November 9, 2009

A New Kind of Office Visit
By Selena Chavis
For The Record
Vol. 21 No. 21 P.  8

Healthcare professionals suggest that interactive patient portals will improve patient experiences and overall quality of care.

School is back in session, flu season is in full play, and it’s business as usual in the average physician waiting room. Add fears about the H1N1 virus to this year’s scenario, and the commotion in many physician offices becomes almost unmanageable.

“The challenge you have in ambulatory care is that there is too much busyness occurring around the front desk,” says Stephen Rosenthal, president and chief operating officer of the Care Management Company in New York, a subsidiary of Montefiore Medical Center, the University Hospital for the Albert Einstein College of Medicine. “No one has a good experience.”

It’s a familiar scene: Parents bring their children in with a multitude of viruses spreading throughout the schools; adults seek early intervention to flu strains to minimize absences from work; and most doctors will quickly acknowledge that many who enter the front door just simply don’t need to be seen in person.

Consider other scenarios where patients just need to come in for a follow-up visit to discuss test results or findings from routine procedures with their physician. If another alternative were available, healthcare professionals agree that many otherwise “healthy” patients would prefer to avoid making another appointment and fighting traffic only to enter a waiting room full of communicable illnesses.

The answer? Many believe that interactive patient portals may provide a cure to the waiting room game in many physician practices, as well as offer access to medical specialties for patients living in remote areas. It’s a better alternative to the clinical setting, as it’s the familiar surroundings of a patient’s home.

“About 40% of my practice has signed up to e-mail me. … I get between three and six e-mails a day,” notes Rahul Parikh, MD, a pediatrician with Kaiser Permanente in northern California who adds that currently, there are about 3 million patients in Kaiser Permanente’s system using e-mail to communicate with their physicians. “It’s convenient for physicians and patients. I can make a decision about whether or not I should see a child based on that interaction.”

Originally designed as a way to optimize workflow efficiencies, reduce costs, and maximize reimbursement opportunities, portals are evolving into a mechanism to deliver care. Patients and physicians are finding that the benefits go well beyond previous offerings of static applications such as making appointments and paying bills.

Louis Cornacchia, MD, CEO of New York-based Doctations Inc, believes portals will continue to evolve as a way to empower patients through a network of healthcare delivery that generates medical documentation in all venues: the physician’s private office, the physician group’s office, the ambulatory surgery center, and hospitals of varying sizes.

“This whole system creates a collaborative network that, in turn, creates more efficient and more effective care,” he says. “The patient is the system; the doctor is the collaborator.”

Electronic Patient Engagement
My Health Manager, the PHR provided by Kaiser Permanente to its adult members, allows participants to securely access their records from home, as well as e-mail their physicians; order prescriptions; make, change, or cancel appointments; and even view lab results. All of these interactions are done on the Web at no extra charge.

Parikh points out that patients currently generate more than 600,000 secure e-mail messages each month to doctors and clinicians, and more than 1.6 million lab test results are viewed online, making them two of the more popular features on My Health Manager.

And age does not seem to matter. “Our largest demographic that is using [the patient portal] is between [the age of] 40 and 50,” Parikh notes. “Those patients who are older say they are very satisfied with My Health Manager.”

Rosenthal notes that Montefiore Medical Center’s Internet-powered patient portal also does not see any differentiation along socioeconomic lines. The offering—MyMontefiore—is a product of RelayHealth that was introduced as a pilot program in 2006 and later rolled out to all 21 Montefiore Medical Group office sites in the Bronx and Westchester.

Explaining that there was concern early on that the socioeconomic status of the Bronx would not lend well to this type of undertaking, Rosenthal notes that the organization has been pleasantly surprised. “What we discovered are things like Internet access and cable—items that can be bundled at low costs—actually become the primary source of entertainment for this group,” he says. “The Bronx is one of our most connected communities.”

Approximately 40,000 patients in the Bronx and Westchester who now receive their care at Montefiore Medical Center use the online service, and more sign up each month, according to Rosenthal, who adds that “we now have about 700 physicians using the online tool.”

While patients have their own “landing system” on MyMontefiore, the program currently does not integrate directly to a patient’s EMR. Rosenthal notes that the organization is in the process of making a “network medical record” for portability purposes to other physicians. “Currently, they get a PHR, but that doesn’t populate to the health record in a physician’s office,” he explains.

A key differentiating feature of My Health Manager is that it is directly connected to Kaiser Permanente HealthConnect, the organization’s EHR. “The two things are not separated,” Parikh notes. “When a patient e-mails me, it goes into the EHR. That integration is really a strength.”

Other strengths of this type of interaction come in the way of more detailed communication than what may be garnered in a phone conversation taken at the front desk.

“You get a first-person question from the patient,” Parikh points out. “If it goes through the call center or front desk, you don’t get the right perception at times.”

