Trial lawyers in FL would love this. Would easily make these consults impossible to defend since humans are not yet clairvoyant. The last thing that I wanted to do after surgery, full day of office, hours of signing off on labs and imaging on EMR was to start trying to treat patients via email. I can visualize the TV, billboard and hear the radio attorney advertising now.
"Were you treated by email? Patients deserve better" Call Salamander, Frog and Snail.
2
Irony?
Warnings of a Dark Side to A.I. in Health Care
https://www.nytimes.com/2019/03/21/science/health-medicine-artificial-intelligence.html
1
Why the focus on consultations? What about communication? In my entire life I’ve only had one MD give me his email address. Sure, email can be a pain. But if college professors can deal with it—“Hey, Dr A, I missed Wednesday. What’d we do?”—so can MDs.
5
"[A] large proportion of referrals...IS not needed." Are people now thinking that it is actually correct to use a plural verb for a singular subject if there is a plural noun in between???
4
My comment is more along the lines of "what if" rather than a response to the nuts and bolts of the article (though it is a good presentation of the current use of email for consultations).
I have always wished that I could email my doctor when I have a simple question for him. I don't mean that I intend to circumvent the need for an office visit, but for the times I need to tell him I have symptoms similar to a previous problem and to ask if he would call a pharmacy to refill a prescription. Most of the time, in this circumstance, the doctor will call in a refill. More than once, I have needed to let him know that a prescription he recently ordered for me has serious, unwanted side-effects.
For calls like these, I feel as if I'm taking valuable time from a nurse in his office when--over the phone--I tell her or him my problem. To me, an email to the nurse would take less time than responding to my phone call. Often we both get involved in a game of phone tag, which is helpful to no one. Bottom line, email might be a solution.
5
Email and using it to communicate in medicine evolved as needed in response to real world conditions. The same thing cannot be said of EMRs. They were imposed from outside, were designed by non medical types and have resulted in:worse patient care, inefficiency, huge expense, doctor and staff burn out and a tremendous transfer of money to companies that have nothing to do with your care. There's a lesson here. The needs of patients and the health care system should be driven by the needs of those groups, not by regulators, politicians and people with an agenda that has nothing to do with health care.
2
E-consults is a subset of Telemedicine whose expansion is the real solution to providing improved access for patients and reducing the bottlenecks in getting specialist care and reducing costs and unnecessary visits .
The Professor here has correctly suggested a solution but appears to be offering a " turkey leg " instead of serving a " whole bird " .
1
Have I been e-consulting without knowing it? My PCP answers emails on various conditions, sends in Rxs for them, doesn't bill extra for them (he's on the faculty of a med school and works on salary). We then review what's been done at my yearly consultation (in person).
5
My husband is an M.D. whose specialty is one of the lowest-paying and he works at a large hospital. His pt. load has increased dramatically over the yrs. and there are also other factors making the practice of medicine nearly untenable. There’s pt. documentation and insurance paperwork; it’s a sinkhole of time and my husband spends hrs. every night contending with that. There are the many hrs. each week spent on the phone, arguing with people at insurance companies to get them to approve medications. Additionally, he must work on most holidays and also one weekend per month. That includes getting numerous calls from medical residents late at night, making sleep nearly impossible.
It took us many yrs. to repay my husband’s med school loans (a *huge* amt. of money) - and there were the many yrs. spent in med school & residency (of which the latter was torturous in those days; residents worked for 36 hours, and then there were only 12 hrs. before it began again). I’m livid when I read screeds about “rich, greedy doctors”; for most doctors, that couldn’t be farther from the truth. If someone wants to earn a lot, medicine is NOT the way to do it; the costs (financial, total sacrifice of time and horrendous stress) are way out of proportion to the gains. If you call your lawyer, the clock starts ticking immediately - and the hourly rate is higher than most physicians’.
If many prospective med students decide it’s simply not worth doing, we’ll be in serious trouble.
10
A physician centered article. What about the patient? Taking time off work (loss of compensation there), transportation costs, childcare, etc, etc, etc. Hours for the patient, too, for a visit to a specialist that may be a waste of the patient's time. Of course the physicians should be compensated (they are selling their time, after all).
4
This seems like an area where expert specialists could build a AI questionnaire tool for the primary care doc and patient to complete, that could make sure all the basics are covered and inform the decision about whether a face-to-face appointment is warranted. I see the biggest risk as incomplete information. This could document the information exchange and protect all parties. And patients could still demand a face to face.
I have a condition that causes me to see a rheumatologist periodically, with long waits to get an appointment. I would love to know in advance when it is worthwhile and when I could just ask my PCP to renew my prescriptions. It would keep me out of the way of others needing attention.
4
As a healthcare provider, I would be very reluctant to go with this as a formal thing - "curbside" consults, which we have long assumed were informal and would not be documented in a patient record, were often done just for information by the primary care. If it gets to the point of my name being entered into the patient record, then I do not want to give advice when I haven't had the opportunity to examine and talk to the patient myself. I have had the caller give incomplete information, leaving out a pertinent piece, convey the patient 's words a little differently than what was actually said, which would have led me in a different direction. I might consider a video consult with the patient if there is a clear legal guidelines on the limitations of this method, but I would find this type of consult concerning.
