September 29, 2008

Virtual Visits — The Way of the Future?
By Lindsey Getz
For The Record
Vol. 20 No. 20 P. 18

A new study reveals what many don’t want to admit: E-medicine can actually be safer than face-to-face office visits.

While the concept of online prescribing or “e-medicine” is still relatively new, there’s little doubt it will play a key role in the future of healthcare. With so many industries already establishing a strong presence in a computer-based world, the change-resistant healthcare profession appears to be falling behind. A new study published in Mayo Clinic Proceedings has shed some light on the issue by taking a comparative look at the safety of online prescribing vs. a traditional physician consultation. The results have been felt throughout the medical profession.

The study, “Safety of Prescribing PDE-5 Inhibitors Via e-Medicine vs Traditional Medicine,” compared the use of e-medicine with a face-to-face doctor’s visit for patients seeking treatment for erectile dysfunction. The researchers randomly selected 1,000 patient medical records. Five hundred of the records were for patients who had used an online prescriber, and 500 were for those who had consulted a physician. The safety of each system was examined using criteria such as the level of patient education provided by prescribers and prescription appropriateness. Using this type of criteria to evaluate each approach, the researchers ultimately concluded that e-medicine “outperformed the traditional system in most of the safety variables tested.” In the area of patient education, e-medicine appeared to be the better approach.

The researchers found that 100% of e-medicine clients received written manufacturer product information, whereas no medication instructions were recorded for 51.8% of the patients who received prescriptions via the traditional route. In addition, standard diagnostic questions were required for e-medicine prescribing but were infrequently asked in traditional medicine consultations.

“To think that a doctor not being present could actually be safer than a face-to-face meeting with your physician is against the entire idea of traditional medicine,” says Allen R. Wenner, MD, one of the study’s authors. “The medical community’s reaction is going to either be to ignore these findings or try to bury them. Nobody wants to believe that Internet medicine is not only possible but safer than traditional medicine. It goes against everything that the medical profession and the general public believe.”

The concept that a face-to-face exam isn’t necessarily the best use of medicine may seem shocking; however, the concept that computers help eliminate error and improve efficiency isn’t necessarily surprising. “It may seem upsetting, but it’s pretty simple to understand,” says Wenner. “Consider it this way: No matter how good you are with numbers, you are always going to get beat by someone with an Excel spreadsheet. Computers eliminate those potential errors. That’s the bottom line.”

Not to mention the fact that it’s the way the rest of the world is already moving. Many other industries have been revolutionized by the Information Age, so it only makes sense that the medical profession would eventually move in the same direction. “Just like the way we do our banking has changed because of computers, the healthcare industry is going the way of computers as well, and there’s simply no stopping it,” says C. Peter Waegemann, CEO of the Medical Records Institute. “There will be opposition, but it’s going to be the way of the future—like it or not.”

Some opposition to e-medicine comes from certain professionals’ strong belief that no patient should be able to access medication or treatment options without being personally seen by a physician, says Waegemann. But in the same way people were initially wary about buying airline tickets on the Web, performing banking functions without a face-to-face meeting with a banker, or even completing their yearly taxes electronically, it’s just a matter of time before the public feels comfortable handling its healthcare through the use of computers.

That the study focused on erectile dysfunction and not something along the lines of a sore throat should not minimize the results, according to Wenner.
 
“The key to the process is an expert interview system that replicates the doctor-patient interaction. The doctor reviews more information in a comprehensive computer-collected subject history of the present illness than he or she would have had time to collect in today’s office visits because of poor reimbursement for talking to the patient,” he says. “The fundamental difference is whether, in the doctor’s expert opinion, he or she can make a diagnosis without a physical examination. Sore throat, maybe, maybe not. There is a scale that predicts likelihood of sore throat accurately. However, a throat culture is sometimes critical to making the diagnosis. An experienced clinician knows when to order tests and when not to based on a thorough history. So it depends on the doctor’s experience also. There are plenty of illnesses for which a physical exam is not needed.”