An initial fear communicated by physicians connected to the MyMontefiore systems centered around concerns that e-mail would actually slow down productivity. That has not been the case, according to Rosenthal.

“Patients with chronic illness have much more frequent communication with physicians,” he notes, adding that the chronically ill sometimes need to speak to their physicians numerous times per week or daily. “Most primary care physicians have a very large burden with chronic illness. [The system] actually proved to shorten the amount of times on those types of cases. Physicians find that e-mail is much quicker and available to them anywhere.”

Building on the success of My Health Manager, Kaiser currently has pilot programs in the works to develop patient questionnaires focused on specific issues—namely infant constipation, thyroid disease, and headaches—whereby physicians can communicate with patients via an electronic portal.

Alongside those initiatives, the organization recently introduced four new online lifestyle programs for diabetes, depression, insomnia, and back pain. These complement the site’s other online health programs, including weight management, pain management, and smoking cessation.

Rosenthal notes that MyMontefiore is also looking at ways to promote more preventive healthcare measures and begin a regular dialogue with segmented patient populations. With 40,000 patients in the system, the organization can do things such as send out reminders for mammography screenings or colonoscopies. There is also the opportunity to communicate with populations of people who carry the same chronic illness.

“It gives us the ability to manage the care of these chronically ill patients,” he says. “It empowers you to communicate in ways that just weren’t available before.”

Who’s Paying the Bill?
For most primary care physicians, the challenge boils down to reimbursement. While the use of electronic communication with patients has the potential to create efficiencies in a practice, the use of e-mail and other electronic interchange via patient portals has not made it into the mainstream of the average private practice. Why? Because most insurance carriers do not cover this type of healthcare delivery.

“For them, it’s about getting patients in the door and charging insurance companies. … It has to be,” Parikh says. “You can’t change this stuff until you change the payment structure of medicine.”

As a capitated system, Kaiser Permanente members prepay for their care, and doctors use these resources to focus on prevention and quality, Parikh points out. Issues over reimbursement do not play into the equation, allowing care to be delivered in more cutting-edge ways.

MyMontefiore is not considered an office visit by most insurers, so it is not a reimbursable consultation. Rosenthal notes that the system was implemented with more of a customer service consideration in mind.

“We decided that there are three insurance companies in our marketplace that do reimburse for Web consults. … For the rest, we wouldn’t charge for it,” he says.

Many healthcare professionals believe insurance companies are beginning to warm up to the idea of Web consults because, in the end, it makes sense, Cornacchia suggests.

“This is going to reduce their costs,” he says, adding that even without the backing of insurance companies, he believes that patients are hungry for these kinds of services. “I think there is an opportunity for pay for service.”

Empowering Patients
Cornacchia says the patient portal concept is evolving past the idea of patients interacting in a narrow community with just their primary care physician.

“The concept of the patient portal is dead. … What we are really talking about now is a platform for commanding healthcare. That requires more than a portal,” he says. “As a patient, I want to be in command of my healthcare. I want a system that provides global healthcare.”

Doctations could be such a network, comprising 250,000 healthcare providers and 62,000 patients. The offering gives physicians and patients access to medical records, billing, and electronic collaboration with their medical team in a real-time, HIPAA-compliant environment.

According to Cornacchia, the bulk of Doctations’ participants are in New York, but the concept is building out across the country.

Pointing to inherent challenges that exist when a patient wants to share data with more than one provider due to conflicts that exist between client-server architectures, he notes that Doctations addresses those interoperability issues. The solution’s concept supports multiple users accessing the same database from multiple sites.

Essentially, patients control their information and manage who is permitted access. Currently, the patient pays for services directly to Doctations, which in turn reimburses the physician.

Patient Experience
Putting the Web to work as a tool for better healthcare will be successful only if patients find it to be to their liking. Rosenthal notes that the patient satisfaction rate with MyMontefiore has been high.

For example, Joyce Denis, a 31-year-old Bronx native, was being treated at Montefiore’s Institute for Reproductive Medicine and Health. After two miscarriages, she is now well into her third pregnancy. She has been using MyMontefiore’s Web site for two years to communicate with her physician, Nanette Santoro, MD, a reproductive medicine specialist at Montefiore Medical Center.

“I think MyMontefiore is wonderful,” says Denis. “I just log on to my home page, and I ask the doctor by e-mail questions that I forgot to ask in the office visit or if I’m worried that my hormone injections aren’t working and if there is anything I can do at home. Or I e-mail requesting lab results, which come back within a day by e-mail. It saves a lot of time compared to playing phone tag. Everyone replies on their own time. It’s also very private. I like that.”

For the past year, Anne and Thomas Kearney, both aged 82 and living in Yonkers, have been using the service to communicate with their internal medicine specialist at Montefiore.  Recently, when Thomas Kearney had lab tests and an x-ray, his doctor got back to him via e-mail with the results and a suggestion that he see a gastroenterologist. “It’s great,” says Anne Kearney. “No telephone calls.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.