7
@DJ!
yes I totally agree. Just because the e-consult is convenient does not mean it is correct! Who is checking to see if the right treatments are actually being given?
1
March 20, 2019
The New York Times
Letter to the Editor,
Re “When Email Comes to the Doctor’s Office, Wait Times Decreases” (The Upshot, March 18):
To the editor,
Medicine is a hands-on profession. Perhaps in the workplace emailing is a quick way to communicate and avoid a business meeting. But in medicine patients need to be seen, listened to, and examined.
It is true, that many patients that are referred to specialists may not need their care. But for the primary care doctor who is already over-burdened with insurance paperwork, tied down answering phone calls and seeing way too many patients because of insurers’ low remuneration rates, eMail consults just add more confusion and distraction.
It is unreasonable to further burden primary care doctors. Some would say unconscionable.
Theoretically, using Email to consult with specialists may in a few selected cases to save time and money, but it has a far greater capacity to create confusion and increase liability for primary care doctors.
Edward Volpintesta MD
12
Nothing really new about this; I've been doing it for all of my 15+ years in practice. We call it curbsiding. Informal questions from one clinician to another (usually from a primary care clinician to a specialist). Previously done via old fashioned telephone (still the best way), more recently via the EHR or secure text messaging. Sometimes it's clear that a formal consult is warranted; other times that is not needed. And there can be really pitfalls in this informal approach. Sometimes there is no good substitute for a formal, in-person consult.
10
A question. If an E-consultant gives an opinion without actually having had an encounter with the patient, is he/she subject to liability if the patient's outcome goes wrong ? What do the physician readers think ?
2
@Shailendra Vaidya
Worse than liability: S/He s subject to years of litigation to determine *who* has liability - The one who is documented to have given incorrect advice, in writing, or the last doctor to actually "lay hands" on the patient... or was the e-mail really a sort of laying-on of hands, in which case the specialist is definitely holding the hot potato, or does the provider of the e-mail service bear some responsibility, or ...?
It's a mess.
12
@Eric, Your comments are in line with my thought process too.To diagnose and treat a patient without face to face in person encounter is like inviting trouble.
6
Take away the lawyers'-casino aspect of email consultations and doctors will start using email as a tool. But the fiendish 5% of outright crrooked lawyers who never had any business in law school are attacking doctors and medical-related companies so much that we MUST reform the tort system.
7
I am quite pleased with how the email consult works using MyChart which provides summary of test results and scheduling appointments. It is understood that if there is an emergency one does not wait to see a primary care physician but visits an emergency unit. Often the Doctor's assistant or nurse responds to email and the Doctor is made aware of the situation. This is a good way to get prompt attention without waiting for an appointment or trekking over to the Doctor's office. More and more use of electronic consultations can indeed save time, expense, headaches and diminish spread of respiratory and gut infections contagious diseases from patient to patient sitting in the waiting room of Doctor's office.
7
Looking through a number of comments (admittedly not all), there seems to be some confusion about what the econsult is. Econsults are when one provider asks a question about a patient to another provider. This is NOT the patient asking a question of their doctor via email. That is often known as secure messaging and is completely different. Econsults can save a patient money (cost of copay) and time if the issue is a minor one that really doesn't need an actual in-person visit. For example, if a doctor is unsure about how clinically significant a test result is, they can send an econsult to the specialist. The specialist does a chart review, and sends back recommendations. The recommendations can be anything from "Eh, that is nothing" to "Hey, you should simply repeat the labs" to "You should order these additional labs" to "Whoa, that is pretty bad, please refer the patient for a face-to-face visit". The specialist may also ask to see the patient face-to-face if they cannot get the info that they need from simply doing a chart review. The asking provider will then let the patient know what the specialist said. I don't know how compensation for econsults works in the private sector, but the VA does give workload credit for doing econsults.
13
@Loofy But most of the systems I am aware of would not provide any compensation.
2
Uhhhh
Do physicians who spend hundreds of thousands of dollars on education, and work over 65 hours a week for decades, do these physicians ever get compensated for their work?
If an e consult on a high risk patient, proves to be inadequate, do patient families get to crucify a physician in court?
8
After decades of medical practice and observing how physicians charge for their time vs how attorneys charge.
I often wondered why physicians do not bill as attorneys do for advice given over the phone or now by e-mail for texts. Is their time or expertise not as valuable?
How does eConsults charge for their time and who pays the primary care physicians for the time they spend with eConsults?
18
Not true around here.
I have NEVER had a physician or staff member respond to an email.
When I need something, I goes to the doctor's office. It's the ONLY way to get through.
5
@Jay David It is a HIPPA violation to respond via unsecured email.
4
@Marvin
Define an "unsecured e-mail."
