Eclectic Views

    
Sorry I've been out-of-pocket this week, but I’ve got a pretty darn
good excuse.  We've been doing a week of Q&A on the New York Times
site.  So, who are "we"?  Alan (DrGreene) has been doing the writing. 
So what else is there you may ask?  For the last 12+ years I've been
doing the behind the scene stuff to make it all work.  Now my point
that is relevant to this discussion -- I think doctors don't get more
involved in online care because they don't have time -- yeah, I know,
old excuse, but hear me out.  When we started DrGreene.com in 1995, we
did it together.  He wrote.  I did the rest. We built an archive of
great pediatric content.  All of a sudden, he could answer an ear
infection question online and refer parents to that URL for the answer
then discuss their specific questions during office visits instead of
going over the same “Ear Infections 101” answer for each individual
family.  This was a major time extender for him.

I think doctors don't email because it's basically typing out answers
to one patient at a time – just like an office visit or phone call. 
It's not a time extender -- at least not for most doctors or at least
it's not perceived as a way to make their schedules less crazy (and
they are crazy).

So why don't they just create a library of answers like Dr. Greene?
Because that require a support staff and in most cases an initial
outlay of funds that aren't easily available.

It's easy to give doctors a bum wrap for not getting with the
technology, but instead I think we should find ways to make it easier
for them to participate in the dialogue -- like funding writing time
and support staff so they can write without staying up all night.  BTW
-- Alan was up all night last night writing :-)
  

    

EMAIL FROM CHARLIE SMITH:

I am also a member of the e Patient Scholars group.  I met Tom Ferguson
while he was a patient at the University of Arkansas and he graciously
invited me to join he and his colleagues.  It just so happened that, at
the time, my wife Connie had recently been diagnosed with Waldenstrom's
Macroglobulinemia and was undergoing stem cell transplantation and
chemotherapy.  So, she and Tom had a lot in common and Connie, as a
patient, was also invited to join the group.  We helped Tom with one of
his passions, exploring more effective ways for patients to give "real
time" feedback to the health care providers who were caring for them,
with the goal of improving a lot of small things as soon as possible.

Those efforts have been generously funded by Tom's wife and her
foundation, and they are continuing here at UAMS to make a difference in
the way we provide care to our patients.

One reason that Tom and I were drawn together was because I had founded
an internet-based health care company, eDocAmerica, whose mission was to
provide patients with the information that they needed to make better
health care decisions.  I have been very interested in the discussions on
this site and elsewhere about the business plan that is going to allow
this movement to really take off.  I, for one, believe that unless
providers are appropriately compensated for their time and effort, the
"ePatient" movement will be forever relegated to the fringes of the
health care system.  But, I don't think that will happen because the
product is so incredibly powerful.

In our case, we "sell" our product as a low cost, per month fee for access
to our team of physicians who operate within a secure web site environment
(http://www.edocamerica.com)
  

    
In terms of my own health info searching online, I tend to stick to
well-respected and mainstream sources. I tend not to differentiate
between commercial and non-commercial, only because I (like I suspect
many Internet searchers) am looking for the quickest legitimate answer.
So I start most of my health searches on Google, just like the public
(even though I should know better).

I've tried many specialized health search engines, even the very 2.0
ones, and find the information they present tends to be *too* limited.
While Google might return an obscene amount of hits for a given
keyword, health search engines are only as "smart" as their creators
allow them. The way they commonly do this is either to limit the sites
they search (which also greatly limits their usefulness to me), or
hand-create search results through self-appointed 'editors' (ala
Yahoo's directory in 1995-1996). It's funny, but the more things
change...

At Psych Central, we've been doing some of these things since Day 1.
We've had a directory of hand-picked mental health resources that we
maintain religiously. But at the end of the day, most users are going
to find us through Google, so we focus on what people are looking for
-- (mental) health information.

In terms of docs answering questions online, we have to pay the
therapists on our site who answer questions. They're providing a
valuable service and deserve to be reimbursed. Over at MedHelp.org, I
understand that docs do it for free. But after reading some of the
responses in the mental health topic area, I guess I see you get what
you pay for... Docs saying, "You are suffering from X, you need to see
a doc to prescribe you some medications right away." Yikes.

I'm not certain what the future of Health 2.0 looks like, except that
we're probably going to see more and more docs communicating directly
with patients as time goes on. I believe a lot of online communication
modalities will eventually be billable and will be seen as what they
are -- just another way to get in touch with your doctor and ask a
question. 