Doctor Plus Internet
While some may fear that these findings take away the need for trips to the physician, that’s not the case at all, say experts. It’s only a matter of changing with the times and adopting electronic skills that will enhance physician practices. “What these findings tell us is not that we don’t need doctors but that doctors should choose information systems,” explains Wenner. “This controlled study found that a doctor who is using all the available tools and resources on the Internet is actually safer and more effective than a doctor who is in his office, face to face with a patient, but doesn’t have that Internet support. There have been instances where drugs were prescribed that shouldn’t have been prescribed, and other mistakes were made which were all related to human error. Luckily, most people don’t die, but these types of medical errors are unacceptable. The attitude that as long as I’m not killing any more people than the doctor down the road is not acceptable.”
 
When it comes to patient health, which ultimately can be a matter of life and death, Wenner says the public should not be so willing to accept the possibility of error. “Why is it that the pilot does the entire safety checklist before taking off, but the doctor doesn’t feel compelled to go through every point on the list?” he asks. “Because the pilot is on the plane. The doctor, however, is not the patient. We’d never let the pilot get away with only checking one wing of the aircraft, and we shouldn’t allow physicians to be careless with our health.”

The use of electronic health records (EHRs) and the Internet allows the doctor to be completely thorough with each and every patient. It eliminates prescribing errors by notifying the doctor of drug interactions and other red flags in a patient’s medical history. And the access to features such as charts and progress reports can make diagnosing easier. “The fact is that the doctor only sees each patient for a few minutes,” says Waegemann. “They aren’t going to remember everything from a patient’s history. That’s why electronic records and the Internet are more precise.”

Besides eliminating potential errors, practicing e-medicine and utilizing EHRs may also enhance what Janet Marchibroda, CEO of the eHealth Initiative, calls a connectivity problem. Communication between a pharmacist, a specialist, a doctor, and a lab can be improved by providing linked electronic records of any patient’s medical history. “Most of the data that a doctor needs is not sitting in their office—it’s in a lab somewhere or at the specialist’s office,” she says, “or sometimes only the patient knows it. Electronic systems can help provide a connection across these various offices that make up our individual healthcare history. It’s a way to ensure that information is where it is needed, and when it is needed, to support better patient care.”

“The fact is that if doctors were willing to adopt an electronic medical records system, they would be able to provide better care,” adds Waegemann. “But because they don’t have these systems and also don’t have a lot of time to spend with each patient, the Internet performed better than them in this recent study. It doesn’t have to be that way. Doctors can adopt these systems and ultimately improve their care.”

You’ve Got Mail
The study also raises the issue of e-mail exchange between patients and physicians. While many patients say they would like to be able to correspond via e-mail with their physician, a survey conducted by Manhattan Research found that only 31% of doctors e-mailed their patients in the first quarter of 2007.

“I’ve actually changed doctors so that I could have a physician who would be willing to correspond via e-mail,” says Waegemann. “Just recently I had a spot on my skin, so I took a photo with my digital camera, e-mailed it, and asked if I should come in. It can actually be quicker than having to wait to get an appointment or spend time in a waiting room. E-mail gives us so many more options. A mother can e-mail a photo of her child’s minor wound to the doctor instead of sitting for two hours in a waiting room only to find out it can be treated easily at home.”

In the case of the study published in Mayo Clinic Proceedings, e-mail correspondence can also be effective for patients who may not seek treatment as a result of embarrassment or discomfort with the subject matter. “If you look at the study, you realize that some of those patients aren’t able to look their doctor in the eye and confess something about their personal health [such as erectile dysfunction],” says Waegemann. “Instead, they’d rather find that information online where it’s convenient and private.” Offering e-mail correspondence is a way for the physician to be involved in the treatment process without making the patient feel uncomfortable or simply ignoring his or her treatment options because of their reluctance to talk to a doctor face to face.