And please cite the HIPPA subsection that says this.
5
Here's a thought... Build more medical schools and license more physicians that will bring down the cost of healthcare. Nowadays. physicians feel entitled to HUGE incomes for what has become poor service and advice. Docs are 'tools' of the pharma companies where they've bought into the idea that every patient leaves with a prescription (or 2 or 3) for every office visit.
I've seen physician incomes and it is the driving force for poor medicine with increased patient loads and less time per visit and increased 'procedures' that are too often, unnecessary. - Dr Welby died decades ago and with him patient-centric healthcare.
7
@drDont As a medical student who will accrue $400,000 in debt from four years of college and four years of medical school by the time I graduate, then land a residency that will pay $50-60,000 per year for the next 3-7 years, then potentially do a fellowship that pays $70k per year for 1-3 years after that, it is no wonder that young physicians these days are not excited about the prospect of getting paid less. I'm not spending a decade studying so that I can be in debt for another two decades to make the same salary I could receive with only an undergraduate degree. No matter how much one likes helping people, there needs to be something to offset the sacrifice made to enter the medical profession.
Additionally if you would like to build more medical schools, please lobby Congress to increase funding for graduate medical education. Many students are already graduating with nowhere to train, and without a residency cannot practice medicine. This issue is larger than greed. You may have "seen physician incomes" but you seem unfamiliar with the intricacies of medicine and medical training.
Finally, "big pharma" may be buying some doctors, but the vast majority of doctors treat to the standard of care. We will get sued. Practicing evidence-based medicine is the best way to ensure a law suit will not end a career. Additionally, many academic medical centers have policy against accepting gifts from pharmaceutical representatives.
18
@drDont
#1 -- There are already over 100 new med schools built or planned from 2005 until now.
#2 -- more doctors = more testing = higher healthcare costs, not lower.
#3 -- If doctors are providing "poor service" then we need less of them, not more. Why is more doctors providing "poor service" a good option?
#4 -- Only 10% of healthcare costs go to doctors' incomes. That means even if you cut doctor income by 50%, total healthcare costs only go down by 5%. That's not very much of a difference.
3
@YR
wrong in so many ways. physicians live a life of privilege. and a life with the chance to be of use to the world. I finished med school in 1970, still go to work every day. It's an honor to serve. And a source of great and deep satisfaction.
3
"Someone has to do the work of figuring out how to respond to each inquiry. Some insurers and public programs — though not Medicare — reimburse physicians for eConsults. But patients don’t pay for eConsults, whereas in-person visits would typically cost them something, depending on insurance coverage." In person visits are always better than virtual visits, so much is lost and the information if it is through another doctor is only as good as the filter. Also, if patients don't pay for the visits, they are incentivized never to see a doctor in person. Care will suffer.
2
In Mexico, x-rays and other lab reports are sent by WhatsApp. I am seeing two orthopedic surgeons in the next two weeks and communicate with both by WhatsApp. Here, the doctor sends you a WhatsApp telling you what tests/x-rays you need. You take it to a laboratory and get the results on your WhatsApp and then forward them to the doctors. This way you always have a copy of your results.
Life is so much easier when you don't have to deal with insurance companies, and, of course, everything is way less expensive here.
8
The title of the article and the first few paragraphs made it sound like this idea was going to be a paradigm shift in patient care, however at the end of the article, it came across as an answer without a clear cut question. More detail might have been helpful not that Kaiser and Mayo think it’s great. The only consistency is that there is an access problem for which telemedicine has been also been proposed as a solution. Computers, AI, and any other third-party initiated solution will never replace the human to human interaction, except for the simple clinical problems. Even then adding more screen time is hardly a good solution.
1
Can't wait to hear that lawyers are taking email consult and doing without charge as well.
33
You have no idea what a detriment it is to job satisfaction to do econsults. It’s horrible.
Make AI do the econsults. Providers want the human connection (LIVE human connection) and in my experience the questions received by econsult do not require high levels of intuition and judgement and listening skills. They are often basic questions that can be solved algorithmically.
Don’t don’t don’t go do some hair rained scheme to have poor already burning out doctors do this min numbing work.
10
In the past 8 years not a single doctor I have gone to has:
1)washed their hands; 2) examined me; or 3)really bothered to look up from their computer. This includes any number of specialists (who book 15 minute initial consults and have someone who is ticking off boxes on a computer interview you prior to them waltzing in with a pronouncement and a prescription pad).
Doctors just rely on "data" and "tests results" regardless of how flawed or useless either might be. They have made themselves irrelevant. I'll be glad when AI takes over from them. They deserve to be squeezed out of the system. They only do what the drug companies and the medical equipment companies tell them anyway.
Medicine has entered a dark age or maybe a stone age. Blow it up and start over!
9
@ck
This behavior you see is largely a result of defensive practices imposed as a protection against tort law bandits. The doctors who DO the things you've been missing get out of the office after 5:00 P.M.
4
As a surgical specialist, I say, “no thanks”.
