Does electronic communication actually improve care?

The subject heading of a recent email correspondence read “beware, graphic picture ahead!” Obviously this piqued my curiosity, so, with one eye closed, I scrolled down on my iPhone to a picture of my patient’s tongue, which, truth be told, had a certain “you haven’t seen anything yet quality.”

The tongue in question? Maybe some white spots, certainly nothing gruesome, and most assuredly nothing I hadn’t seen before in my 12+ years in clinical practice. My advice to the patient, after confirming through a few back and forth emails that this was not an immediate threat to her, was that she see her dentist and/or primary care doctor for evaluation. If she wasn’t able to book either of them, then, yes, I would be happy to take a look myself.

What was remarkable about this exchange was not that a patient was asking for guidance, or for that matter, a diagnosis, about a symptom that drew her concern. Rather, it was that this correspondence did not involve an actual doctor-patient conversation, in the traditional sense of the word. Currently, a little under one third of physicians say the communicate with patients by email, according to Manhattan Research. That said, the practice is far from routine. On the patient side, data from the National Health Interview Survey found that just over five percent of Americans say they email with their doctor.

A number of explanations have been offered for physicians’ reluctance to use email rather than a traditional face-to-face visit. Frequently cited is the concern about increasing workload without a commensurate increase in compensation. Yet as my lawyer husband reminds me, “not every minute can be monetized in medicine.”

In other words, doctors are not lawyers worried about billable hours. Nevertheless, with reimbursements from Medicare and insurance companies down, and pressure to create revenue for our hospitals and practices ever on the rise, it is becoming increasingly difficult for physicians of this generation to engage in “pro bono” work, to borrow a term from our lawyer brothers and sisters.

Not unexpectedly, a major concern (and one which most physicians freely acknowledge) is patient privacy, data security, and liability. The EMR, which has already been adopted more universally as federal requirements have mandated, is likely going to be the IT wave of the future for even the most reluctant among us. Indeed, in July 2010, the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology announced final rules to implement the provisions of the America Recovery and Reinvestment Act of 2009.

My belief is that while EMR reimbursements are not currently linked directly to electronic communication with patients, there will likely be some financial incentive to use the electronic messaging tools available in the EMR, and this may encourage more use, thereby solving the “billable hours” barrier to entry I mentioned earlier.

Additionally, some private health plans such as Aetna and CIGNA have explored reimbursement for providers for virtual or “e-visits.” Another option which may be even more popular with physicians, is a “one size fits all” annual fee that they charge a patient for access to email correspondence with their doctors.

But here is the real question: Is the care of our patients being compromised by the use of electronic communication? Or are we improving communication and thereby enhancing efficiency, and then ultimately, patient care? I am fairly certain it will take a generation or two to know for sure. In the meantime, I propose that we all keep an open mind, adapt to the changing world we live in, and — as we do in the office — tailor our approach to each case as it comes.

Natalie Azar is a rheumatologist who blogs at The Doctor Blog.

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