The practice of e-medicine also shifts some responsibility for health records to the patient, says Richard L. Reece, MD, editor-in-chief of Physician Practice Options and author of Innovation Driven Healthcare: 34 Key Concepts for Transformation. Utilization of e-medicine allows patients to enter their own medical history. “They know that information better than anyone else, so why pay someone else to do that work?” he asks. “Consumers are willing to do their own data entry, plus it becomes a way to eliminate data entry error.”

Resistance to Change
There are several reasons why doctors haven’t already begun e-mailing with their patients. One barrier is the lack of reimbursement for these consultations, says Marchibroda. “We simply haven’t given doctors enough incentive to start operating this way,” she says. For the most part, doctors don’t get paid for practicing e-medicine. However, CIGNA and Aetna, two major health insurers, have recently expanded their pilot programs to compensate doctors utilizing a secure Internet site to practice medicine.

Security is another concern, adds Marchibroda. How can the privacy and confidentiality of patients’ information be ensured as it flows over the Internet? Marchibroda says as doctors start accepting more regular e-mail correspondence, it’ll be important that they adopt safe e-mailing skills and educate their patients about using precautions as well.

Some opponents of e-visits say the practice could mean missing nuances in body language that would only be obvious in a face-to-face exam. However, Wenner says there are plenty of complaints, such as erectile dysfunction, where body language issues would not make any difference in the treatment outcome. In fact, for certain embarrassing issues, a patient may react with signs of stress that are not related to the true symptoms but rather to their discomfort with the visit itself.

In addition, Wenner notes that face-to-face exams are often unnecessary when following up with patients. “Follow-up visits with doctors very rarely require a hands-on physical exam but rather an interpretation of complex medical information,” he says. “This is something that is more effective electronically rather than through a face-to-face visit with the physician.”
 
While it’s also been argued that the use of e-mail could become too time consuming for doctors, studies seem to indicate that patients who are already corresponding through this medium don’t abuse their privileges. In fact, using the Internet to correspond with a patient may actually be more productive for the physician. A University of Pittsburgh study published in Pediatrics followed 121 families who exchanged e-mails with their doctors and found that physicians received approximately one e-mail per day and responded 57% faster than by phone. Written e-mails can often be more concise and to the point than telephone conversations, and patients say they like having their treatment options or medical advice in writing, so they can refer to it and come away with a clearer understanding of their health.

Of course, there are those who are simply opposed to change because it seems so radical. And there’s no question that the country’s small practices are resistant, according to Reece. “The principal obstacle is the fact that 80% of doctors in the United States are grouped in five doctors or less,” he says. “Unless these practices adopt, change will not happen. We have the information that these systems would be better, but knowledge not used is useless.”
 
Some say the problem is that the idea of providing medical treatment without a physical exam and exchanging information over the Internet in its stead sounds extreme to small practices that have been operating in a set manner for years. “But those physicians who have a mistrust of the Internet have to realize that patients who are getting information off the Web are usually getting correct information,” says Waegemann. “In fact, electronic medical information is probably more accurate than printed textbooks, which may be out of date. The Internet is constantly able to update and provide the most cutting-edge information.”

Disinclination toward change has always been a slow barrier to overcome in the medical profession. For example, when telephones first became available, doctors were reluctant to talk to patients over the phone. “It took 40 years for doctors to accept the telephone as a valid method of communication with patients,” says Wenner. “It would appear that the Internet will take the same track unless the public starts to demand doctors who use e-health.”

Despite its slow progress, the effects of e-medicine should be long lasting. “We’ve moved from a place where five years ago there was not a broad awareness of the importance of e-health or e-medicine,” says Marchibroda. “But we’ve come a long way, and today it’s an issue that both political parties are getting behind, as well as the consumers. There are definitely barriers in the way, but there’s finally recognition of e-health’s importance. It’s just a matter of how do we get there quickly and, at the same time, assure effective adoption in a way that will truly improve the quality, safety, and efficiency of care.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.