The task of completing my electronic medical records, routes of patient information, dealing with patient portals, calls from patients, calls from insurance companies to preauthorize or deal with a rejection of care is insurmountable. My “free time” to do this is from 7 am to 8 am and then any time after 5 pm.
I am not looking for a shoulder to cry on, but people not in the medical world don’t understand how computer and phone time are a real burden.
If a specialist is in a care organization and has administrative time built into the day, great. If not, I just say no to this idea or any idea that increases computer screen time.
32
eConsults when coupled with AI need to be firmly embraced. Outcomes will improve and costs will decline.
@Andy Golden
Yes, but please don't require any human doctors to be involved. This is not why we went to medical school! We want to interact with patients and have time to talk to and examine them appropriately, rather than being on a computer all the time. So as a physician, I agree with all AI for this eConsult work! (And don't forget the AI malpractice insurance for the computers for when they get things wrong)
8
This can have disastrous consequences!!
There is an assumption that the patient understands and can properly phrase the question he/she is emailing. I once had a patient ask about treatment for athlete's foot over the phone and only at the end of the conversation did he casually mention it was 'a funny color.' It wasn't athlete's foot it was gangrene necessitating emergency hospitalization. He could/would have died without proper treatment if I'd just given the athlete's foot advice without full information. Email sets everyone up for this kind of disaster to happen!
21
@SM A good point, but one which can be addressed by amending the referral protocol to require that a photo accompany any query that requires visual assessment.
2
@Keith Wolfson
Easy to say, but getting patients to send usefully evaluable photographs is much easier said than done. I've seen a lot of emailed photos and in many cases I've told the patients I wouldn't bet their welfare on the poor quality image sent and made them come in.
9
@Keith Wolfson-I just took my Board Qualification examinations, and on the test were photos of certain conditions. Even being some of the best, most classic presentations of these diagnoseses, one could hardly make out what they were. Photos sent by patients sound great in practice, but nothing beats a real exam (and I will qualify that by saying that most patients need real exams).
5
Seems like the IT guys all saw that old Life cereal commercial "Let's get Mikey. He'll try anything." only in this case it is the primary care provider. Beta test new EHR - check. Data entry clerk - check. Take medical and legal responsibility when hastily entered data in poorly designed EHR has real consequences for patient - check. And now administer another system to deal with poorly designed referral flow. Make time to see patient who does not understand why they can't see specialist anyway - check. Copy records when said patient leaves practice. See number three above - check. Maintain work life balance while completing all uncompensated tasks at 3 AM. Most people I know in primary care LOVE talking to patients and would happily spend the time to do that and coordinate care for their patients if the business of medicine would allow it. I knew a few people who tried anyway in small practices and they were out of business in a year. We have to decide where we can make space for kind, thoughtful, expert care and how much we are willing to pay in time and money.
11
A Naive, well intention typically ignorant administrative idea.
Cheap, not good.
No personal interface establishing physician nor patient trust ,no relationship, no way to determine patient interpretation, no way to determine physician expertise, same forensic liability,a setup for errors of omission or commission,none or insignificant remuneration,inefficient utilization of physicians time thus increasing physician overhead expense and time requirements.
Other professions are paid for time,expertise and performance , not nonreflective codes .Here codes invented by a bureaucrat might exist ,but are meaningless.
I want to sit down with, see and converse “face to face”and establish a DOCTOR-PATIENT relationship.My patients, who I know, get all the advice they need through my personal phone.We KNOW EACH OTHER.
Government, Insurance companies and Corporate Heath Care Systems and a priori theorists interfere.
I wonder whether administratots will next suggest a system to order a Hernia repair from an on-line vender,present the BarCode at the operating Room,give discount code;Select materials,Buy an Extended Warantee for Replacement Parts and Service,Select economy,executive or first class, pick a procedure ,”do it yourself” or select a surgeon or other techician etc.
However,you have to go through a telephone prompted to obtain An explanation or telephone consultation.
Someone will buy it!
Advising a stranger is high risk.
‘’In medicine,good turns get punished”’
9
@Dr.ADH
I have no trust in medical providers and the last thing a want is a "relationship".
I want them to do what I need, and I will tell them.
This type of "doc in a box" sounds great, and will not necessitate re-doing innumerable tests that are always negative but provide income for each provider who "wants their own data" despite years and years of my prior test results including raw scan data on CDs.
You people have brought this development upon yourself, live with it.
2
The good news, Ivy, is we don’t have to just live with it. We just won’t do it.
8
@Ivy
Hi Ivy. If you should ever come to see me (and by "me," I mean "any doctor"), please be sure to remind me of this post, so that I can give you the care that you both need and deserve.
2
In medicine, time spent responding to emails is not compensated. You get to work for free!!
Once that door is opened, an MD could spend all day answering questions. Is he/she liable if they don't answer an email immediately and someone dies? A misunderstood or poorly written email, diagnosing without seeing a patient are a lawsuit waiting to happen.
Sure it sounds great! Sign me up!!
