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Topics : e-Visits

e-Visits:
The Tipping Point - Are We There Yet?

By Rhondda Francis


The Patient's Perspective
E-visits and e-services via a web-based service – aka patient portals – are a very convenient way for patients to get access to their primary care physicians for non-urgent health care or follow-up treatment. E-Visits eliminate the inconvenience of patient travel and wait time on hold. Because the communications are typed and archived, there is the assurance of accuracy, continuity— reducing the risks for potential errors. Patients can interact with their own personal health record, which includes and organizes their e-communications, test results, prescriptions, etc. And best of all, patients overview and think through their communications with their health care providers at their own pace and a time of of their choosing. The secure communications and web-based applications that these patient portals provide enable patients to better collaborate in their own health and wellness.

laptop with a mountain view...

E-Health is in Demand
About three quarters of Americans have Internet access of some sort and American health care consumers say they want e-Visit access. According to a 2006 Wall Street Journal Online/Harris Interactive poll,  62% of Americans said physicians' use of email to communicate directly with them or a family member would influence their choice of a doctor a great deal or to some extent. About three-quarters of all respondents said they would like to use e-mail to make appointments, receive reminders for visits, and communicate directly with their doctors.

Adoption Among Physicians is Slow
While rates of e-Health technology adoption among physicians have risen slowly but steadily, with roughly 1 in 4 physicians reporting that e-mail was used in their practice to communicate clinical issues with patients in 2005, up from one in five in 2001, according the Center for Studying Health System Change – about 75% of patients polled in the 2007 WSJ/Harris poll reported that their doctor does not currently offer e-Visits or other e-services. That would seem to indicate there's been very little change in overall physician adopting of e-communication technologies in the last few years.

The Physician's Perspective
So, if patients want and are beginning to demand e-Visits and other e-services, and physicians are devoted to improved access and patient care... why aren't more practices embracing patient portals?

Professional Liability and Patient Privacy Concerns
HIPAA privacy rules do not make distinctions on the means of communication so secure messaging does not raise privacy issues beyond those raised by face-to-face or phone communication. Handled properly, e-Visits and e-services actually have the potential to reduce provider risk and liability, because there's a complete record of communications and prescriptions. Before you begin offering e-Visits, TransforMED recommends you check with your malpractice insurance carrier for specific risk-management information and advice.

Workload Worries
Credible anecdotal reporting counters the objection of a flood of communications inundating practices. For busy practices, e-Visits can be more time-efficient than office visits or phone calls by shifting non-urgent communications to a more efficient channel that has the unique benefits of being organized, integrated, self-service, self-documenting and asynchronous. Physicians, especially, have been concerned that e-Visits and e-communications might overwhelm them. But the TransforMED model of care reminds us that quality care is provided not in episodic, illness-oriented, complaint-based care – but through patient-centered, physician-guided, team-based care.

Loss of Revenue

"At our clinic, the staff members encourage patients to complete an online visit if the patient doesn't have time to come in for an appointment, or if there is no room on the schedule on the day the patient is requesting to be seen."

Dr. Amy Mullins
Trinity Clinic Whitehouse

There have been claims that e-Visits may reduce physician revenues by drawing patients away from office visits to less expensive online consultations. Certainly the cost-saving hopes of payers pivot largely on this point. But others are finding that by shifting non-urgent medical issues online, they are able to make room for more acute office visits.  As one NDP participant, Dr. Amy Mullins at Trinity Clinic Whitehouse says  "At our clinic, the staff members encourage patients to complete an online visit if the patient doesn't have time to come in for an appointment, or if there is no room on the schedule on the day the patient is requesting to be seen." Certainly more research needs to be done in relation to practice finances and e-services. Until the evidence is in, practices should work to ensure that e-Visits are an addition to and extension of office visits, rather than a replacement for them. Seen as part of a larger set of changes, it's also useful to consider whether the time-savings might be shifted toward providing more time in the office for evidence-based health care issues and interventions that are more valuable to patients' long term health outcomes. With a major political contest looming, that allocation is part of a debate that is more and more relevant, timely and necessary.

Compensation and Lack of Reimbursement
For a long time, only a few doctors offered e-Visits under fee-for-service, subscription or annual fee arrangements, or sometimes for free. They were not reimbursed by payers at all. Payers were resistant to reimbursing for online consultations. However in just the last few years, the reimbursement landscape has begun to change rapidly, as payers have seen pilot projects and studies prove the value of e-Visits to the health of their members— and their corporate bottom line. Today, a growing number of insurance plans nationwide are reimbursing physicians for online consultations.

