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Patient-doctor e-mail gets look

September 8, 2001

WASHINGTON - Health-care providers are slowly taking up an idea that could transform medical care: e-mail exchanges between patients and their doctors.

Patients who are fed up with 15-minute appointments that disrupt entire workdays couldn't be happier. Doctors are proving a much tougher sell.

One recent poll found that while 34 million patients would like to e-mail their doctors, only 3.7 million had done so. Another poll found that only 13 percent of doctors e-mail their patients.

Many physicians say they fear that responding to e-mail will add to their workload. They also worry about getting paid, their liability and patients' privacy online.

But with consumers, lawmakers and health plans all looking for ways to deliver better care at lower prices, even wary doctors may be forced to accept the technology.

"Patients have been asking for this for a long time," said Dr. David Trager, a San Jose pediatrician who has e-mail connections with about 100 patients. "It's a technology we just can't avoid, and more and more physicians are starting to realize this."

Several try it out

Large health plans such as Blue Shield of California, smaller ones such as ConnectiCare of Farmington, Conn., and big self-insured employers in Silicon Valley already have bought in. Each allows members to contact their doctors online about medical problems and get professional advice in return -- usually within a day. Doctors typically earn about $20 for an online consultation.

In a typical system, patients log on with a secure password and describe their symptoms on a standardized questionnaire. The software may prompt additional questions, such as whether a person who reports a sore throat and fever also has night sweats or a discolored tongue.

After reviewing the information, the doctor decides the next step for the patient, including writing a prescription, requesting an office visit or referring the patient to another physician.

Doctors use the system only with patients they currently treat. The exchanges, unlike conventional e-mail, are encrypted for privacy and can be accessed only by authorized staff. Only non-emergency problems -- such as allergies, colds and minor flare-ups of such chronic problems as diabetes and high blood pressure -- are handled online. Those with medical emergencies are asked to seek immediate help in person.

Patients also can use the system, at no charge, to schedule appointments, refill prescriptions and check lab-test results.

"It's pretty darn cool," said Connie West of Middletown, Conn. "I used to go to bed at night thinking, 'Oh, that's the last pill I have. I'll have to call for a prescription tomorrow.' Now I just go on the computer, say I need a refill and know it'll be in the drugstore ready for me to pick up the next day."

So why don't doctors like e-mail?

Some doctors skeptical

"If I ask a patient on the phone, 'Are you short of breath?' I can hear the huffing and puffing," said Dr. Sandra Fryhofer of Atlanta, past president of the American College of Physicians-American Society of Internal Medicine. "On the Internet I can't hear anything. So it cuts down on the input we get about the patient."

In addition, "Doctors are already overloaded, and this is just one more thing to check," Fryhofer said. "You could have so many messages to check that you can't get your work done."

Many doctors already resent spending several hours a day talking to patients on the phone -- at no charge.

"They feel like they got snookered into giving that (advice) away and they're not going to do that on the Internet," said Dr. Eugenia Marcus, a Boston pediatrician who favors using e-mail. "But if you put a dollar sign on that e-mail, the doctors would be glad to do it. Not because they're greedy and avaricious, but because they give away so much knowledge and have to take on the liability for their advice."

Blue Shield's plan

To test the waters, Blue Shield of California in May 2000 offered its 50,000 network doctors a secure e-mail system designed by the Healinx Corp. of Alameda to communicate with their patients. Doctors get a $20 fee for e-mail consultations that require medical evaluations and judgments.

"This looked like a way to improve access and communication," said Dr. Jeffrey Rideout, chief medical officer at Blue Shield in San Francisco.

But fewer than 3,000 of the doctors have enrolled, Rideout said. "The big conceptual hurdle is 'Will this add work as opposed to reduce work in my office?' "

Dr. Michael Good, an internist in Middletown, Conn., who's engaged in a one-year pilot study, finds the Internet is a time-saver. Patients who used to phone for appointments and lab results now do both online.

Trager, the San Jose pediatrician, has handled about 50 online consultations with computer-savvy employees of companies such as Oracle, Cisco Systems, Apple Computer and NEC Electronics. These companies, which pay their employees' health costs, hope e-mail consultations will cut medical-related absences from work. Trager, who is not paid for phone consultations, gets $20 apiece for them online.

Marcus, the Boston pediatrician, has offered patients e-mail access since 1996. She recently helped design a secure messaging-software system for which she'll charge patients an annual fee. The fee will include a set number of free consultations, and additional sessions will cost about $20 each.

Like many software pioneers, she's uncertain her patients will buy the new idea.

Said Marcus: "Call me in six months."




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