15
@Sam-agreed. Watch this become yet another task that "insurers" will require doctors to do for free, in our "free" time. No thanks without a revenue stream...
12
If the insurance company doesn't have to pay much for an eConsult, why should the customer be charged anything for it? Co-pays are already criminal. I pay more than twice per month in co-pays what I pay for my insurance itself.
1
My only experience with E consulting is the system used by UCLA medical system. I have found it to be used in conjunction with, not in place of, providing information needed by me or my team of physicians. Test results are available for me after the doctor has reviewed them and given the go ahead for me to see them. They are followed by an email by the PA with reassurance that all is ok. If I have a question regarding a symptom or prescription, I receive a response by my doctors in a timely fashion. All four of my specialists (sad but true that I require 4) can access all my test results and confer with each other.
From others’ comments, it sounds as though not all use the system as intended. They either overuse the system, don’t respond in a timely manner, or use it in place of proper care. I think the issues raised are valid, but the fault is not in the E consult system, but in the humans and institutions misuse of it. My father was a medical researcher and med school professor. I learned early on the importance of finding the right doctor and for going to a facility attached to a teaching/research medical center for any concern greater than a cold or broken arm. If you are not happy with the way your concerns are responded to, find another doctor. All major medical centers have a doctor referral system. Feel free to ask where the doctor trained. If you feel you are not being listened to keep searching. The system is only as good as the people using it.
5
I had a skin condition and sent my general practitioner a picture via email. He went down the hall and showed it to a dermatologist (specialist) on his cell phone. He had a diagnosis in seconds. Is there a "Walk over with your cell phone-consult" system in place? Seemed to work for me.
5
@Michael F - Not every general practitioner has dermatologist down the hall.
6
Physicians are so busy that using
their EHR email system is an efficient
win/win for patients and doctors. It is
the way forward for noncritical issues.
When I email my (very busy) primary
care doctor, he responds quickly.
He knows from my description of
the issue if I should be seen. It is such
a relief to avoid the drive to the
office, the waiting room, the prep from
the nurse, etc. for a minutes long exchange
on the computer.
2
I quite like my PCP. He's a pleasant young man who is always very helpful and understanding, but doesn't get ideas above his station about things like doctors giving orders. He gives advice; sometimes I take it, sometimes not. However, I must work for a living and can't make money while I'm twiddling my thumbs in a doctor's office. He also understands that and is more than happy to make do with Email when I ask him to. I enjoy face-to-face visits, but I don't always need them.
4
@John
I am a retired PCP who was quite willing to answer questions and give advice by email, recognizing and discussing with my patient when I thought I could do this safely without a face to face visit. I imagine this will continue to get more and more common.
Keep in mind that while you are "twiddling your thumbs and not getting paid", the same is true for your physician while he/she is considering your ailment and preparing/sending a thoughtful response. The system will need to account for our time and figure out reasonable reimbursement for it as this practice increases and takes up more of our time.
17
One of the (numerous) elephants in the room is the Data Privacy Act. I'm limited--as is everyone else--as to how I can communicate electronically with my doctor. One needs a legal degree.
What I would like to see is a government-sponsored (i.e. no ads) interactive health care website that allows you to plug in your symptoms and allows you to obtain a PRELIMINARY diagnosis/alternative diagnoses and possible treatment options.
My experience suggests a computer would provide better diagnoses than many doctors, especially since they're always under such time pressure.
1
I am a specialist who does eConsults. Thoughtful, helpful eConsults take time to do and can add up to 2 hours to my already long day. While I can see the appeal, the time I spend on these, as far as I can tell, is uncompensated time AND constitutes work that is simply added to all my other responsibilities. Mixed feelings.
31
@dloVT Amen.
2
Who is going to cover malpractice for these email consultations?
12
While I can understand the doctor's points of view on this added "service" to the patient, I implore you to consider this: As a patient with primary autoimmune disease and several offshoots, I now see the following:
Primary care, Rheumatologist, Pulmonologist, Spine Clinic, Gastroenterologist, Pain Management, Physical Therapist, Dermatologist, and assorted labs and imaging. What I don't see if communication between the primary and any of the specialists or the new specialists and the referring doctor. Without communication between them, how am I to feel confident that I am getting the best care that I can and that all of the medications, treatments and such aren't counteracting one another? I see all of these people in order to keep me in good enough health to continue to work to pay for my insurance, deductibles, and co-pays, Yet I am left wondering how much good it really is doing to see a bunch of different doctors with no one point person to go to for explanations and answers.
6
And when during the doctor's day are these eConsults conducted? While the patient is present? I already spend most of my visit staring at my doctor's backside while he performs data entry, barely uttering a word to me. Now I can watch as he further confirms my non-existence by conversing with someone else, as I sit there feeling like a schmo.
19
The health care system used by my HMO has a secure email system. Not one of my three questions was ever answered. No one at my primary care physician's office is responsible for monitoring the emails.
No way to charge for it, I guess.
