that was iteration version 1.0. Now, in version 2.0, we’re tracking our antibiotic usage and working towards providing care and assessing that care, in a more algorithmically driven fashion.  Protocols and pathways and less, “art of medicine” decisions with respect to most conditions submitted are now the norm.  I expect that in addition to the decreased cost, we will soon see an analysis which shows that our antibiotic usage between in person and e-visits will equilibrate.

Given all that we’ve learned so far, should it come as a surprise that our e-visit program has been so successful and such a hit with both patients and physicians? Really, it shouldn’t. Let’s face it: the world is changing quickly, and we live in the Internet Age. Think about the expectations of younger healthcare consumers for immediacy of response and action. But even with people my age (“young” middle age), we’re becoming accustomed to split-second responses, and consumer-centric service. Meanwhile, there will of course always be a place for traditional doctor office visits, but the co-pay for healthcare consumers for that traditional visit is rising higher and higher, and as healthcare reform brings more insured patients into the system even at a time that our population is aging, and is experiencing increased rates of chronic illness, the pressure on the healthcare delivery system to provide care for everyone is only going to increase.