The Emerging Role Of Online
Communication Between
Patients And Their Provider
Steven Katz M.D. M.P.H.
Associate Professor
Departments of Medicine and
Health Management and Policy
University of Michigan

Agenda
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Motivation
 Patients
 Frustrated with between-visit access
 Are increasingly connected online
 Providers
 Are frustrated with between-visit communication
 Current modes are burdensome, fragmented and inefficient
 There is enormous mismatch between communication mode and tasks

Why web is right
 It is asynchronous
 It has enormous reach
 It is robust
 exchange and store information
 provide services
 connect people
 Communication can be tracked, managed, documented, and evaluated
 It is secure

Great Expectations
The Internet will have a profound effect on the practice and business of medicine. Physicians, eager to provide high-quality care and forced by competition to offer online services, will introduce e-mail and patient-friendly Web sites to improve administrative services and manage common medical conditions. Patients will identify more health information online and will take more responsibility for their care. The doctor/patient relationship will be altered...
Jerome Kassirer. Health Affairs 2000

Trends in internet use
Type of use 2000 2003
E-mail/IM
Browsing
57 63
55 60
News 38 40
Information 36 37
Shopping 30 33
Any Internet 67 77
Source: http://www.digitalcenter.org

Source: http://www.digitalcenter.org

Digital Divide
Source: Pew Internet and American Life Surveys

Internet Use 2004
60
50
40
E-mail
Surfing
Buying
Banking 30
20
10
0
50-64 65+
Pew Internet and American Life Project 2004 pewinternet.org

Challenges
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Patients
 Lack experience with use
 Cavernous digital divide
Providers
 Concerns about workload
 Uncertain value of online communication
 Little consensus about communication management
Organization
 Lack a coherent business model/ROI
 No roadmap to building online communication tools

Dear Dr. Katz,
My name is XXX and I am a patient of Dr. XXX. While I am more than extremely pleased with the care that Dr. XXX provides my husband and me, it is our understanding that he is required to obtain your final approval before prescriptions can be written, or blood tests ordered, etc. Therefore, I thought I might eliminate the middle man, so to speak, and ask you about a concern I have had for over 20 years. In 1969 I had a cancerous tumor removed from my thyroid, and in 1978 I had a complete thyroidectomy as the cancer grew back in the same spot. After the surgery, I was placed on .2mg of Synthroid, and stayed at that dosage until about 1982-83. During this timeframe, I did not have any problems with fatigue, weight gain, lack of concentration, etc. The doctor I was seeing at the time ordered the normal barrage of thyroid blood tests and they all came back within normal limits, except for, I believe, my TSH, which was slightly elevated. Due to this fact he lowered my dosage to
.15mg. Within a couple of months, my life ceased to exist as I had known it, and it has been that way ever since. Now that I am well into menopause, my symptoms have become more intense. One suggestion was to go to bed earlier and get 8 hours of sleep. I have been doing this for about 5 years and I still feel exhausted by about 3:00 p.m. every day and when I get home from work all I want to do is lie on the couch. I find myself falling asleep watching TV at about 8:00 p.m. every night. Lack of concentration is another real concern for me, especially during the day at work. I try to get up and walk around to see if that would help get the mental juices flowing again, and it does help in the short term, but not the long term. This is not from depression. I'm a pretty happy person. Another concern is my inability to lose weight. I have been on diets after diets and nothing works. I joined a women's only exercise group and that hasn't helped either. We eat well-balanced meals and I'm not a sugar junkie, so I'm very frustrated that nothing seems to work. All of these symptoms seem to me to be a direct result of a low dose of synthroid.
My husband and I have appointments with Dr. XXXX tomorrow and I will discuss these issues with him as well. Again, let me reiterate that this is in no way a reflection on the care that we receive from Dr. XXX.
I would greatly appreciate your advice and counsel regarding these concerns. Thank you for your time.
Regards,

Dr. Katz:
I am a patient of yours through Great Care Network. Generally, I am seen by Dr. Rufus T. Firefly but I have not been able to contact him nor have I been able to get an appointment to see any doctor in the Internal Medicine clinic. When I called I was simply told there were no available appointment times. I am currently experiencing intense pain when I urinate as a result of a bladder infection and would very much like to get a antibiotic to start treating this. The symptoms are constant urge to urinate and painful urination followed by blood in my urine at the end of the urination. Can you please facilitate an appointment to see a doctor in your staff or prescribe an antibiotic. I am not taking any other medicines at this time.

