Agenda
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
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„
Motivation
Current online landscape
Challenges
Early Experiences
Prognosis
Motivation
„ Patients
Why web is right
„
„ Frustrated
with betweenbetween-visit access
„ Are increasingly connected online
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„ Providers
It is asynchronous
It has enormous reach
It is robust
exchange and store information
provide services
„ connect people
„
frustrated with betweenbetween-visit
communication
„ Current modes are burdensome, fragmented
and inefficient
„ There is enormous mismatch between
communication mode and tasks
„
„ Are
Great Expectations
The Internet will have a profound effect on the
practice and business of medicine. Physicians,
eager to provide highhigh-quality care and forced by
competition to offer online services, will introduce
e-mail and patientpatient-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...
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Communication can be tracked, managed,
documented, and evaluated
It is secure
Trends in internet use
Type of use
2000 2003
E-mail/IM
57
63
Browsing
55
60
News
38
40
Information
36
37
Shopping
30
33
Any Internet
67
77
Source: http://www.digitalcenter.org
Jerome Kassirer. Health Affairs 2000
1
Digital Divide
Source: http://www.digitalcenter.org
Source: Pew Internet and American Life Surveys
Internet Use 2004
Challenges
„
60
Patients
„
50
E-mail
Surfing
Buying
Banking
40
30
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Lack experience with use
Cavernous digital divide
Providers
Concerns about workload
Uncertain value of online communication
„ Little consensus about communication management
„
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20
10
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Organization
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0
50-64
65+
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Lack a coherent business model/ROI
No roadmap to building online communication tools
Pew Internet and American Life Project 2004 pewinternet.org
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.
2
Components of a patient portal
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ServiceService-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
„ E-mail
„ Application
Service Provider
„ Integrated Clinical Information System
E-mail
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„
Advantages
„ Seamless Communication
„ Enormous reach
„ Asynchronous messaging
Disadvantages
„ Security concerns
„ Unstructured freefree-text
„ Cannot track messages
„ Messages cannot be automatically routed
„ Cannot be easily documented
Application Service Provider
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Summary Of Experiences With
Online Communication
CIS application
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Hosted by provider
„ Secure messaging
„ Rx Renewal, scheduling
„ Portal record
Disadvantages
„ High startstart-up costs
„ Limited bridging with other clinical practices
„ Slow startstart-up
„ Provider partners with vendor on updates
Advantages
„ Robust integration with CIS
„ Data stays onsite
„ Does not require ongoing service contract
Hosted by vendor
„ Secure messaging
„ Rx renewal, schedule requests
Advantages
„ Low startstart-up costs
„ Bridges clinical practices
„ Quick start
„ Vendor is responsible for updates
Disadvantages
„ Limited integration with CIS
„ Data moves offsite
„ Requires ongoing service contract
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„
Patients
„ Slow initial uptake
„ Patients will follow the rules
„ Digital divide exists in clinic
Providers
„ Staff don’
don’t like EE-mail
„ Doctors warm up to online communication
„ Doctors and patients view EE-mail differently
Organization
„ Resource offsets?: CostCost-saving vs CostCost-effective
„ Clinical processes and outcomes?
3
University of Michigan Context
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Integrated multimulti-specialty provider group
Clinical Information System
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robust electronic medical record since 1999
encrypted ee-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 rollroll-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
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„
Katz SJ, Moyer CA. J Gen Intern Med. 2004 Sept;19:978-983.
PatientPatient-Provider Portal
Portal Account:
Access to my records:
PatientPatient-Provider PortalPortal- Phase 1
Portal Account:
Access to my records:
Patient Sign-on
Prescriptions
Patient Sign-on
Prescriptions
Account Info
Lab/Test Results
Account Info
Lab/Test Results
Referring Physician
Reminders
Referring Physician
Reminders
Communicate with my provider:
Health Record &
History
Communicate with my provider:
Health Record &
History
Pre-Registration
Pre-Registration
Appointments & Scheduling
Appointments & Scheduling
Referrals
My insurance:
Referrals
My insurance:
Prescriptions
MCARE Services
Prescriptions
MCARE Services
Send/receive a secure message
Self-Help
Send/receive a secure message
Maintain my own records:
Self-Help
Maintain my own records:
Maps & Directories
Disease Management
Maps & Directories
Disease Management
Education & Cross Promotions
Personal Health Record
Education & Cross Promotions
Personal Health Record
PatientPatient-Provider PortalPortal- Phase 2
Portal Account:
Access to my records:
Patient Sign-on
Prescriptions
Account Info
Lab/Test Results
Referring Physician
Reminders
Communicate with my provider:
Health Record &
History
Emerald Cities
Pre-Registration
Appointments & Scheduling
Referrals
My insurance:
Prescriptions
MCARE Services
Send/receive a secure message
Self-Help
Maintain my own records:
Maps & Directories
Disease Management
Education & Cross Promotions
Personal Health Record
4
Early Challenges
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Variable staff acceptance
Perceived additional work
No clear reimbursement plan
Delayed rollroll-outs
Uncertain budgeting
Scope creep
No single system solution
Prognosis: Good
„
Patient facility and access is growing
„
increase in broadband access
„ Better
online communication tools
„ Better clinical data systems
„ Beginning of the “J curve”
curve”
„ Uncertain business model
5