Online physician access is key to future patient communications

Imagine using Skype to contact your physician for a consult.

In the midst of this rapidly progressing technologic era, our delivery of medical services is being transformed by health information technology (HIT), electronic medical records (EMR), and advanced telecommunications.  In meeting criteria for “meaningful use,” physicians are driven to use these technologies to empower patients with communication through electronic medical records.  A primary goal is to allow patients to obtain electronic copies of their medical records and share their health information securely over the Internet with their families.  An overarching  goal is to increase patient accessibility and communication with a physician to bolster continuity of care.

Communication.  It all comes down to communication.  This accessibility for patients to immediately communicate their worries of symptom or illness to a physician.  The opportunity for physicians to instantaneously respond.  As we embrace these technological opportunities of communication, physicians are open to new modalities for health care delivery – office visits can be supplemented not only by telephone calls, but now email, Skype, Gchat, or any other imaginable resource or emerging technology.

Under the current Medicare payment system, a physician can only be paid for seeing a patient in the office.  On my clinical rotations, I have witnessed an increasing number of physicians who respond to patient emails through secure health care portals.  These emails promptly and conveniently enable a physician to address patient concerns.  In the event that an email is not satisfactory to do so, the physician simply asks the patient to schedule an office visit.  Our physicians should be reimbursed for this time.

CPT codes exist for non-face-to-face services, including telephone calls, but these codes are not included in payment models through Medicare.  Further, there is currently no established method of payment for any advanced telecommunications counseling or physician interaction.

Online physicians counseling has been increasing in the past five years – charging around $25 for a five minute consultation – with the ability to provide personal prescription.  These sort of interactions may be able to address simple patient questions, but really may go a long way towards harming the bond of the patient-physician relationship.  Interactive care simply cannot be coordinated within the confines of a five minute video chat.

However, I believe that there is an ever-increasing potential for the integration of these video chats, and other counsel through advanced telecommunication, as a compliment to the traditional office visit.  Imagine the typical family physician that holds normal office hours for patients throughout the day.  Suppose that from, say, 1-2pm each day that physician also chose to hold online “office-hours” for any of the patients within his practice.  During this time, patients could address basic questions, initiate follow-up issues, or discuss health maintenance.  Just think of the wonders of diabetic counseling!  A family doctor would have the accessibility to voice chat with a difficult or non-adherent patient once each week for five minutes, with appropriate reimbursement for time spent.

Nothing can truly supplant the face-to-face relationship between a doctor and patient.  That bond and the value of that interaction can not be underestimated.  Nor do I believe that proper diagnosis or treatment can be duplicated across a platform like Gchat.  However, with ever-rising patient needs and increasing accessibility issues, physician time is increasingly valuable.  Patients too may struggle in regularly scheduling and attending office visits.  Ultimately, utilizing these technologies would be cost-saving, efficient, could reduce preventable hospital admissions, expedite the identification of acute care instances and decrease time to treatment.  For those patients that choose to embrace this modality, this could improve quality and patient satisfaction.

Aaron George is a medical student who blogs at Future of Family Medicine.

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  • Ralph

    There must be reimbursement or else no one will do it. I am too busy in my office and have no time away from the office to do more work with out getting paid for it.

    • Schumacher Group

      What do you see as being a reasonable rate for online communications? The same as an in-office visit, or some fraction?

  • Steve Wilkins


    The quality of physician-patient communications in primary care is already substandard due to lack of time, competing priorities and paternalistic or physician-directed communication styles. Simply transposing the same ineffective communications skills to the digital world solves nothing.

    Add to that the fact that the majority of complex cases seen in primary care today are > 65 years old and non-digital, what’s the point? Why not fix what needs fixing first!

    Steve Wilkins

    • Aaron George


      I agree with you that we need to bolster physician communication and non-technical competencies – the Patient-Physician relationship is undoubtedly the core of medicine.

      But as physicians, we also must be prepared for the future of health care delivery. It is unimaginable that the delivery of this care will remain solely within the confines of the face-to-face office visit. Even now I watch as residents and attendings spend hours responding to patient inquiries through email. Recent studies have demonstrated that only around 20% of patient office visits require a face-to-face or physical examination.

      I’m not suggesting that physicians should move fully towards digital delivery of care. Rather, that there is an effective place for digital integration within primary care medicine – as an integrated component of longitudinal care. AND, if we are to continue to look towards the future of medicine – physicians must look for defined payment models for this time spent.