Components of a patient portal
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Service-related features
 Medication renewals, scheduling, forms, registration/billing
A clinical communication tool
 Secure messaging
A patient health record
 Populated from provider and patient data sources
 Medical record
 Patient: current meds, immunizations, health status information (e.g. blood sugar or blood pressure log)

Three solutions
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E-mail
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Advantages
 Seamless Communication
 Enormous reach
 Asynchronous messaging
Disadvantages
 Security concerns
 Unstructured free-text
 Cannot track messages
 Messages cannot be automatically routed
 Cannot be easily documented

Application Service Provider
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Hosted by vendor
 Secure messaging
 Rx renewal, schedule requests
Advantages
 Low start-up costs
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Bridges clinical practices
Quick start
Vendor is responsible for updates
Disadvantages
 Limited integration with CIS
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Data moves offsite
Requires ongoing service contract

CIS application
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Hosted by provider
 Secure messaging
 Rx Renewal, scheduling
 Portal record
Disadvantages
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High start-up costs
Limited bridging with other clinical practices
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Slow start-up
Provider partners with vendor on updates
Advantages
 Robust integration with CIS
Data stays onsite
 Does not require ongoing service contract

Summary Of Experiences With
Online Communication
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Patients
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Slow initial uptake
Patients will follow the rules
 Digital divide exists in clinic
Providers
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Staff don’t like E-mail
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Doctors warm up to online communication
Doctors and patients view E-mail differently
Organization
 Resource offsets?: Cost-saving vs Cost-effective
 Clinical processes and outcomes?

University of Michigan Context
 Integrated multi-specialty provider group
 Clinical Information System
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 robust electronic medical record since 1999 encrypted e-mail system since 1999 no online patient order entry
 Substantial enthusiasm for a patient portal

Yellow brick road
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Develop the business model
Prioritize functions and features
Build or buy communication tools
Identify organizational enablers
Develop roll-out strategy
 Map relationships and workflow
 Develop rules of engagement and exchange
 Develop education and promotion strategy
 Allocate provider effort during rollout
 Evaluate processes and outcomes
Katz SJ, Moyer CA. J Gen Intern Med. 2004 Sept;19:978-983.

Portal Account:
Patient Sign-on
Account Info
Referring Physician
Patient-Provider Portal
Access to my records:
Prescriptions
Lab/Test Results
Reminders
Health Record &
History
Communicate with my provider:
Pre-Registration
Appointments & Scheduling
Referrals
Prescriptions
Send/receive a secure message
My insurance:
MCARE Services
Self-Help
Maps & Directories
Education & Cross Promotions
Maintain my own records:
Disease Management
Personal Health Record

Patient-Provider Portal- Phase 1
Portal Account:
Patient Sign-on
Account Info
Referring Physician
Communicate with my provider:
Access to my records:
Prescriptions
Lab/Test Results
Reminders
Health Record &
History
Pre-Registration
Appointments & Scheduling
Referrals
Prescriptions
Send/receive a secure message
My insurance:
MCARE Services
Self-Help
Maps & Directories
Education & Cross Promotions
Maintain my own records:
Disease Management
Personal Health Record

Patient-Provider Portal- Phase 2
Portal Account:
Patient Sign-on
Account Info
Referring Physician
Communicate with my provider:
Access to my records:
Prescriptions
Lab/Test Results
Reminders
Health Record &
History
Pre-Registration
Appointments & Scheduling
Referrals
Prescriptions
Send/receive a secure message
My insurance:
MCARE Services
Self-Help
Maps & Directories
Education & Cross Promotions
Maintain my own records:
Disease Management
Personal Health Record

Emerald Cities

Early Challenges
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Prognosis: Good
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 increase in broadband access
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