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A Time of Change

July 1, 2007
by Lyle Berkowitz, M.D.
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New technology-enhanced care models may change everything. Will you be able to adapt?

Today's physicians need to be aware of an increasing number of new, technology-enhanced care models being driven by consumer demands for better pricing and more convenient access to their healthcare providers.


Lyle Berkowitz, M.D.

These new models—which include both Web-based care and non-traditional office settings—may improve efficiency and volume for physicians, but may also compete with established practice patterns. Combine this with a rising number of consumers having more control of their healthcare dollars, and physicians need to consider how they can better serve their current patient population or risk losing patients to those who do.

How these new models affect a physician's practice will be determined by a variety of factors, including geography, payer mix, regulatory controls, provider shortages, and just as importantly, physicians' responses to these new delivery models. This article will explore two of the most important consumer-directed, IT-enabled changes taking place, and provide a basis for physicians to evaluate their own practices in light of these evolving practices.

Online communication

In today's wired world, many patients want to interact as easily with their doctor's office as they do when they manage their banking accounts, make travel arrangements or buy books and other goods online. Even as far back as 2002, a Rochester, N.Y.-based Harris Interactive Study found that about 70 percent of patients with Internet access wanted to make appointments, refill prescriptions, and get test results online, while more than 75 percent wanted to ask their physicians questions online.

To drive the importance home, nearly 40 percent said they would even pay for the time- and money-saving convenience of being able to do these services online. A repeat of this Harris Interactive Study in 2005 found almost identical results. And perhaps more importantly, a separate survey from Black Diamond, Wash.-based Osterman Research in 2003 found that more than one-third of patients would consider switching doctors for the ability to communicate with them online.

Using regular e-mail would allow for most of this functionality, but that has not gained great acceptance by physicians due to concerns about authentication and security, inability to control the content or organization of the inquiries, and difficulty in creating and enforcing a fair compensation model.

Fortunately, various electronic health record (EHR) systems and a variety of independent Web-based messaging companies (e.g. RelayHealth, Emeryville, Calif.—purchased by Alpharetta, Ga.-based McKesson in June—Medem, San Francisco; Kryptiq, Portland, Ore.) are solving the authentication and security issues, while also offering the ability to charge for online "visits."

Using these services, patients can go to a password protected Web site and send in a secure message to physicians or their staffs. These systems are already in place and are growing quickly. In fact, the healthcare giant Kaiser Permanente (Oakland, Calif.) has publicly announced its intention to provide just these services (clinical e-mail, prescription refill, appointments, lab results and a patient-focused medical record) to all 10 million of its members within the next two years.

Two examples of clinical utilization bear further discussion. The first is the ability for a physician to send patients summary and/or full details of recent test results. The patient thus has a more formal record of what happened and a physician can better track whether patients actually view their messages.

The second important use involves a patient-physician interaction for a non-urgent medical problem (e.g. cold symptoms, or chronic disease follow-up). In this scenario, a patient fills out a structured questionnaire online, his or her physician reviews it online, and then either helps set up an appointment or responds to the patient with a plan, and possibly a prescription, to treat the problem. In the latter case, patients or their insurance company would pay an established fee to be able to complete the service.

This can be a major win-win for patients and physicians. Patients appreciate being able to communicate when it is most convenient for them. They might send in a question from their home computer at 11 p.m. and then retrieve the answer the following day at work. Like e-mail, this asynchronous communication is much easier than waiting on hold or playing phone tag—one of the most frustrating things a patient can experience. And even more valuable for some patients is the option to complete a Web-based encounter fully online and thus not have to leave work to get a simple problem addressed.

Physicians, meanwhile, can benefit by improving patient satisfaction, decreasing call volume, strengthening their patient-physician relationship, and creating a new revenue source. Additionally, at least one webVisit study, sponsored by Blue Shield of California and conducted by investigators at the University of California, Berkeley, and Stanford University, found that taking care of simple issues via the Web meant physicians could have more time in their schedules for complex visits, for which they may be better compensated.

Risks with these Web-based messaging systems include managing expectations about the timeliness of responses, making it clear that patients should not use the system for any urgent problems, and addressing the associated costs and learning curve that comes with any new system. Additionally, by making it easier to communicate with a physician and his or her office, there is the risk of increasing the total volume of messages coming into an office. Some physicians may see this as an increased burden, while others may see this as an invaluable opportunity to provide a higher level of care and differentiate themselves from their competition.

