Doctor visits move into cyberspace

There are lots of reasons why you'd want to "see" your doctor virtually instead of face to face: Save time. Not inhale germs in a coughing-sneezing-snuffling waiting room. Have time to describe your symptoms.

Your employer likes the idea that you wouldn't have to leave work for hours.

But your doctor, despite believing that the episodic, crisis-care nature of office visits isn't the best for managing most chronic conditions, most likely has shunned computer patient "visits" for one perfectly good reason: Health insurers won't pay for them.

A pilot project at Microsoft may change that.

More than 5,200 Microsoft employees, about 100 Virginia Mason doctors, and health insurer Premera Blue Cross have teamed up to test something new in the Northwest: reimbursing doctors for providing non-emergency health care online.

Patients e-mailing doctors isn't new, but it's been limited to health-maintenance organizations (such as Group Health) or scattered practices that must charge extra fees because until recently, reimbursement by insurers wasn't possible: "Cybervisits" didn't have a "code," the number issued by the American Medical Association that allows health providers to bill insurers. In 2004, that all changed when the AMA issued a new, temporary code for such consultations.

The 18-month pilot at Microsoft, which began Jan. 1, will begin testing a template for online doctor consultations, paying doctors $30 per online visit, considerably less than what doctors typically get for an office visit. The patient pays nothing.

Rather than a totally free-form e-mail exchange, the "webVisit" protocol designed by California-based RelayHealth uses a structured set of questions and "branching logic" to elicit the information your doctor would need to diagnose you and recommend treatment. The form allows patients to send messages to their doctors.

The doctor can be expected to reply via e-mail within 24 hours and, if needed, order a prescription.

Logistical questions

Whether the program continues after its trial period and whether it becomes more widely available depend on the answers to some crucial questions: Do such online consultations make health care more effective and efficient? Will they end up saving — or wasting — time for patients or doctors? What will be the financial impact on Microsoft, a self-insured company?

There are other pressing questions, as well. For example, does a structured "interview" work better than a free-form e-mail exchange? Or how do such online consultations get integrated into the patient's permanent record?

This pilot will require Virginia Mason to input the online information manually into the patient's electronic record, because the two systems aren't compatible, said Marnee Iseman, Virginia Mason vice president for ambulatory services.

"We're not very happy about the work we're going to have to do," she said. But, she added: "We think it's dangerous to run multiple systems, so we're not going to let our patients do that."

Eventually, the health-care industry will have to solve the problem of incompatible electronic systems, she said.

Convenient, efficient

Amanda Johnson, a 34-year-old Microsoft manager, expects online consultations will help her cope with her 3-year-old's frequent ear infections without having to leave work for two hours or more for a doctor visit.

"I've dealt with them before," Johnson says. "I know the symptoms that occur prior to each ear infection."

She expects the service will be a "huge convenience" for her.

Tom McPherson, senior benefits manager at Microsoft, says that, on average, employees there visit their doctors 3.5 times per year. That adds up to considerable cost to the company both in benefits and in time lost. "We're looking to be creative and innovative, not only to offset health-care costs, but to provide high-quality care," he says.

In particular, he expects employees with chronic conditions such as asthma or diabetes to benefit. The more engaged patients are with their health-care provider, he says, "the healthier they will be, and the less costly for the company providing health care."

Dr. Tom Numrych, a Virginia Mason pediatrician, says e-mail can be a much faster way to communicate with patients than playing phone tag. "I think this is just a huge step forward to increase communications with patients."

Furthermore, "if Microsoft is able to keep their employee there, not spending two hours going in for an office visit, that's a huge benefit for them."

Premera's medical director for quality, Dr. Roki Chauhan, believes the structured "interview," compared to a free-form e-mail exchange, condenses a "back-and-forth that might take days."

In other, early tests elsewhere in the country, online consultations saved money, but Chauhan said Premera's actuaries wanted more data, which he hopes will be provided by the pilot study. Businesses, which ultimately pay the costs, will have to be convinced.

So will some doctors, who would rather not get insurance involved.

Avoiding the insurer

In Bellingham, the Family Care Network charges $7 a month for e-mail access to its 44 providers. More than 450 patients pay for the service, said Dr. David Lynch, a family doctor and vice president of clinical process improvement for the network, a group of family doctors working at 11 locations in Whatcom County. He believes theirs is the largest single group of patients in the country paying for e-mail access.

"We think when you can improve patient access and satisfaction, decrease costs, meet the needs of providers and patients, it ought to be a home run for everyone."

But Lynch thinks getting insurers involved is a bad idea.

"As soon as you get insurance involved, the cost goes up exponentially," he said. "Our desire is to work directly with a patient."

Lynch's network is only one of many indications that patients around Puget Sound are enthusiastically embracing such online consultations. But widespread use of the technology has been held up, in large part, by the reimbursement issue.

Up to now, providers who have adopted some form of e-mail consultation have had either to be a provider-insurer where reimbursement wasn't an issue — such as Group Health Cooperative, where 162,000 patients have signed up since the service began in 2002 — or to charge patients an additional fee.

For example, four doctors in a "Partnership in Health" program at Seattle's Polyclinic charge $25 per month per patient for various "extra" services, including e-mail access, in addition to billing insurers for covered services.

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com