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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.


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