And of course, anybody who is running a 2.0 company will make heaps of
money off of many (but not all) of these ideas, or more accurately,
the promise these ideas offer. 
  

    

From a patient's perspective, trying to get direct contact to a doctor
is complicated these days. The doctor's time is protected from patients 
less urgent needs by voice mail systems that are tedious, time-consuming 
and sometimes confusing to navigate. 

It's my understanding that most medical offices are contracted with
various medical insurance programs, and that they derrive the bulk of
their income from set per-patient fees the insurance companies pay.
Whether a patient comes in one time or ten in a month makes no diff
as far as how much the insurance company pays the medical office.

An office visit with a patient probably takes at least 15 minutes of
the doctor's time, plus some more minutes from support staff to process
the patient and his/her paperwork. In many cases, an email exchange
could save the medical office money, and save time for both the doctor
and the patient.

I would love to see more doctors making themselves available via email.

What advice would the medical professionals here offer to laypeople who
would like to convince their doctors to open themselves up to email? 

What can WE do to promote this idea to the people who can effect the 
change?
  

    
I think getting doctors to make themselves available is will require
two steps. First, Cynthia, I suspect you're in California, based on the
fact that you are familiar with the idea of preset reimbursement. In
fact, that model of capitated payment is not all that common at all.
Kaiser has used it very effectively, and even has lots of providers on
salary out there. The vast majority of reimbursement is based on paying
for services rendered. AND, in most parts of the country, doctors do
not get paid for encounters that are not face to face. Secondly, the
vast majority of doctors were not raised in the digital age, and thus
are not as comfortable with the tools as most patients. Once motivated,
patients may put in a lot of time learning the tools, or if a digital
native, be completely comfortable at the start. For doctors, is just
another barrier to entry to something for which there is no
reimbursement. 

Am I making it sound like all docs are just mercenaries? hmm, well,
since they are mostly pretty bright, and could have become investment
bankers or something like that, i would guess they are not solely
motivated by money, but, they gotta eat, put kids through college, etc.
So, I'll toss out a simplistic answer to the question and propose that
as soon as doctors are paid, in money or time, for more digital
activities, they will quickly adopt them and become more available. On
a personal level, i spend over an hour a day on emails and web based
interactions with patients. I'm salaried, at a large department, and
get regular statements from the administration saying I'm not covering
my salary and am not productive enough. Sooner or later the party will
probably end for me too and I'll have to cut  back. 
  

    

That's interesting info, Dan. I didn't realize that capitated payment 
was such a limited model. I'd figured it was pretty much standard across 
most of the United States. 

You say:

> as soon as doctors are paid, in money or time, for more digital
> activities, they will quickly adopt them and become more available.

So who does control this? If patients are private-pay, it would be up to
the doctor to determine a fee for email exchanges, wouldn't it? 

If it's up to the insurance companies, what would be holding them back 
from creating a "fees for email" category to fit into their payment
structure?
  

    
>If it's up to the insurance companies, what would be holding them
back 
from creating a "fees for email" category to fit into their payment
structure

They have no interest in finding a whole new category of something to
pay for.  

>I'm salaried, at a large department, and
get regular statements from the administration saying I'm not covering
my salary and am not productive enough.

Even if I have no problem giving away my time (and I do give away
quite a bit of it here in the health conference), if that takes away
from my formal clinical duties, which do not include e-mail
communication with my patients, then it will be actively discouraged.  
  

    

> [insurance companies] have no interest in finding a whole new
> category of something to pay for

Well, yeah, that makes sense. I was thinking more that insurance
companies could include a "email with your doctor" option within a
health insurance plan. Those who subscribed to that type of coverage
would be allowed X number of email exchanges at some specified rate. 
  

    

And now, to shift gears, I wanted to note that it's been two weeks since
this discussion began and I wanted to thank the members of the E-patients
group who've joined us to talk about their work. I also want to thank Jon
Lebkowsky for his help in lining up our guests and for participating here
in this conversation.

Glad you could be here. If you'd like to continue, the topic here will
remain open for a while. If there are other things demanding your time
and attention, we appreciate you for sharing with us these past two
weeks.

Keep up the good work!
  

    
Sorry I disappeared for a while... things were hectic on my end. the
e-patients group is in conversations now and may have more to talk
about in a month or two, so I suggest we reconvene in April or so for
more conversation.