E-Visits Foster Continuum of Care and Communication, but there is a Price

The quest for the right communication formula and balance that will satisfy doctors and e-patients who want to experience continuous care can be partially resolved with the spread of virtual clinical electronic messaging or e-visits. The e-visit is a specific encounter between a provider and his or her established patient over a secure online connection. It is an asynchronous communication reserved for non-emergency issues.

 A 2009 Manhattan research study of 8,600 healthcare consumers found that a majority of these individuals were interested in having electronic online consultations with their physician. Patients who have engaged in e-visits claim that  these encounters are particularly useful for monitoring chronic conditions such as diabetes, chronic bronchitis, and high blood pressure or for discussing minor ailments that occur during the months following their annual visit, such as sore throats, stomach pains and colds.  However, although 42% of U.S. physicians report having discussed clinical symptoms with patients online, only 5% of physicians said that they were paid for these online consultations.  This is clearly a barrier to advancing this digital communication technology.

http://www.ihealthbeat.org/articles/2010/6/7/more-patients-doctors-pursuing-online-visits-but-challenges-remain.aspx#ixzz1VgDfAYJ7.

In 2008, a billing code was approved (Current Procedural Terminology (CPT) code 99444) that would enable doctors to charge for e-visits. But often these online communications have not met the criteria required for the code.  Several of the  large payers  such as Cigna, Aetna, a number of Blue Shield plans, WellPoint and Humana now recognize the value to patients and the cost savings to the system of paying for e-visits, rather than have the patient come to the doctor in the office, and  are reimbursing doctors for online clinical consultations. They require that the  e-visit take place through a secure Web portal with encryption, and  that the providers  comply with Health Insurance Portability and Accountability Act (HIPAA) privacy rules. Payments average $30 per e-visit, about the same as the cost of a patient visiting a retail clinic, as compared with $75 to $100 for an in-office consultation. 

The Center for Medicare and Medicaid (CMS) is considering e-visit reimbursement. As a result of the Healthcare Reform law, CMS is reviewing innovations that would help facilitate doctors’ meeting with their patients through video chats, telephone checkups and in-home monitoring devices. This could prove to be a real game-changer for online remotely delivered healthcare.

There is another barrier to the expansion of the e-visit. There is a pervasive lack of sufficient infrastructure to provide meaningful online communications, including back-end technology to capture and store data from the visits, templates on how visits be presented to patients;  agreement of what  interface will be best for doctors to use in delivering care; questions about whether  e-visits be text-based or video, or  IP video? There are also bandwidth issues for supporting the technology and a lack of resources to install the necessary equipment and train providers in conducting effective e-visits.

There are a few  larger healthcare institutions and payer companies that have either developed their own infrastructure to handle e-visits or outsource those services to an organization such as the RelayHealth webVisit®. Beyond those isolated examples, it is unlikely that e-visits will expand to the general patient population in the near term. I would argue that the e-visit can have a tremendous impact on a patient’s overall well-being and positively affect the cost of care. It behooves the medical establishment, public and private, to find the ways to make this happen sooner rather than later.

Communication, a Challenge to Participatory Medicine

Communication or the exchange of thoughts, opinions, or information by speech, writing, video or signs that include body language continues to be a hotly debated,   difficult to execute practice in healthcare. There have been hundreds of studies over the years that reinforce the correlation between good communication among patients and providers and improved health outcomes. Health information gathered from patient interviews, laboratory tests, face-to-face exams email interactions, and e-visits, is essential to guiding strategic health behaviors of patients and providers, enabling them to collaborate on treatment decisions and ongoing health monitoring. Participatory medicine depends on the availability of health information to all members of a care team.

However, low expectations regarding teamwork and communication have for many years encouraged a culture where teamwork and collaboration are difficult to achieve. It’s ironic that ever since the publication in 2000, of the original IOM report, To Err Is Human,  healthcare  organizations have worked hard to improve  patient systems and patient safety  but most have failed to address poor communication habits that  would enhance  information sharing. It is clear that when health care professionals do not know what their colleagues are doing to manage a patient they are seeing, and when patients do not have the opportunity to share the information held by their providers,  all the patient safety rules in the world cannot compensate.

During the past 25 years there has been a lot of talk about the need for training medical students in communication skills. It was not until June, 2004, that a communication skills component was added to the U.S. Medical Licensing Exam to test medical students on their ability to gather information from patients, perform a physical examination and communicate their findings to patients and colleagues.

 The Agency for healthcare Research and Quality has developed CAHPS,   (Consumer Assessment of Healthcare Providers and Systems) a public-private initiative to develop standardized surveys of patients' experiences with ambulatory and facility-level care. These surveys ask consumers and patients to report on and evaluate their experiences with health care in areas such as the communication skills of providers and the accessibility of services. The results of these surveys help determine where there are strengths and weaknesses in the system.   CAHPS also publishes guidelines for patients to help them understand the important communication skills they need to improve their ability to share information with providers. These guidelines include four areas:

1. Record Sharing- patient access to the electronic health record
2. Patient Question Lists – what to ask the doctor at a typical visit
3. Feed Forward – a questionnaire filled out by the patient prior to receiving care
4. Coached Care- teaching patients how to ask the right questions and be more assertive during a face-to –face visit with their physician

www.cahps.ahrq.gov

Other organizations including many hospitals and medical centers strive to enforce good communication habits among their physicians and encourage their patients to participate in their care and collaborate with their providers. Many payers work with enrollees to help them understand communication skills needed in their increased participatory role. 

As e-Patients become more invested in the partnership model they have to improve their own ability to share information. Health care consumers are inherently well-equipped to judge the ability of their clinicians to communicate with them effectively. Helping them understand when and how to ask the right questions and be more aggressive about speaking up when they do not understand an explanation is a leap forward toward better communication for better healthcare.