Within the next decade, “all individuals, their families, and care providers should be able to send, receive, find, and use health information in a manner that is appropriate, secure, timely, and reliable.” That’s the anemic commitment offered up recently by the Office of the National Coordinator for Health Information Technology in its dazzlingly vague 10-Year Vision. We’ve drifted far off course since 1962, when President John F. Kennedy proclaimed the nation’s intention to “send to the moon … a giant rocket … before this decade is out.” NASA accomplished Kennedy’s heady mission in less than seven years. It will take considerably longer for us to sort out how to exchange electronic health information.
Research and common sense indicate that Americans want to be able to exchange email with their doctors, and it’s easy to see why: There are not enough primary care providers in practice to handle the increasing number of insured patients. New fee-for-value payment models focus on disease prevention or early intervention. Tablets and smartphones are ubiquitous and broadband services widely available. But a 2012 Harris Interactive poll found that only 12 percent of respondents reported having email access to their physicians, although more than half said such communication was important to them. Similarly, a 2012 Consumer Reports survey showed that just 9 percent of participants had contacted their doctors by email within the past year. Inadequate infrastructure, patchy insurance coverage for patients, insufficient reimbursement for providers, and uneasiness on both sides about online privacy have been blamed for the nation’s listless effort to implement electronic health information exchange.
Messages can be categorized as either clinical or administrative. Structured clinical consultations, or e-visits, are carried out by channeling encrypted email through a secure online portal linked to the patient’s electronic health record. The provider responds as he or she would in an office—for instance, by writing a prescription, ordering a lab test or imaging study, referring the patient to a specialist, or recommending a follow-up appointment. Such interaction can replace office visits for nuisance illnesses, saving patients the time, cash, and hassle of missing work and schlepping to the doctor’s office. A large Mayo Clinic study found that patients who opted for e-visits were primarily women taking advantage of the service during working hours. According to Deloitte, about half of Americans’ and Canadians’ 600 million annual primary care visits could be transacted online instead of face to face. Fees for e-visits range from $35 to $75 out of pocket, but can be as little as $15 with an insurance copay.
Secure messaging is also a handy administrative tool. Patients can log in free to an online portal to check lab and test results, pay bills, make appointments, ask questions, and request medication refills or routine dosage adjustments. Messages intended for the doctor are usually triaged by a medical assistant or other staff member. The system is available 24/7, so it’s no longer necessary to confine such business to office hours. The practice benefits, too, by reducing overhead, improving quality, and increasing customer satisfaction.
Update, June 26, 2014: Medicare’s electronic health records incentive program requires that secure messaging be available, but mandates only one-way communication: In Stage 2, at least 5 percent of an eligible provider’s patients must send him or her a secure message. The doctor, however, is explicitly relieved of any obligation to reply personally. Stage 3 draft recommendations call merely for providers or their staff to send reminders for preventive or follow-up care to at least 20 percent of patients “in the format of the patient’s preference.” The possibility of “electronic episodes of care” may be considered at some future stage.
So why isn’t the medical industry embracing technology as a way to communicate with patients? The twin threats of increased workload and inadequate compensation are primarily responsible for providers’ reluctance to adopt email in their practices. Nearly 1 million U.S. doctors rely on Medicare reimbursement, yet Medicare doesn’t pay them one thin dime for answering email messages or offering e-visits. Two weeks ago tech-friendly physicians gained an important ally when the American Medical Association rescinded its 1994 prohibition on rendering clinical telemedicine services. The group asserted that doctors should be adequately compensated for email consultation and pledged its support for Medicare pilot projects to test innovative payment and incentive systems. The only two under way now, however—the unremarkable Alaska and Hawaii telehealth demonstration projects—are hardly groundbreaking. Privacy and security concerns are another reason providers have snubbed email. And who can blame them? Anxiety over the possibility of a HIPAA breach has escalated to a level of hysteria not seen since the Bay of Pigs crisis.