Monday, March 31, 2008

A Reality Check for Virtual Patient E-Mail Visits

As regular readers know, the Disease Management Care Blog is somewhat skeptical about the value of unbundled stand-alone technology in primary care, especially when it comes to chronic illness. So it was with a jaundiced eye that it read the Sunday Philadelphia Inquirer article on virtual visits. As far as the DMCB can tell, this is an email-like function that can be used to make appointments, obtain test results, get prescriptions or ask questions. According to the Inquirer (and the WSJ Health Blog) health insurers are overcoming their inertia, have seen the light and are finally “paying” for this service.

Good news you say? Using Pub Med as well as High Wire Press, the DMCB was unable to find any peer review research showing that this is quite the breakthrough the worshipers at the Health Information Technology Tabernacle would have you believe. While using email to get renewals or make appointments seem to be a no-brainer, can patients really can fire up their computer, author an email about a medical issue like interpreting abnormal test results or bothersome symptoms, hit 'send' and receive truly helpful communication back from Dr. M Welby? Do physicians embrace this technology and, now that they’re paid for it, they will come?

There is good scientific literature that shows email-based communication increases patient and physician satisfaction. Physicians are also not unfamiliar with the concept, and many are already using email gratis, especially in large multi-specialty practices. Interestingly, age and gender of the physician has no correlation with the likelihood of it being used.

That’s the good news. The bad news is that there is no solid evidence that this increases the quality or decreases the cost of care. The DMCB cannot find any prospectively randomized studies in which patients were allocated to usual care vs. email virtual visit care to determine if there is any impact on outcomes for any clinical condition. As far as cost goes, there is one retrospective report from Kaiser that shows that e-mail style virtual visits were associated with fewer clinic visits and phone calls. The DMCB is willing to bet that Kaiser still filled the clinic schedules with patients, didn’t downsize as a result of the better efficiency or decrease their insurance rates. In addition, email is better suited for self limited episodic problems anyway, which are not a large cost in the health care system. Last but not least, there is research showing this approach to care favors the socioeconomic group that already has the least problem accessing and paying for healthcare: white males.

It doesn’t end there. According to the Inquirer, payment rates for each interaction will range from approximately $25 to $35. The basis for this figure is not only unknown, but it can be argued this is simply one more example of the dysfunctional commoditized piecework payment system that must be endured by providers. Many may end up seeing this for what it's truly worth.

HIPAA and the health care system’s ceaseless talent for creating process is also likely to make this less user-friendly than many would anticipate. The DMCB anticipates password protected web clients and having to get through several pages of categorical questions (‘fever?, yes-no,’ and ‘list your medicines here’) along with many warnings and disclaimers before patients truly and finally get to 'send.'

And once it is sent, will physicians really be at the receiving end and waiting to reply? More likely many messages will be routed to same nurse triage system who will use new menu-driven responses that look and feel like the old menu driven responses ('take two aspirin and email us in the morning').

In the end, however, the DMCB is a fan of virtual visits. If a) physicians are fairly compensated, b) the fee meets cost plus margin, c) it is reasonably user friendly, d) doesn’t exacerbate health care disparities, e) the visits are linked to robust decision support, f) there is supervised teaming and oversight, g) there are links to a medical record h) there are ongoing studies to help us better understand its value and i) the value proposition is extended to chronic illness, it’s a good idea. It’ll be a great idea if it’s integrated in those other “systems” level initiatives that promise to redesign primary care. In the meantime, I don’t blame the commercial insurers for their reluctance and I’m not sure their enrollees realize what $25 worth of virtual care really entails.

By the way, in the spirit of getting real versus all that virtual hokum above, the DMCB points out that disease management vendors have used email visits in their systems of care with many of the ingredients described above for years. They provide it as part of their global fee for the global suite of services. The DMCB suspects patients are getting their money's worth.


Unknown said...

I love this topic. Here's a few of my thoughts:

I think the use of "virtual visits" is still getting started and that more formal means of analysis (prospectively randomized studies) will/need to be done in the future.

There are definitely areas where virtual visits are more appropriate. Some of these being things that are not even happening with the current situation...such as reminders, follow ups for outcomes, imparting new information.

The digital divide does need to be addressed. Utilizing other modalities, such as cell phones, telephones in general, and other technology, more people will be included.

You hit the nail on the head with reimbursement. This needs to be thought out better and implemented.

I don't think these types of messages will *ever* be included in in email. Typical email is sent as clear text, with anyone able to read it as it winds its way through the Internet. Dropping a message into your general email account might allow other's whom you've shared that account with, to read it as well. (Not sure if I'd want my boss seeing that's my third appointment to an oncologist this month.)

Triage of messages will occur, as well as menu driven responses. Because when properly done, they are the most effective for both provider and patient.

A while back I wrote up a paper describing a proper patient/provider messaging system that addresses many of these issues:

One of the biggest reasons virtual visits will happen...Patients will expect it.

Now a virtual visit in Second your illustration another topic!

Jaan Sidorov said...

Excellent points! I agree there is a role for these visits and that the science is still being developed - and the market will demand it. One reason your paper didn't get the attention it deserved is maybe because it was ahead of its time.