December 6, 2010
Online diagnosis: UPMC doctors treating patients over the Internet see benefits
By Sean D. Hamill
On Oct. 11, for the first time in his life, Mark Gleeson, 83, got a diagnosis for an illness without seeing a doctor in person, or even speaking to one on a phone.
Instead, the retired executive sat down at the computer at 7 p.m. in his bedroom in Oakmont and explained his lingering cough and cold troubles to a doctor online via UPMC's eVisit system.
"Rather than trying to get a visit to go see my doctor, I thought, 'Why not try this?' " he said. "For someone who didn't want to get into a car and go into one of these off-the-street urgent care centers at night, it worked for me."
Within an hour, Grant Shevchik, the Murrysville-based doctor Mr. Gleeson corresponded with -- via a set of formatted questions specific to his symptoms -- prescribed antibiotics for his upper chest infection and medication to loosen his congestion.
Three days later, "I felt good as new," Mr. Gleeson said.
He was one of the first patients to try eVisit when UPMC made it available in October to the patients of all of UPMC's 277 primary care physicians by sending out e-mails that advertised it as a "digital house call."
Over the previous two years the system -- the first in southwestern Pennsylvania -- was a pilot program for 30 UPMC physicians. During that time a team of UPMC physicians added new ailments to the list of symptoms -- and individualized questions for each-- methodically growing from, at first, six common problems, like colds and red eye, to 20, now including shingles and erectile dysfunction.
Use has grown rapidly in the past two months, going from about one eVisit request a day systemwide to five each day, despite the fact that few health insurers will cover its costs and most patients have to pay a $30 fee.
Dr. Shevchik, who came up with the idea for eVisits in 2007 after seeing other models start around the country, said UPMC's still-fledgling system for now amounts to "a well-kept secret" about to grow exponentially.
And even though there are few similar systems nationally -- very few are as structured as UPMC's -- the idea of online consultations with doctors is among the most talked about issues in healthcare today.
"Every major medical system in the country, if they haven't implemented it yet, they're looking at doing it," said Jonathan Linkous, CEO of the American Telemedicine Association, an advocacy group physicians founded to lobby for remote medical technology. "Many of them see this as a way to keep their heads above water with large growth in patients and chronic healthcare needs."
The promise of online diagnosis is nothing short of a technological marvel: a perfect combination of convenience for patients, a time saver for doctors and a money saver for insurance companies.
"Think about it," Dr. Shevchik said, "you can have your doctor tell you what's wrong with you without you having to go to the office, and it takes less time for you and the doctor, and it generally costs less than an office visit."
"From a business perspective, it's a win-win-win," he said.
But the promise of the technology has formidable concerns from a number of constituents: from cautious doctors and health systems worried about whether it works as well as an office visit, insurance companies worried about increased use and costs, and patients nervous about getting medical advice via the Internet.
As an example of that concern, other than UPMC, none of the other largest healthcare systems in the region would provide someone to talk about what if any plans they have to create their own online consultation systems.
While UPMC's Health Plan does cover eVisits, requiring a $20 co-pay, Highmark, the local Blue Cross-Blue Shield affiliate that dominates health insurance in Western Pennsylvania, does not cover any online consultations.
Highmark would provide only a written statement saying, in part: "Highmark is continuing to look at and explore new methods of care delivery and determining how this might work for our members across the nation."
Even within UPMC, which prides itself as a healthcare technology leader, the concept has not firmly taken hold. Of UPMC's 277 primary care physicians, only 60 percent of them have agreed to be part of eVisits since it expanded in October.
The 100 or so physicians who have not signed on "is a group that said, 'We don't understand this concept. We don't know what it is,' " Dr. Shevchik said.
UPMC is allowing any of its 42,000 patients who have signed onto HealthTrak-- a secure, 4-year-old online system that provides electronic access to a patient's medical records, medications and other information -- to have access to eVisits.
So, even though Mr. Gleeson's own primary care physician has not signed on to eVisits, he was able to use the system, which is why Dr. Shevchik handled the consultation. (Mr. Gleeson's doctor would not return a call seeking comment.)
Some of those doctors who haven't signed on simply don't want to give a diagnosis without seeing a patient in person, said Ken Gibson, a primary care physician who works in the same Murrysville practice as Dr. Shevchik.
"I understand. I'm always the guy most resistant to change," said Dr. Gibson, 50, who added that he had never used a computer until 1997 and he hated the idea of electronic records.
"But now I'm waiting for the day when a patient can stick their finger in the computer and we'll be able to see a full holographic workup of their body -- and we're probably not too far away from that," he said.
Online communication between patients and doctors is nothing new. Since the advent of e-mail patients have been reaching out to their doctors online. Recent surveys demonstrate that it's becoming more and more common, despite the dearth of reimbursement and rarity of formalized systems like eVisits.
A survey by health information firm Manhattan Research in 2009 found that 42 percent of physicians had some online communication with patients, though most of that was for nondiagnostic reasons, such as checking on lab results or when the next appointment is scheduled.
The American Academy of Family Physicians, an advocacy group representing about 63,000 family physicians nationally, said that a 2009 survey of its members showed that just 6 percent of them had done a Web-based consultation -- but that number was more than double the 2.6 percent who had done so in 2008.
"If we're going to do the task well in the future, we're going to have to use all the tools available to us, and that's including e-visits," said Roland Goertz, a Waco, Texas-based family physician who is the president of the academy.
Dr. Goertz's organization has been advocating for the use of new technology like e-visits for a decade now for a very basic reason, he said: "It's the only way we're going to be able to care for the larger and larger number of people who will need care."
Although there is concern among his members about making consultations online without seeing a patient in person, Dr. Goertz -- like virtually every other healthcare expert contacted for this story -- believes the biggest roadblock holding back the technology is also obvious: "Our archaic payment system; health insurance companies just aren't paying for it."
But some, like Aetna, are not only paying for it, the company created its own online consultation system in 2006, called webVisit, that it tries to get its member physicians to use.
"We do believe it will reduce costs and improve efficiency," said Aetna spokesman Walt Cherniak. "But we haven't done a study of that yet, and we're all waiting to see what studies will show us about that."
Even in its fledgling form, UPMC's eVisit program has caught the eye of perhaps the most influential insurance institutions in the country: Medicare and Medicaid.
Medicare officials last year asked Dr. Shevchik to make a presentation about the program in Washington, D.C. And this past May, Pennsylvania Medicaid officials began a pilot program with a limited number of UPMC physicians to see if it benefits Medicaid patients -- and ultimately saves the government-funded system money.
The pilot program hasn't been analyzed yet, but, "I think if there are any cost savings here, it would be in preventing emergency room visits for our clients" who couldn't get in to see their regular family physician, said David Kelly, medical director for Pennsylvania's Medicaid program.
A survey last year of 121 UPMC eVisit patients by the University of Pittsburgh found that patients by-and-large liked using the system, thought they got advice as good as they'd get in person, and overwhelmingly said they used it for convenience.
The survey results were the "proof of concept" that convinced UPMC officials to begin expanding it to more physicians, said Steve Albert, the Pitt professor of behavioral and community health sciences who oversaw the study.
"The main thing is that people really liked it," Dr. Albert said. "You don't have to be on the phone for 45 minutes. You avoid traveling to the office and sitting there. And all of these things make it attractive for a large volume of care."
That's exactly the experience Mr. Gleeson said he had.
"I'll use it again, sure," he said. "I don't want to sit in the doctor's office all day if I don't have to."
UPMC doctors treating patients over the Internet see benefits
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