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Academy News: August 2003

Electronic Physician-Patient Communication
Charles Jaffe, MD, PhD

At the heart of patient care lies communication. In the hospital, we may call it bedside manner, but we really mean the ability to reach out to the patient. The process is not much different in the ambulatory care setting, but many more individuals are involved. The receptionists, nursing staff, paraprofessionals, and even billing office personnel significantly impact the practice of caring for our patients. In addition to the words we say, there are the ramifications of unspoken communication…like what we don't say.

Telephone Tag
Sharing information is intrinsic to our clinical basic skill set. For the latter half of the last century, our most trusted form of electronic communication was the telephone. Now, message tracking and voice mail have become the bane of office practice. For the most part, these calls are very labor intensive, intrusive, poorly documented, and frustrating for all parties. With the advent of a series of government regulations, including but not limited to HIPAA, protecting the privacy of these communications can be added to the list of the phone call mêlée. In a recent article in the Philadelphia Inquirer, a small primary care group in a bedroom community described the dilemma it faced in managing phone calls. Most dramatic was the fact they the sheer volume of calls was three times greater than those received by the local police department.

Option Quarterback
If the nightmare of "press 1 for an appointment" is to end, we need to discover another means of connecting patients and caregivers. Numerous studies have documented that improved communication is the key to the quality of care as well as a principal factor in patient satisfaction. Fortunately, we already have an option to this escalating dilemma. It's called email…but it's not your "kids email." With contentious retorts and caustic rejoinders, casual polls of physician adoption of patient email are met with a resounding "no." By comparison, Attila, camped at the gates of an enemy city, was often met with a more endearing welcome.

In deed, most resistance to patient email has been cultivated out of ignorance rather a well-founded understanding of the opportunities. Too many physicians envision another demand on their time and another expense straining the dwindling bottom line. Of course, there's the perception of a steep learning curve for any new technology. But even worse, there is a haunting vision of more government intrusion into patient care. Step back and leave yourself open for a pleasant surprise. There are existing technologies that not only overcome these objections, but also return time to the practice day and add income to the business.

Mind Meld
As a rule, office phone calls suffer from the worst kind of time management malevolence. In general, the events that have the lowest priority command the most attention. Could there be a more inefficient way to schedule an appointment? From time resource studies, we learn that refilling a simple prescription requires between two and three phone calls, not including the nearly 20% of pharmacy calls that necessitate clarification. The key element of process re-engineering is in changing when we do business in addition to how we do business.

Think asynchronously. Not wishing to repeat the grammatical abuse of a popular computer advertising campaign, more attention must be paid to providing a service or offering a resource when it is most needed. Patients would find it more convenient to request a refill after traditional office hours, and staff would be more efficient if several calls were not required to convey a lab result. Telephone voice messaging is not the only solution.

The challenge of change
A more efficient, asynchronous process already exists. It is inherently self-documenting, significantly less prone to error, and does not require several intermediaries. Moreover, these tools can provide a self-selecting triage of inquiries and responses that are directed to individuals most capable of helping. It's a common practice for someone other than the physician to answer the phone. Likewise, with modern communication solutions, someone from the office staff may redirect the incoming electronic message.

Several specialized technologies already provide this kind of capability. Although each solution may implement the process somewhat differently, these enhanced computer resources can provide every patient with a personal electronic healthcare record, through access from the Internet, while providing a secure conduit to the physician or healthcare provider. The technology deploys state of the art security and meets HIPAA requirements for privacy. Such Web sites are available 24 hours a day from any computer and offer resources not provided by traditional telephone messaging.

The Raison D'être
Within the framework of each personal healthcare site, the patient can utilize distinct areas for a health record, appointment requests and tracking, as well as medication lists (with directions) and the ability to request and track refills. Almost seamlessly, appointments can be directed to the front office, refills are brought to the attention of the nursing staff, and billing inquiries may be channeled to the business organization. Moreover, the patient can identify changes in personal information, directives, insurance data and retail or online pharmacy preferences. Some sites also provide access to lab reports and other technical care data. Even for the most cynical, its evident that none of this "messaging" has yet to involve the physician or even require provider input. This technology has served to reduce phone calls, decrease the likelihood for errors, and provide new opportunities for patient participation.

All that said, the most innovative of these solutions provide direct electronic physician-patient communication. Some allow for inquiries about care, and perhaps more importantly a codified environment for patient reminders and disease tracking. In the most sophisticated form, these services create an opportunity for "pre-visit" history taking and even the "virtual consultation." In this scenario, a patient is able to pose a non-emergent question to the physician, who in turn is able to respond with care advice, a prescription, or a request for an office visit. Perhaps as importantly, this is all self-documented. To create incentives for this behavior, many third party payors are providing reimbursement for electronic consultations. Specialty societies have requested CPT codes and some Telemedicine organizations have helped define RBRVS values.

There are a multitude of electronic solutions and services that support physician-patient communication. Each one requires a different degree of expertise and varying levels of commitment. For the individual physician or physician group, the decision to utilize one of these tools is the very first step in the continual reevaluation of patient communication. It is a fundamental change for the patient and for the caregiver as well. The resources provided by many of these services can vary significantly, and will impact the professional staff, many colleagues, and our patients.

Carpe Caseus (Grab your cheese)
There are few opportunities to improve healthcare practice with so little expenditure of resources and with so few risks. Electronic patient communication provides this opportunity through innovative use of existing technology.

To share your concerns and experiences with patient email, send and e-mail to webeditors@aaaai.org.

Charles Jaffe, MD, PhD is a member of the AAAAI Medical Informatics committee and Chair of Clinical Information Systems for the American Medical Informatics Association. Presently, he heads a task force for improving physician access to clinical trials research.

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