July 23, 2007

The Informed Patient
By Kim M. Norton
For The Record
Vol. 19 No. 15 P. 34

An increasing number of patients travel to the doctor’s office fueled with data collected from the Internet, a trend that has the potential to change the way practices operate.

The doctor-patient relationship historically has been one in which the clinician held all the information. However, this paternalistic relationship has undergone several changes in recent years. Today, an increasing number of patients are coming to their appointments armed with information obtained from Internet searches.

This development has helped shift the doctor-patient relationship from a one-sided transfer of information to a more equal arrangement that allows patients to be more proactive in their healthcare. Naturally, this fundamental change has been greeted with mixed reviews.

“Today, we see that the patient’s age dictates how the doctor-patient relationship has changed,” says Rick Kellerman, MD, FAAFP, a family physician in Wichita, Kan., and president of the American Academy of Family Physicians (AAFP). “Younger patients with greater access to the Internet are more involved in their healthcare choices and are generally more informed due to the abundance of medical information available online. Still, some other patients are so overwhelmed with the sheer amount of information out there that they want their doctor to tell them what to do.”

Whether the medical profession embraces the Internet—or even approves of it—doctors are finding that they have more informed discussions with their patients when the patient learned the basics of a given condition before scheduling an appointment, explains Devon M. Herrick, PhD, a healthcare economist and senior fellow with the National Center for Policy Analysis in Dallas. “Historically, patients would receive virtually all their information about diseases and conditions from their doctors, and they mostly accepted their doctors’ advice without question. Now, patients can spend a few hours on the Internet and learn about the latest developments in treating a disease or condition. A patient could never afford to have their physicians educate them to this degree,” he says.

With this increased knowledge in tow, patients should establish a personal medical home, according to Kellerman. “Having a personal medical home [an ongoing relationship with a family physician] is similar to a marriage. Both parties must be honest and comfortable with each other. Once this relationship has been established, the physician is able to provide a higher quality of care,” he says.

If the patient and physician have a standing relationship, the doctor will likely be more receptive to a patient presenting data from the Internet concerning specific symptoms. Both parties can discuss what the patient found and move forward with tests toward a diagnosis. However, according to Kellerman, should a patient who the physician has never seen before show up with a stack of papers from the Internet, the doctor is less likely to invest the time to review the information.

Deciphering the Net
“Reliability of the information on the Internet is the single greatest drawback to its wealth of information,” says David C. Dale, MD, FACP, a professor of medicine at the University of Washington in Seattle and president of the American College of Physicians. Advertisements for health aids, pills, supplements, and advice—whether on television, radio, or the Internet—make it difficult for the patient to determine what is useful and what is not, says Dale. “My advice is to determine what the problem is first. If you have a diagnosis of cancer, or want more information about cancer, look to those organizations that specialize in that particular area, such as the American Cancer Society,” he explains.

Dale says the main reason patients will turn to the Internet is for information on a symptom they are experiencing. Their first question, he explains, is, “Am I sick?” In this respect, the Internet is a good initial resource for patients and doctors. If patients can go online and find out about symptoms, they are better informed when they visit the doctor. “By having information about the symptoms, the patient is exhibiting [that he or she] can assist in making a diagnosis and recommending the correct tests rather than starting blindly,” he explains.

Because illnesses come in many shapes and varying degrees, Dale is not implying that patients can use the Internet to make diagnoses. “The only person who can accurately make a diagnosis is the doctor. The Internet is a good resource for information, but it does not replace a visit to the doctor or routine tests to render a diagnosis,” he says.

The Value of Information
Kellerman and Dale agree that the informed patient is a better overall patient. “Dealing with a patient who is informed allows for more open communication between the doctor and the patient,” Kellerman says. “The doctor can speak with the patient on a different level because he knows that the patient does have a body of information to draw from in relation to his own health.”

“In my practice, I find that more informed patients ask more educated questions. And that is wonderful,” says Dale. The drawback to the informed patient is that the Internet may create false hopes. For example, if a patient researching a particular disease discovers a treatment or surgical procedure, he or she may ask for it specifically. In reality, however, the procedure or treatment may not be feasible for that particular case. This is where the importance of a personal medical physician comes into play. “The doctor and patient must have an established relationship to openly discuss the information the patient found on the Internet with the reality of his own medical situation,” says Kellerman.

Pitfalls of Too Much Information
Just as an informed patient is an asset to the doctor-patient relationship, he or she can also be a detriment. Even before the wide accessibility of medical information on the Internet, there were medical dictionaries and educational materials that patients used to dig deeper into their health. Still, with the large volume of information on the Internet, some patients can go overboard. If the patient tends toward hypochondria, the Internet only feeds into that problem, says Kellerman.

The Internet, while an excellent informational resource, is also a work in progress. Anyone can put up a Web site. Anyone can start a company touting the benefits of an herb for cancer treatment. Patients who turn to the Internet for information are bombarded with quality information, as well as material that is either unknown or of suspect origin. “This is why it is imperative that if a patient comes in with information from a Web site, they at least bring in the link to the site so the doctor can determine its validity,” says Dale.

