By DAVID C. KIBBE

At a recent symposium on Online Care in Hawaii, two Family Physicians and a primary care Internist participated in a panel in which they described their experiences with Online Care and Telehealth.

– Ron Dixon, MD is the Director of Massachusetts General Hospital’s Virtual Practice Project. He talked about his practice using videoconferencing for patient visits, and discussed results of his research on e-visits, which includes the largest randomized comparative trial to date of videoconferenced medical visits versus face-to-face visits.

– Peggy Latare, MD is Chief of Family Medicine at the Hawaii Kaiser Permanente Medical Group, and the physician lead charged with the implementation of KP HealthConnect in the Hawaii region.  For over two years she has used Kaiser’s online tools on a daily basis for communicating with and caring for her patients.

– Dr. Michele Shimizu, a native Hawaiian, is a family physician in private practice on the Big Island, and uses the American Well platform for Online Care to maintain relationships with her former patients on Oahu, despite being separated by more than 100 miles of Pacific Ocean, and to treat new patients as well.  She uses the web-based Telehealth system made available through HMSA, the Blue Cross Blue Shield of Hawaii ,  on average three times a day, mostly in the evenings.

These physicians are at the front line of a trend that will almost certainly grow at an exponential rate over the next several years.   It strikes me how entirely comfortable they are with the online experience of e-mail, web chat, and video visits, and by every indication so are their patients.  Dr. Dixon’s studies indicate that patients rate the quality of the online experience on a par with face-to-face visits, and they prefer them when consideration of waiting times is included.   Dr. Latare has found that e-visits help her keep patients aware of their medical conditions and less likely to miss check ups and preventive care activities.  And Dr. Shimizu, who was initially surprised that her patients were so familiar and comfortable with the technology, now finds that Online Care is a valuable means of increasing patient access and more than adequate in history taking and effectiveness of therapy, even for new patients.And then there is the issue of cost and efficiency.  A recent Kaiser study published in Health Affairs found that between the implementation of KP HealthConnect™ in 2004 and 2007, office visits per member decreased 26.2 percent.  During this period total scheduled telephone visits per member increased nearly 900 percent, and secure e-mail, which began in late 2005, increased nearly six-fold by 2007.    This finding may not be so welcome to physicians or groups who rely entirely on fee-for-service payment and are not compensated for Online Care interactions with their patients.  On the other hand, these findings support both the arguments for charging a fee for Online Care — which is the methodology used by HSMA through the American Well platform in Hawaii — and for a management or care coordination bonus to physician groups who deploy these tools as part of their routine care delivery within the Medical Home framework.  The drivers for adoption of Online Care and Telehealth seem fairly strong and convincing according to these and other experts: increased convenience for the patient; better access to care where distance, primary care shortages, or both, make getting to an office or hospital difficult or expensive; physician interest in and familiarity with the technology of email, Skype, and EHRs; and pressures from Medicare and Medicaid to make care more affordable across a broad spectrum of care modalities, but especially for beneficiaries with chronic illnesses who are at risk for high rates of ER visitation and hospitalization.  But there are still some challenges before Online Care becomes truly mainstream.  At the symposium in Hawaii I led a panel on policy issues associated with Online Care in which these issues were easily identified. – Roger Netzer, MD, the Chair of the Hawaii Medical Board was admittedly skeptical. He wanted to make sure that online care was safe, and challenged the group to consider whether it was effective and ethical to treat patients without the opportunity to do a physical examination. But he also said that he was learning about these new online possibilities, and more favorably impressed all the time as his colleagues gain experience.

– State Senator Rosalyn Baker has been the champion of remote health & telemedicine in Hawaii — not least because her constituency on the island of Maui is a plane ride away from the specialists in Honolulu. She led the effort to change Hawaiian law that now permits physicians using Online Care and Telehealth to establish “a patient relationship,” and therefore treat new patients using these technologies.  – Margaret Laws (from the California Health Care Foundation) explained her vision of how innovative technology could deal with access disparities, and spoke about the many uses of Telehealth in California.  Although California law supports the use of Online Care and Telehealth by physicians and other providers, she admitted that there were still pockets of opposition among physician groups, especially those who are compensated by fee-for-service and view these new online visits as undermining their economic well-being.