In-store clinics

One of the hottest new trends is the proliferation of retail-based health clinics being opened in drugstores and supermarkets (e.g. Take Care Clinics, Conshohocken, Pa.; RediClinic, Houston; MinuteClinic, Minneapolis). These clinics are usually staffed by nurse practitioners (NPs) who use an EHR system customized with standardized management protocols for the 30-40 conditions they treat. They focus on quick visits for minor issues such as sore throats, sports physicals and flu shots and charge between $30 and $80 depending on the visit type. Some insurance companies will even contract with these firms so patients only pay their normal co-pay.

While some physicians are worried about losing market share, it is important to note that these clinics are not looking to be the medical home for patients. Rather, they plan to have relationships with local physicians to help take care of the estimated 60 million patients who do not have primary care providers today.

Physicians need to consider what their relationship will be with these new clinics. A good relationship could provide an important referral service for new patients, as well as a convenient option for patients with minor issues. The results could be increased new patients, improved patient satisfaction, as well as decreased phone calls and minor visits, thus providing more clinic time for complex and better-compensated visits. On the other hand, if a practice relies on minor problems as a significant amount of its volume and/or feels it is critical to the patient-doctor relationship to see patients for all issues, then it needs to consider how to offer competitive options. These might include expanded hours, decreased prices, and Web-based visits as described earlier.

Right now, only a few hundred clinics are open, but it is estimated that several thousand will open in the next few years. However, to be successful they have to address two major challenges: how to differentiate themselves from the urgent-care clinics that are already established, and how to adequately staff these clinics from a limited national pool of NPs. Physicians should be aware of these challenges and be prepared for further technical innovations that could cause additional cooperation or competition.

The most obvious technical innovation from these new clinics will be their ability to use computerization to streamline the workflow process by having a computer do almost all the check in, evaluation and management of the patient.

In fact, it is estimated that 80 to 90 percent of the time the presenting problems will be very straightforward, making this a very reasonable approach for this "low hanging fruit." And when a patient answers anything that might signal a "red flag," the system will tell the NPs to send the patient to see a physician for further evaluation. If successful, this process could both increase efficiency and decrease costs, while ensuring a standardized and high quality visit every time.

Another option these clinics might pursue is to create a telemedicine system that allows for more experienced professionals to oversee multiple clinics at once. While this may seem far fetched at first, the truth is that the first telemedicine-enabled health clinic for minor visits actually opened in August 2006 (Georgia based Health-e-Station).

The future is here



The future presents an even more interesting landscape. New models involving physician extenders, telemedicine, and robotic-enhanced encounters are already starting to meet consumer demands for a more convenient and lower priced system. As these innovative systems start to appear, primary care physicians should start considering what would happen if more and more "minor problems" were addressed via other mechanisms.

For example, what if an insurance company set up a centralized clinic that focused solely on taking care of upper respiratory infections via a phone call or a Web-visit, and did not charge a co-pay for its use?

  • Would your patients use this system or come into your office to handle this type of problem?

  • Will you offer them services that allow for less traditional models of care, such as Web-based visits?

  • Is your practice prepared for a shift to more complex office visits in the situation where simple visits are taken care of by other entities streamlined for just those situations?

Meanwhile, specialists should consider what would happen if patients could easily and cheaply obtain consults via telemedicine visits to external centers of excellence. Places like the Cleveland Clinic are already doing Web-based second opinions; tele-psychiatry is a booming market; and public companies like Nighthawk Radiology (Coeur d'Alene, Idaho) have radiologists stationed all over the globe to read radiology films any time day or night for hospitals and ERs that cannot afford full-time coverage themselves.

Software from companies like Visicu (Baltimore) allow for remote monitoring of ICU patients at multiple facilities by an intensivist centralized at one location. And how about robots? The Robo-doc system from InTouchHealth (Santa Barbara, Calif.) can roll around a hospital's floors and allow offsite doctors to "virtually visit" their patients at any time using a two way video monitor, while Sunnyvale, Calif.-based Intuitive Surgical's da Vinci Surgical System can improve precision and allow a surgeon to work from a remote location.

It is not unreasonable to imagine that these same technologies will eventually be in common use in regular offices and in-store clinics. Thinking about these scenarios now will help make sure physicians keep their practices healthy and competitive in the years to come.

Lyle Berkowitz, M.D., (lyle@drlyle.com) is a practicing internal medicine physician and the medical director of clinical information systems for the largest primary care group in the city of Chicago. Additionally, Berkowitz serves as an independent consultant to a variety of healthcare organizations and vendors, and is a member of the Healthcare Informatics editorial board.

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