8
@Al Gladis eConsults work differently when hosted within a web-based application. It's not pure email to email. There are notifications etc that go out.
1
Time sap for primary care but also the specialists are not reimbursed at any kind of sustainable rate. Current billing structure is not built for this (or for appropriately compensating the time consuming burdens of outpatient work in general).
17
Primary care physicians, depending on the insuror, employer, hospital system, are scheduled and reimbursed for seeing patients every 6 - 15 minutes.
How should the doctor evaluate patients in such assembly line fashion and also respond to email, except nights and weekends?
Ask your payor how long a visit should be scheduled for and what the reimbursement is.
20
Your kidding, right? Emails, electronic records, Press Ganey scores, RVUs, all detract not contribute to the patient physician relationship. From now on let the administrator, the IT person, insurance plan, or government agency take care of patients. They are doing it already but don’t take the responsibility or the liability.
42
Ah yes, the US healthcare system (and I use that term advisedly) would be even better than merely just the best in the world if we would make this one tweak. A tweak that would only be a cost to our workers and users, not to the insurance/provider complex, in other words, a win-win!
5
I emailed my primary care physician of 20+ years to ask 2 questions which were answered but I was told that if I had more to make an appointment and come to the office. Currently looking for a new doctor.
2
@Connie You asked your doctor to provide services for free. This person was willing to take the time to do so for a few questions but wasn't able or willing to do so for more. Most physicians carry a panel of close to 1,000 patients. Their 8-10 hour days don't include time for documentation in the charts let alone answering phone calls and emails. This is all done when they are supposed to be home with their families. In addition, they have call responsibilities. It sounds like you want concierge health care. It's out there, you just have to pay out of pocket for it. Until then, use the email for essential simple questions and try to limit them.
71
@Connie If every patient emailed their PCP 2 questions every week, then how would the physician see any other patients or make enough money to pay their overhead and staff? Remember many physicians are small employers or they are employees of hospitals that have overhead expenses. Why do you expect to get knowledge for free? See what happens if you email your lawyer a couple of questions!!!
55
Finding a doctor one can trust for your health is not easy. giving up your doctor of 20 years for this seems extremely short-sighted
40
This is one of the reasons I quit primary care. Endless well-intentioned, good ideas that dumped more work on me while pretending to improve patient care. I saw so many patients every day, I never had time to send out e-Consults - it took too much time. I was already spending four hours a night finishing my charts at home. It nearly destroyed my marriage.
64
@ Another Doctor - some of these laments are nearly identical to what we hear in education: too many new requirements, rules and regulations; never enough time; using off hours to complete ever mounting tasks.
11
@Another Doctor
A simple two or three sentence summary from the "good old days" was much much more useful than the e-garbage that today's charts generate.
Most of the systems were not in fact checked--they merely required a checkmark.
I have copies of both my handwritten and e-charts, from hospitals, MDs, ambulance services etc. across three far-flung states (about as far apart as possible) and I welcome the silo-ing of health records.
Nobody will EVER get these from me, it is need-to-know basis only.
3
I pay over 600 dollars per month for a health plan that charges me 80 dollars to see an in-network specialist. Yet my PCP is so busy that she will readily refer me to a specialist if a problem takes more than 7 minutes for her to diagnose and treat. I would really appreciate if she would do this - and get reimbursed for her time - to potentially avoid another expensive referral!
17
@Pat-I hope you support single-payer or some other similar non-profit medical coverage plan because your $600/month is going to executives and stockholders and not to doctors or anyone actually helping you. Oh, it's also going to uneducated bureaucrats whose sole job is to deny you the care you contracted for and which you need and to dump your clinical needs on your family. You are paying quite a lot of money but it is not for insurance or care.
12
This is yet another bandaid suggestion that would keep America saddled with our dysfunctional, for-profit health care system, preserving massive profits for the increasingly concentrated for-profit hospital system, while shortchanging patients.
Perhaps Mr Frakt can explain to us why we need to give up visits to the doctor for the sake of "reducing waiting times for others," when in Britain nurses and midwives make regular house calls to expectant mothers to ascertain their needs and health?
Why are we once again being sold a short cut method to keep profits up, while everywhere else in the developed world, patients see doctors more frequently, and pay a fraction- or nothing- of what Americans are charged?
Why can't The Upshot tell us the truth: That this healthcare system, even with bandaids like eConsults applied, is still expensive, exclusionary, and immoral.
26
They are only now figuring this out? Honestly.
6
Getting appointments with doctors is already difficult enough. Trying to actually speak to one on the phone is already well nigh impossible. So now we should we should move faster to electronics?
I receive emails of my lab reports from my doctors. Most of them are gobbledygook to me. I suspect this is true of the vast majority of the elderly, handicapped and low income patients who receive these.
Show me a doctor who is doing everything possible to bring the latest advances of electronic communication technology into his practice, and I will show you a doctor who is succeeding in annoying his patients.
11
... who is succeeding in annoying and mystifying his patients.