The marketing aspect of the Internet makes it especially difficult for consumers to differentiate between a Web site that is selling a product and one that is explaining a disease in an unbiased way, says Kellerman. Ideally, patients should refer to sources that are reputable, but therein lies the problem: differentiating between the useful and the useless.

Larry Van Horn, PhD, an expert and researcher on healthcare management and economics and associate professor of management at the Owen Graduate School of Management at Vanderbilt University in Nashville, Tenn., says even the most user-friendly sites, such as WebMD, serve a purpose. “WebMD is a high-profile site, but it is largely driven by advertisers who have their own incentive in providing valuable information to the healthcare consumer,” he says. It is for this reason that Van Horn encourages patients to discuss anything they find on the Web with their doctors.

Guidelines for Using the Internet
When surfing the Web for health information, it’s important to determine each site’s sponsors, says Herrick. For example, if the site is hosted by a drug manufacturer, the information is more than likely accurate, but the patient may not be receiving the full scope of treatments available for a particular disease, he notes.

Van Horn directs patients to academic and peer-reviewed journals for information, if feasible. As for the Internet, he suggests using sites sponsored by teaching hospitals or other acknowledged experts in the field.

Kellerman believes there are two types of sites for researching an illness. “There is the site that is written by doctors for the patient that is easy to understand and digest, such as WebMD, and then there are sites that are more technical in nature, such as the National Library of Medicine. Knowing your patients’ threshold for understanding will dictate which type of site you would direct your patients to,” he says.

Kellerman and Dale recommend the following sites as trusted sources:

• WebMD (www.WebMD.com) is a reliable resource for information on a wide range of illnesses and symptoms.

• The National Library of Medicine (www.nlm.nih.gov) or MedlinePlus (www.medlineplus.gov) are both good resources for the more Web-savvy consumer.

• Maintained by the AAFP, www.familydoctor.org provides general information and research.

• Revolution Health (www.revolutionhealth.com) is a new site that offers a variety of information and resources. In addition to providing patient education, it enables consumers to develop a personal health page. It also offers premium services that allow visitors to develop a personal health record and health expense manager.

More Knowledge, More Money
The plethora of available medical information, symptom checkers, and health calculators has analysts forecasting an increase in healthcare consumption. Although it would seem that a more informed patient would be less likely to use more healthcare resources, the opposite appears to be true. “Patients who are turning to the Internet would likely consume more healthcare than not, which would probably increase the demand for healthcare,” explains Herrick.

Such a theory is based on the idea that consumers who research a potential illness are then more likely to schedule a doctor’s visit. From there, the doctor will likely order blood work or other tests to determine a diagnosis, all of which adds to the cost of healthcare, Herrick says.

Instead of using the Internet to diagnosis a series of symptoms—which have a high degree of variability—Van Horn suggests employing the technology to gather information after the diagnosis. “Determining a diagnosis requires judgment on the physician’s part and to use the Internet as a diagnostic tool seems futile. It could be better served as a resource for treatment options and support,” he says.

Web Portals
As the medical profession evolves to incorporate technological advances, some offices are offering their patients what they are looking for: a Web portal run by their personal medical home that offers reliable, trusted information about their health and health-related topics.

For the past three years, Atlanta Women’s Specialists (AWS) has been using HealthMatics Access, a Web portal that is part of Allscripts’ HealthMatics Office electronic medical record (EMR) solution. The software provides patients with an online EMR featuring limited information, such as lab results and diagnoses, and the ability to schedule an appointment, pay a bill, receive patient education, and e-mail staff members.

“The ability to communicate with anyone in our practice has been a huge benefit for our patients,” says AWS practice administrator Paul Barry. He says that when a patient comes for a checkup, his or her time with the physician is limited and follow-up questions often occur. Fortunately, the patient can e-mail any concerns to the physician or one of the nurses.

“What has been the most advantageous to our firm is the reduced amount of nuisance calls we receive. Our nursing staff is able to answer calls that are more important or urgent rather than answering basic pregnancy questions,” says Barry. The portal enables patients to contact their doctors via e-mail, thus avoiding playing phone tag.

At AWS, approximately 25% of the patient base uses the portal. Although Barry admits that some patients are reluctant to use it and it is not necessarily a cost saver for the practice, he does recognize other benefits. “We are realizing intangible benefits of the Web portal in that our entire staff is able to provide better care and customer service with it rather than without it,” he notes. “Another benefit is that if our clients are happy and pleased with the service they are receiving, they can help increase our business by referring friends and family to us, thereby growing our business for the $50 to $100 per doctor per month fee that the portal costs.”

Kellerman views Web portals and other Internet features as tools to increase business and customer service. Although the technology has yet to reach its full potential, it is gradually becoming a force that will help empower patients to take a more active role in their own care, he adds.

— Kim M. Norton is a New Jersey-based freelance writer specializing in healthcare-related topics for various trade and consumer publications.