  • L Faith Birmingham MD

    While the scenario you outline “sounds great” for both patient and physician, it is not based on the reality of how patient concerns or complaints should be appropriately evaluated which is a more significant issue than reimbursement. “Primum non nocere”. The quick response to a patient’s concern via text or email may seem a most desirable goal, often it may not be that patient’s best interest even though the patient believes that it is.
    I have found I learned as much if not more from what I observe during a face to face interaction with my patient and this also allows me to perform any indicated examination to further define the real nature of the patient’s complaint.
    If a substantial amount of my time is spent providing “instant responses” to emails or texted messages, the real value of my years of training and experience are being wasted. I have always had a “triage system” of trained ancillary support personnel to provide that quick response to a patient concern. They also were trained to promptly route to me “red flag” items that required my attention for an immediate decision.
    Back to your proposal I could provide such services to a patient, but I would have to shrink the number of patients I could directly provide care for in a safe, effective manner, to around 400 patients.
    Keep in mind the burgeoning non clinical work required of physicians which takes not insignificant amounts of time for the practicing clinician. It then becomes a “trade off” scenario of immediacy of response, earlier identification of evolving problems in a patient afforded by direct communication with the physician, etc ( “cost saving” benefits of utilizing this technology that you noted) vs the number of patients a physician can safely and appropriately provide such care for. Reimbursement would need to be reconfigured to account for such non-office visit related professional services. Since the number of patients a primary care physician could realistically provide care for would be substantially smaller in the scenario you propose, access to care likely would suffer, certainly problematic in the current environment of fewer and fewer physicians choosing primary care training (family practice, internal medicine, pediatrics eg).
    After a number of years in practice I recognize the pitfalls of incorrectly utilized “telecommunications-medicine” but can also see the great benefit. I would love to have a patient panel of 400-500 patients where I could pursue precisely the type of care delivery you outlined utilizing these evolving communication technologies. What reimbursement should be provided for this care delivery scenario? Who should be responsible for the reimbursement and in what proportion? Insurance company, the patients or government subsidies?
    Is there data consistently showing this type of utilization of physician services consistently improves outcomes and reduces cost for a variety of chronic and acute medical conditions. This is important information when considering reimbursement. Keep in mind that in some states the provision of such “on-line” medical services without appropriate face to face patient evaluation initially and periodically thereafter may result in disciplinary action by a state medical board.
    The preceding comments represent a number of the issues I as practicing physician, have considered in utilizing technologies for providing more immediate access by patients. Reimbursement is only one aspect but certainly needs to be addressed soon if further implementation of these technologies is to proceed. It is my opinion that the practice of Medicine should never be approached as just another “consumer service”. The above comments represent some of the issues from my perspective (through my filter of 22+ year of active clinical practice) on your posting.

  • Scott Macleod

    Add to all the above comments, that I agree, the following:

    I find that as a primary provider my time is already overloaded. The so called educated patient is exposed to multiple media messages about medicine senational news and all that is “not so true” internet sites with latest medical news and stuff to sell. I would spend too many hours responding to the worried well with money or those with chronic diesease who have just heard…. This would result in the people who really need my help not getting it. Those with money resources would be able to get their personal docotor to be ready all those “pressing” questions whenever they felt. Without reducing our patient load this would quickly result in burnout of an already increasilngly deficit supply of family physicians,

    The public have yet to realize how valuable a resource having a primary physician is. The experience the Canadian public had with not enough is be recognized. To head into radicaly changing the system that has taken hundreds or years to develop, is just foolish. To feed the instant gratification of todays society is not necessarily good medicine, Some of it yes, but lets properly test it out before we plug the whole system into this.

  • Anonymous

    I have physicians who will answer email pretty much 24/7, without any form of reimbursement except for constant thank you’s from me because I know that their time is invaluable.  One of them practices in 3 clinics, teaches, does full-time research, and travels frequently.  How he even finds the time to answer emails is beyond me but he does it because he cares, not because he “has” to.  I do, however, feel bad that he gets no form of reimbursement, even though we email several times a week now.  I often try to think of a way to express my gratitude such as a gift card to take his family out to dinner, but have yet to come up with the “right” idea since what’s appropriate in the situation doesn’t really exist yet.

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