5
No. No more time in front of the computer taking away time from looking at my patient. This is a sorry excuse for patient care. What is needed is a trend away from 30 patient a day productivity goals.
Maybe if I had enough time to do something like drain the bursa, do the biopsy, clean my patient’s ears, then our local Ortho, dermatologists, and ENT would get fewer referrals.
This reliance on “e” solutions is magical to management and death to the health care provider.
68
As a physician I see this as yet another administrative task on top of the many others I have to complete in a day that is booked solid. You can’t just keep adding tasks to our days and touting it as some “great solution” with flimsy supporting data. I already have to email patients through the EMR monopoly of EPIC despite the fact that my salary is based on RVU’s and answering these emails and returning calls generates zero RVU’s. Feasibly, these e-Consults would have to take the place of some amount of face to face patient care time.
56
“But patients don’t pay for eConsults, whereas in-person visits would typically cost them something, depending on insurance coverage.”
In-person visits always cost patients something. Granting that a patient needs medical care…an in-person visit means taking time out of a daily routine, travel to a physician’s office or clinic, and waiting anywhere from 15 minutes to an hour past the scheduled appointment time for a 10 minute consultation. While my PCP is sensitive to this reality, other clinics I have attended really have not cared about spending my time. If the consideration here is insurance coverage, that’s one more argument for universal health care, and ensuring that physicians have a healthy, just salary rather than weighing the rewards of e-mail versus in-person consultations.
7
As a matter of fact, Medicare started paying for eConsults in the beginning of 2019. The challenge is the administrative part of it, patient consent, coinsurance, tracking results, burden on physicians, etc. As a healthcare administrator myself, it was great to see Medicare's willingness to pay as an endorsement of eConsults, although I doubt the incentive alone is enough to drive any significant shift of referrals to eConsults under the current context that the majority of healthcare services in this country are still paid as fee for service.
9
@anonymous
Pray tell, what effort on the part of the MD is required to charge for this service and what is the reimbursement. I think the ratio is likely near infinity.
7
What is the dollar amount they pay for the e consult? How much is that doctor reimbursed on an hourly basis? Could he/she make a living ( minus office, insurance, etc) by just doing these econsults? Seriously that number would answer a lot of questions. Please inform us.
1
As a former public health researcher and someone who turned out to be a “zebra,” I bristle at this facile approach. Medical records are frequently incorrect, and sometimes these details are crucial to a specialist’s diagnosis. Playing telephone may mean even longer delays in diagnosis and appropriate treatment. This will disproportionately impact women, whose symptoms and pain are often dismissed as psychosomatic by PCPs and myopic specialists. I use email via patient portals to communicate with my doctors in between visits, but, like many women with a complex chronic illness, I’ve had to become my own best expert, advocate, documentarian, and care coordinator. My PCP is great (one of the best in an academic health system), but frankly she doesn’t have the time or expertise to do this.
Beyond that, our current system and provide pipeline are a total mismatch for this approach. We have a PCP doctor shortage that will only get worse in the coming years, particularly if we shift more un/under-reimbursed responsibilities to PCPs.
23
@ES
I get full copies of all my health records and they invariably (except for one) contain innumerable errors.
The exception was an EMT's record of ambulance trip. I tried to show my MD, and rather than absorbing content I was pointing out, MD marveled at the clarity of EMT's printing and wondered if could hire him.
All EHRs do is create unnecessary background noise, and vast majority of "systems" were in fact NOT checked, they merely required a checkmark.
2
As an observation patient, it has increasing occurred to me, the execution of the healthcare, system especially ones interface with Physicians, is simply a poorly designed model. Any wonder our Physicians are over worked, and are spending less and less time, face to face with patients.
9
Following orthopaedic surgery, I was given both the surgeon's and the PA's email addresses, which came in handy when I was enquiring as to whether a wound was infected or not, and I could just email a photo rather than visit the office. I've also communicated with my PCP via email with quick questions or clarifications. Both these medical offices have a large support staff, which is why this is possible, otherwise, I don't know how they would have the time. Personally, I think eConsults are a useful adjunct rather than a replacement. I do find it frustrating, however, that my PCP has a tendency to just refer me to a specialist for things in the past, and in other countries, that they would handle themselves.
2
@catee-Surgery falls into a different reimbursement category in that there is a "global" charge for a number of days rather than fee for service each visit. So it was actually more cost effective for that office to do it by email. Standard single visit primary care reimbursement doesn't exist without an office visit, so the work is done for free.
2
I am a physician, and heavy IT user.
E-mail between patients, especially ones not known well to the MD, and the MD on the receiving end of the email are accidents waiting to happen.
In essence, the article dispenses with the centuries old believe is history, physical, objective data review, impression and plan approach and moved directly into the Facebook fake news, shoddy science, no facts world while patient’s health and lives, not just elections and reputations, are on the line.
