Physician-Patient E-Mail Can Save Both Time and Cost

As a new employee with HealthLeaders Media, I joined the company health plan, and needed to transfer my prescriptions from a mail-order pharmacy in Florida.

It turned into a bureaucratic hassle.

So I e-mailed my internist asking if he would write me a new prescription that I could send to my new plan's pharmacy.

"Of course," he affably replied.

No need to schedule an appointment for an office visit. No need to wait three to six weeks. No need to waste his time or mine for something so routine. My prescription was in my snail mailbox a short time later.

Just as the Obama administration this week is encouraging providers everywhere to be creative in reducing unnecessary costs, it seems as if both my doctor and I were doing our small part too.

Greater exchange of health information between physicians and patients through e-mail is the wave of the future, says Joe Scherger, MD, vice president for primary care at Eisenhower Medical Center, in the Coachella Valley near Palm Desert, CA. It's one of many easy ways to reduce unnecessary health costs for providers, health plans, and patients. In rural areas or places where transportation is a challenge, it can save hours of time for patients and avoid many hours of lost time from work or family responsibilities.

It can also improve patient care by increasing the linkages and communication between patients and their physicians. It makes patients more pro-active about taking responsibility for their health. Given the ability to e-mail their physicians, they are more engaged in the process.

Scherger and many other physicians who use e-mail to advise their patients say that 50% or more of visits to the doctor aren't necessary; they're just traditional. It's not always essential for the patient to return to the office for the results of a test, for example.

The care is necessary, absolutely, they say but providing that at all times in an office setting is not.

According to an article in the March/April Health Affairs, Kaiser Permanente documented a decline of costly office visits to primary care providers by 25% and to specialists by 21% for specialists. The improved efficiencies were seen between 2004 and 2005 in an ambulatory population of 225,000 enrollees after implementation of a comprehensive electronic health record system including secure e-mail messaging and telephone office visits.

But that's a closed system that many providers think is not transferrable to the typical physician practice.

Doctors and payers have to figure out a way to get paid for their time looking through their patients' e-mail throughout the day, double-checking with charts and records and responding appropriately. For the most part, insurance plans and government programs so far won't pay for it although Medicare has launched some demonstration projects.

The system also must devise a way to educate patients on what are appropriate topics for e-mail, and what should have them calling 911 or getting themselves quickly to an urgent care setting. Conveying information about a rash or a blood glucose reading may be entirely appropriate via e-mail, but complaining about chest or sharp abdomen pain is not.

Soon to come to Palm Desert under Scherger's direction is a program called "Eisenhower Personalized Care-$365," a plan by which patients pay $1 a day for "open-ended e-mail communication with their physicians that's apart from necessary office visits," he says. The endpoint is "better management of chronic illnesses resulting in reduced hospitalizations, and reduced costs."

Scherger, and a growing number of physicians around the country, say this hybrid model of physician practice, by which patients pay a fee out-of-pocket for the right to get e-mail care in addition to office visits reimbursed by their health plans or other payers, is the best bang for the buck.

"This is the sort of system that works best for people with chronic conditions such as diabetes, asthma, heart disease, and depression," says Scherger, former editor of the journal Hippocrates, a member of the Harvard/Kennedy School of Government Health Care Delivery Policy Project.

You'd only have to be an Eisenhower patient to be eligible.

Certainly the concept–sometimes called "concierge medicine" is not new, and according to recent reports, even the slumping economy has not dampened patients' willingness to participate. The very name implies that only people who can afford expensive hotel rooms would sign on.

Not so anymore, says Scherger, who formerly worked with Revolution Health and E-Doc, and who has held a special interest in the redesign of office practice using IT. For patients with multiple issues, there would be vast savings in avoided co-payments, for example.

Scherger says he borrowed the model for Eisenhower from Charles Kilo, MD, of GreeenField Health in Portland, OR, an internist he called a "guru" on the hybrid model of healthcare.

Kilo says he launched the concept in 2001 after spending time creating "idealized clinical office practice design" with the Institute for Healthcare Improvement.

"Most primary care physicians for the most part are on a hamster wheel, seeing a new patient every 15 to 20 minutes," he says. "There are multiple visits for multiple problems in the same patients and a high rate of physician burnout, which is not also healthy for the patient."

"We are very deeply engaged in system change," he says. GreenField health's success, he says, is in part because of its full electronic health record, secure messaging system, and efficient connectivity to laboratory results. Patients receive responses to e-mails within 24 hours, but usually within three or four, Kilo says.

"I order a lab test, it gets done, it's generally back on my desktop in 12-18 hours. I can sign off on it and get results back to the patient," he says.

GreenField's nine physicians charge prices for e-mail privileges ranging from $250 for children under age 10 to $650 for patients age 60 to 70. Today, he says, his four-physician practice has several thousand participants.

Questions come in about diarrhea, sore throat, or rashes, sometimes accompanied by digital photos, he says. Patients e-mail from as far as Mexico City and Italy, he says, and some 1.5 hours away on the Oregon coast. Many patients with blood pressure issues can e-mail their results.

The system also improves efficiency and communication with patients and instills better compliance with their prescribed regimens. That may be in part because patients may be more eager to use what they're paying extra to have.

That goes for patients in his practice who are on Medicaid and Medicare as well, many of whom are allowed e-mail privileges for free, he says.

He predicts a much more expansive use of e-mail by physicians to interact with their patients in the next few years. "Surveys say many doctors are already doing it, but what that means is that they gave their e-mail addresses to 10 patients. Today, most doctors are not doing it as a core part of the way they practice. I hope we get there. We need to get there," he says.

Does he have any proof that he's saving money?

"We have data from one insurer who says that we're 20% less expensive than the average practice in the area," Kilo says.

In time, he says, many more physicians will be using e-mail with their patients. And newer models of reimbursement will actually pay for it.