Barry Bershow, M.D., a family physician and administrator for Fairview Health Services, has used e-visits to care for his long-term patients.

Photo by Steve Wewerka

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January 2009 | Back to Table of Contents

Pulse

The Doctor Is In (Your Inbox)

E-visits can be an efficient way to practice, but they have been slow to catch on.

As a busy administrator for Fairview Health Services, family physician Barry Bershow, M.D., only has time to see patients in the clinic a half day per week. But with the help of secure emails and an online patient portal called MyChart, Bershow can be available to his patients any time. He can keep in touch with the people he cares for virtually—through a new type of patient-provider interaction known as the e-visit.

Bershow uses e-visits as an alternative to regular office visits. He can review descriptions of symptoms of common ailments patients have emailed him and follow up by diagnosing the problem and prescribing a treatment. E-visits go beyond 24-hour advice services, in which nurses might triage patients who call or email using clinical protocols for common conditions and concerns. And whereas counseling done by nurses is not billable, e-visits are. Currently, Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, and PreferredOne pay for them.

Bershow, who serves as medical director of quality and informatics for Fairview, explains that e-visits work best for diagnosing and treating recurrent problems that have classic symptoms such as yeast infections or for monitoring a chronic condition such as hypertension, diabetes, or depression. For example, if a patient reports blood pressure readings during an e-visit, Bershow can use that information to determine whether the dosage of the patient’s medication needs to be changed. “These are for single, relatively simple problems where we have enough information—either from the patient’s medical record or from what the patient tells us—to render a sound medical decision,” he says of e-visits.

A Work in Progress
Bershow, who has a small panel of patients, does about 14 e-visits a year. He says both he and his patients appreciate the convenience. “Patients don’t have to leave their place of employment, drive across town, have other people cough in their face, and then drive back,” he says. “And it’s a great way for me to provide care for people who have been seeing me for years.”

Despite those advantages, e-visits have been slow to catch on in Minnesota. HealthPartners Medical Group, which has been offering e-visits for three years, averaged about 6,700 online encounters per month in the last quarter of 2008 out of a total of nearly 160,000 monthly encounters. The entire Fairview system averages 10 e-visits a week. “When you consider that we employ more than 400 physicians, that’s not a lot of visits in the aggregate,” Bershow notes. “On the other hand, it’s up from about one e-visit per day a year ago.”

Kevin Palattao, vice president of patient care systems at HealthPartners, considers the patients who are making use of the e-visit option innovators and early adopters. He says until more people start using them and they become a standard part of practice, they will remain a work in progress. E-visits also will become more common as more clinics adopt electronic health record (EHR) systems. Both Palattao and Bershow say EHRs are needed to properly do e-visits. However, according to Stratis Health, a Bloomington organization that helps clinics make the transition from paper to electronic record systems, only about 60 percent of adult primary care clinics in Minnesota have EHRs.

With the major insurance providers paying for e-visits in Minnesota, one factor that is not a work in progress is reimbursement for these virtual encounters. Among the payers currently covering e-visits, the requirements are almost identical: The e-visit must be initiated by the patient. (Health systems can’t “troll” their list of patients and try to solicit e-visits.) The patient must agree to pay for the encounter if their insurer does not. And the physician cannot take longer than 24 hours to respond to the patient’s initial e-visit request. Also, a physician who is licensed only in Minnesota can conduct e-visits only with patients who permanently reside in the state.

E-visits are reimbursed at a different rate than in-person clinic visits, and opinions differ as to whether the current reimbursement rate for an e-visit—which is around $35—is enough. (In order to be billable, an e-visit must bring new information into the patient’s history and involve medical decision-making, says Bershow. In other words, physicians can’t send the patient lab results or answer follow-up questions after an office visit and call it a billable e-visit.)

Palattao says HealthPartners’ physicians suggest that the complexity of e-visits can vary and that they do not take less time than office visits. He says the organization is studying who uses e-visits, measuring the physician and staff time required to complete one and comparing that with the time it takes to do an office visit, and measuring patient satisfaction in order to better understand the full potential of this type of encounter.

Bershow believes e-visits can help primary care physicians practice more efficiently. “They did a study in England which demonstrated that a provider could complete an e-visit in three minutes, so if you were really working efficiently, you could do 20 e-visits per hour, which obviously you cannot do in the clinical setting,” he says. “Plus there’s no office overhead in terms of table paper, gowns, tongue blades, etc.” Bershow adds that e-visits can cut down on some unnecessary tests such as in the case of a patient who has a history of yeast infections and describes classic symptoms in the electronic inquiry.

The technology also makes it more convenient for the physician to document the visit. Because the e-visit takes place within a secure portal that requires the patient to supply a user name and password, the email exchanges, along with any other ancillary data, are automatically imported into the patient’s electronic medical record.

A High Bar
Perhaps the biggest concern for physicians doing e-visits is whether they can gather enough information from the patient during a virtual visit to safely render an accurate diagnosis. HealthPartners also has begun comparing the level of documentation in an e-visit with that of a face-to-face visit in order to find out.

Not surprising, providers and payers find themselves wanting to cover all the bases within the virtual environment—most likely because of the potential for ambiguity in cybercommunications. To prevent misunderstandings, Bershow says he uses e-visits only with established patients for whom he has a chart and history and only for less-serious, recurrent complaints or routine monitoring. “We’re careful and confident about the way we handle e-visits here, but there is always this extra step that we find ourselves wanting to take,” Palattao says. “The bar is always higher when you do things online for some reason.”—Jeanne Mettner

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