40
@AL
Very well said, Al. I would add further that the author of this piece seemed to misunderstand the 2011 medical study to which he cited that referrals to specialists are a waste of time for 40% of the referrals. Moreover, PCP's have a lot to do in a little amount of time, some of which is their own choosing to be employed by a hospital or other corporation that dictates their time, some of which is just a function of their area of medicine. Most do a very fine job for what they do, which is to have a broad but not deep fund of knowledge for the entire spectrum of life for their patients. But PCPs are NOT board certified specialists and do not have the experience or education to go into the weeds, so to speak. I hope the author will do a follow up piece that does more than skim the surface, as if the author's point was the economics are the main concern versus the patient's health, that former point was not clearly made.
3
@Lu
PCP is an insurance term. Very few "PCP"s in the USA are not board certified in their specialty, whether it is Internal Medicine, Family Practice, Pediatrics or OBGYN.
2
One of the few things we do right in our de facto criminal health care system. I have seen how it has reduced my time re getting prescription meds, test results etc.
Of course anything can be abused. Some of my doctors have been demoted to data entry clerks instead of doctors. The system should be streamlined more.
Now if we could only get a universal, quality, affordable health care system like almost all of our peer countries, we will move out of the Middle Ages re our medical care.
13
How can wait times decrease when I'm spending my time emailing specialists? If I think the patient should see a specialist, getting a consult can sometimes hone in on the best diagnostic procedures rather than using a shotgun approach.
Nothing in the article justifies the title.
This sounds like another way to restrict what we primary-care physicians think we should do for the patient, and shifts more liability to us.
Now please solve the problem of why medical graduates don't want to go into primary care, and then we'll talk.
51
"Some insurers and public programs — though not Medicare — reimburse physicians for eConsults."
Really? How much?
Is it anywhere near as much as they would receive for seeing and documenting care on another patient?
Because, as a primary care doctor, I can tell you that my employer would have no interest in my telling him that the reason why I saw one or two fewer patients in a given day was because I was e-mailing back and forth with a specialist, an activity for which I cannot bill, and that time (ie: the time I should have spent seeing another patient) would come right out of my wallet as I lost incentive pay. It sure wouldn't come out of my employer's.
The rationale would be the same on the specialist's side.
A dermatologist may see fifty patients a day, in a carefully choreographed system involving nurses taking care of the first and final portions of appointments, notes being economically dictated, and the doctor flying in, performing a procedure or exam, and flying out. You really thing he's going to sit down in the middle of all of that and exchange e-mails?
In the end, as Jim from NY said above, if doctors can't bill for their time like lawyers can, and if they're not fully compensated for what they could have earned (for themselves and their institutions), something like this won't even get down the runway, never mind off the ground.
And the liability? Don't even get me started.
83
@Eric
At least your priorities are clear. Nary a mention of the patient's welfare.
It's all about your wallet.
5
@aek
My priorities are clear:
I have to put food on the table.
I am not a volunteer.
My services are valuable, the result of decades of training and experience, and whether I give them away or not is my choice, not anyone else's.
Patient welfare is not my concern here, partly because it cannot be addressed through blanket statements. In each individual case, the patient's best interests will vary, and I must determine how to balance that each time. The patient welfare aspect of this discussion has been addressed by other posters here, and there is nothing that I can contribute to it now.
Why not go to your boss and offer to work a few more hours a week without pay, just because it would be good for his "welfare"?
I'm sure s/he'd be really grateful and say you were a great person.
6
I am a cardiologist. I estimate that I elicit significant historical information that influences my thoughts on diagnosis and treatment that was missed by the primary physician from at least half of the patients who are referred to me; this would not be possible with e consults. My malpractice carrier has cautioned me that rendering an opinion without seeing a patient creates a physician patient relationship with potential liability for a poor outcome. Physicians are already doing too much “free work” with all of the documentation requirements of electronic records. Perhaps a better alternative would be telemedicine consults where the specialist can at least look at and converse with the patient; I use this system to do consults for a large prison system and it works very well.
69
Sounds great on paper but is very concerning. I am sure the primary care MDs will bombard specialists with econsults to shift care onto them and responsibility for outcomes. We see this all the time as our primary care providers are getting bombarded themselves and won't or can't do preauthorizations to do imaging studies or stress tests and they refer out for everything that needs a pre authorization. I have seen it my own practice, rather than order a simples test which may incur more paper work they refer to the corresponding specialist. I can't blame them. So then there is a wait to see someone. Also, again how is the person doing the econsult getting paid? Is this free work? A lawyer would bill for this and that is acceptable, a doctor bills for his time, he is greedy. If you are taking liability for providing advice on a patient you have not seen you should be compensated well. Unless this is addressed, this won't find widespread adoption.
38
@Jim - Your concern is focused on whom gets compensated, who gets paid, and who gets billed for this service. My concern is patients receiving inadequate or incorrect medical advice communicated via email by a corresponding specialist; who then becomes liable if anything goes wrong? Society is so obsessed with instant gratification, they assume this can apply to on-line medical advice as fast-track treatment, the same mindset that there's a pill for every ill whether real or imagined.
20