Despite heading up myriad technology and innovation offices, Medicare clings to an illogical, outmoded definition of telehealth as a way to reach geographically remote populations. Reimbursement is granted for only a narrow spectrum of services, such as depression screening and smoking cessation counseling. Consultation must occur by means of “an interactive audio and video telecommunications system … that permits real-time communication between [the provider] at the distant site and the beneficiary at the originating site.” Asynchronous platforms—email, remote MRI interpretation, and the like—are considered experimental. Inexplicably, the patient must be physically present at the “originating site” (such as a clinic or hospital in a rural, unincorporated, or underserved area) during the encounter, thereby defeating the purpose of telehealth altogether.
With increasing documentation demands, dwindling autonomy, crushing student loan debt, and other reimbursement cuts already making more than one-third of doctors wish they’d chosen a different profession, they’d be foolish to take on an additional burden for free. But email messages can supersede phone calls, saving time by allowing providers to skirt all that tedious chitchat. Results of a survey published in the journal Pediatrics concluded that answering medical questions by email is almost 60 percent faster than doing so by phone. And as the American College of Physicians points out, email has the advantage of being “self-documenting.”
Email-averse providers also seem to anticipate receiving more messages than their tech-savvy counterparts actually do. In before-and-after surveys of internal medicine residents and internal/family medicine physicians, 60 percent of the former and 87 percent of the latter found that using email did not increase their workload. A different study revealed that internists in one Philadelphia practice averaged 17 emails a day, only 20 percent of which were replies to patient-initiated messages. Physicians at Kaiser reported receiving just five messages a day on average. “Qualitative evidence indicates that patients are conscious not to be seen to bombard their GP with emails,” comments Helen Atherton, an Oxford, United Kingdom, physician who has written extensively about the role of email in general practice.
Many doctors, however, persist in regarding email as a worthless drain on their time, and incentives to use it are scarce. After all, those in solo and small-group practice who operate within the traditional fee-for-service model can’t bill Medicare for email correspondence. Likewise, salaried doctors aren’t keen on the idea of working harder for the same paycheck. What these practitioners have in common is a desire to improve patient care. A large Kaiser study showed that patient-physician email communication can help stabilize patients’ glycemic or hypertensive status. Other research suggests that email and text messaging can be used, for example, to increase medication compliance, treat eating disorders, lower the rate of emergency department readmissions, and improve quality of life in patients receiving palliative care.
Congress is weighing legislation intended to shore up Medicare’s telehealth payment infrastructure. In addition, Medicaid programs cover electronic messaging in a wider variety of platforms and circumstances than Medicare does, and private payers must match that coverage in 19 states and in the District of Colombia. Several private insurers actually encourage e-visits for nonemergency care and specialist consultations. Humana, for example, urges members to “think of an eVisit like [a] secure Skype™ or Facetime™ session.”
All of these email applications fall under the umbrella of telehealth services, promoted by various factions as telemedicine, mobile health (mHealth), connected health, and e-health. Attempts to standardize the contested terminology in this area have provoked fierce territorial hair splitting. For example, some groups insist that the word telemedicine be reserved for clinical interactions involving physicians. The term mobile health might mean e-visits, remote medical device monitoring, or mammography vans. One new study counted seven discrete definitions of telehealth or telemedicine in use within 26 federal agencies. According to the researchers, this linguistic in-fighting and confusion have stalled the implementation of e-anything.
The industry’s tepid response to the demand for electronic communication sets physicians apart from professionals in other service sectors. Would you patronize an attorney or accountant or real estate agent who could be reached only by phone, and only at her convenience? Or one who had instructed an assistant to read his email and phone you with a reply? Patients have begun to recognize that they are also customers, but doctors clearly have not been trained to do things the Nordstrom way. Letting patients deal with humdrum afflictions and housekeeping details by email could help customer-focused practices attract and retain patients as alternatives to traditional medical care become increasingly appealing. Nearly 40 percent of the nation’s 9,000 urgent care clinics have opened within the past five years, and the number of retail clinics, which now stands at 2,200, is expanding at an annual rate of about 25 percent.
The Office of the National Coordinator for Health Information Technology’s wishy-washy manifesto has somehow failed to persuade grudging physicians to share in its pale vision of unspecified “interoperability across the health IT ecosystem.” For now, then, communication between most patients and their doctors will remain pretty much as it was the day Americans watched the Apollo 11 moon landing on their portable black-and-white TV sets. Will someone please get up and change the channel?
This article is part of Future Tense, a collaboration among Arizona State University, the New America Foundation, and Slate. Future Tense explores the ways emerging technologies affect society, policy, and culture. To read more, visit the Future Tense blog and the Future Tense home page. You can also follow us on Twitter.