The American Well e-visit platform may help to solve some of these concerns.  For one thing, it is offered exclusively by health plans such as HSMA, and includes the payment methodology necessary to compensate all physicians who engage in Online Care.  In essence, they are reimbursed immediately. The rates for an Online Care visit vary by time spent with the patient and by specialty, but in general they are equal to or exceed office-based care on an hourly basis.   Furthermore, physicians have access to a prospective patient’s health care claims data, and may even have additional information from the patient through Microsoft HealthVault’s PHR, prior to and during the Online Care visit.   Physicians are able to flexibly schedule their availability for Online Care visits, and they need not accept a patient for online consultation if they deem the reasons or circumstances inappropriate or unsuited for Online Care.But there is still the tricky issue of when there is a “relationship” between doctor and patient.

– Should there be a requirement that the patient and doctor must establish, previous to the Online Care visit, a relationship through a face-to-face visit?   The Hawaiian state legislature voted that there should not be such a requirement.  However, most medical specialty organizations have policies that recommend strongly that Telehealth be employed only with established patients, meaning those patients the doctors has met and examined face-to-face.  – What are the key actions or principles that define a therapeutic relationship?  Doctors in the majority appear to think that a face-to-face meeting is required, but then don’t necessarily practice what they preach.  For example, many physicians take call for other doctors’ patients, and will take telephone calls from these patients and prescribe treatments, without ever having met them.  – If a relationship is defined by the willingness of the individual doctor to treat a patient through Online Care and Telehealth, how are fraud and abuse to be avoided?   Is the requirement of a face-to-face visit a reasonable proscription in the Internet age, or simply a way for doctors to protect their guild privileges and incomes?

These questions, and others like them, are going to be with us for some time, and are worthy of evaluation and study.And, finally, we should consider whether Online Care and Telehealth technologies may help qualify a physician or organization for federal HITECH stimulus dollars, by fulfilling the criteria for “meaningful use” to which those funds are associated.   It seems doubtful that engagement in Online Care and Telehealth visits alone will convey a “meaningful use” of health IT under the new law.   But Internet-based technologies make it possible to add functionality to a platform such as the one developed by American Well, or, conversely, to add Online Care modules to patient registry programs, EHR-lite applications, and even e-Prescribing software.  This creates a whole new landscape for health IT that includes options for patient-doctor communication and e-visits of various kinds that were hardly imaginable a few short years ago.Harvard physicians and IT experts Kenneth Mandl and Isaac Kohane recently published an editorial in the NEJM in which they stressed the need for flexibility in the infrastructure that HITECH expenditures are used to finance:

A health care system adapting to the effects of an aging population, growing expenditures, and a diminishing primary care workforce needs the support of a flexible information infrastructure that facilitates innovation in wellness, health care, and public health.”

The authors then describe their views about how to obtain that flexibility through the deployment of EHR technology that is “not only interoperable, but substitutable.” They propose that components as various as e-Prescribing, decision support, documentation, and patient panel management/registry can now be assembled within a Web-based browser environment, allowing providers not only the ability to mix-and-match applications based upon their needs, but also permitting the apps to be replaced if competitors come up with better products.  They compare this mix-and-match design with the way that Google allows users to create a personalized home page which can then be populated with “widgets” — plug-in programs for document creation and management, calendars, weather reports, etc.  The iPhone is another example in which many hundreds of applications can be downloaded and used for all sorts of purposes, now including health records and decision support (see HealthCloud and iTriage).The platform approach to health IT software design is something that I’ve also written about recently, naming this new breed of flexible and low cost applications Clinical Groupware, primarily because a hallmark of early entrant companies, e.g. SharedHealth, RMD Networks, and VisionTree, is support for the complex communications and teamwork necessary for health care.   In this approach, Online Care and Telehealth could become component applications used within an EHR technology, which has other components.  HHS might encourage this design for EHR technology by recognizing and respecting the demands on physicians’ time and effort, and structuring incentives to reduce the demand for excessive documentation in support of medicolegal defense and billing.This is an area that I  follow very closely, and hope to keep you posted on new developments from time to time.David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.