The Health Plan Perspective
Payers value innovations that create market differentiation for their products, reduce health care costs, improve the quality of care for members (especially for those with chronic disease, who account for a significant portion of total health care costs) and increase member satisfaction and retention.

The satisfaction and savings results of a few influential studies and a handful of pilot projects have been persuasive enough to payers that approximately 20 health plans have begun reimbursing for RelayHealth webVisits®. Notable among this group are several "heavy-hitters" such as Blue Cross and Blue Shield health plans in California, Florida, Missouri, Massachusetts, Tennessee, New York and Washington. In April 2007 CIGNA HealthCare for Seniors began offering free e-Visits and other online health care services through its physician network. In 2006 Kaiser Permanente implemented an "e-mail your doctor" functionality and Aetna began covering online physician-patient communications for members in California and Florida. Also in 2006, the Star Tribune reported that some of Minnesota’s largest health insurers, including HealthPartners and Blue Cross and Blue Shield, had begun to cover secure web-based visits,

The results of one 2002 study by researchers at Berkeley in California and Stanford in Connecticut showed strong patient satisfaction to the access, convenience, and quality of e-technologies offered through the RelayHealth portal. Physicians were also highly satisfied and the cost of care was reduced by as much as $1.77 per person, per month.  While that might seem like a small amount, as the study's authors noted, "...many other health plan activities produce smaller percentage reductions in per-member per-month spending and yet are highly valued by health plans."

Blue Shield of California has estimated that the use of online patient-provider communications tools by its members will save the organization $4 million a year in office visit claims. One of the health plan participants in the study, ConnectiCare, asserted "a greater than 5-to-1 return on investment, suggesting a dramatic opportunity to reduce costs while concurrently improving patient and physician satisfaction." ConnectiCare is now one of the health plans that reimburses for Relay Health webVisits®.

In 2004 the AMA established the CPT code 0074T for online medical evaluations between doctors and current patients. Insurers that recognize the code, and reimburse for associated claims require that the e-Visit produce a documentable action such as a medication change, ordering of a diagnostic test or a referral to a specialist. It's also worthwhile to remember there are models for compensation outside of reimbursement by insurance companies, including a low monthly subscription fee, a higher one-time annual fee and fee-for-service arrangements.

If the number of "health care e-services" pilot studies currently in process and the influx of venture capital and heavy-hitter IT players is any indication, the trend toward reimbursement will continue to expand.

The Bottom line.
The real reason to integrate e-Services into your primary care practice isn't consumer convenience or practice revenue or payer cost savings or business productivity. It's because research has shown that health care professional-patient communication is strongly linked to patient satisfaction, adherence to medical instructions and improved health outcomes. E-communications can enhance and extend the personal connections patients have with their doctors and providers, offering patients a sustained collaboration with their doctor and  more involvement in their own care. In a nutshell: e-communications are emerging as a key component in patient-centered care and patient-centered relationships.

Plus, with their low cost, relative speed and ease of implementation, and the flexibility of incremental adoption – with many potential synergies down the road – e-Health offerings via a patient portal can be an easy win.

If your primary care practice doesn't have an EHR or any current plans to begin using one, a web-based standalone secure messaging portal subscription is a very good, low risk first step. Plus, the habits and workflow practices and processes that you develop to support e-Visits and other e-services will translate to the more complex and difficult health care IT adoptions (such as EHR) that are on the horizon.

If you do have and use an EHR or practice management suite that accommodates e-Visits and other services, TransforMED recommends you use the integrated functionalities. While it might take longer to implement, there is significant "bang for your buck" in the efficiencies to be gained from an end-to-end integrated system of communications and documentation.

Regardless of the option that's right for your practice, the time is now. Because the day appears to be coming soon when financial incentives will reward primary care physicians – rather than just payers – for the investments they make in improving patient care and reducing costs. Should public payer (CMS) reimbursement emerge parallel to that provided by the private health plans, there would no doubt be a dramatic effect on adoption and impact.

Online consultations and e-services are coming. It pays to be both prudent and prepared. Start your investigations, preparations and decision-making now so that you'll be poised to act when the reimbursement landscape is right for your practice.

 


 


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