Back to Table of Contents | April 2011

Pulse

Virtual Visits

Two Twin Cities-based online diagnostic services are bringing relief to patients—and providers.

By Jeanne Mettner

It’s nearly midnight and your hacking cough, chills, and sore throat are keeping you awake. You think about going to urgent care, but you feel terrible and it’s snowing. Rather than call a nurse line and risk being put on hold, you boot up your computer and go online to access a virtual diagnostic service. You click on responses to questions about your symptoms, whether you are being treated for any other medical conditions, whether you are allergic to medications and which ones, and where you prefer to pick up your prescriptions. In just a few minutes, you finish the online patient interview and submit your payment information. Within a half hour, a nurse practitioner emails you a diagnosis and treatment plan, and sends a prescription to your pharmacy.

As recently as a decade ago, this may have sounded incredible, but today, online diagnostic services are realities. And they’re catching on. In May 2010, St. Louis Park-based Park Nicollet Health Services began a one-year pilot with Zipnosis, an online care provider. In October, HealthPartners in Bloomington rolled out its own online diagnostic offering, Virtuwell.

Both systems are web-based and were designed to diagnose approximately 30 straightforward conditions such as sinusitis, urinary tract infections, acne, and conjunctivitis that can be reliably identified through a medical history, rather than laboratory testing and/or a physical examination. Both use clinical algorithms built on evidence-based guidelines such as those developed by the Institute for Clinical Systems Improvement and the American Academy of Family Physicians. And both lead users through a series of questions crafted to capture data required for effective clinical decision-making. After users submit their responses, the information is sent to a provider, who then generates a treatment plan. Virtuwell’s diagnoses and treatment decisions are made by a nurse practitioner or physician assistant who works for HealthPartners. Zipnosis uses physician assistants and nurse practitioners who work for Park Nicollet’s urgent care clinics.

“What led us to try this was basically a sign of the times,” says Jon Bylander, M.D., chair of urgent care at Park Nicollet, who is the lead physician for the Zipnosis pilot project. He explains that people are looking for convenient, affordable ways to get care. A Zipnosis visit costs $25; a Virtuwell one runs $40—a fraction of the price of an urgent care or office visit, or even a visit to a retail clinic (MinuteClinic, for example, charges $60 to $75 to see a patient with an upper respiratory illness.) Although he doesn’t know of any similar services elsewhere in the country, Zipnosis co-founder Steve Claypool, M.D., expects he will start seeing them soon. “Patients want to be able to communicate with their providers electronically, so the market forces are right for change in this area; this isn’t going to be a fad that fades,” he says.

Guarding against Risk

Critics have argued that online diagnostic systems could compromise patient safety. The creators of Virtuwell and Zipnosis strongly disagree, however, noting that there’s little risk because the systems have built-in protocols.

Others have expressed concern about misdiagnosis. The systems’ defenders say that’s unlikely because the types of conditions these systems address are common and easy to diagnose. In addition, duration of symptoms is used as safeguard. For example, a Virtuwell user who indicates he or she has had burning or frequent urination for more than seven days is prompted to halt their Virtuwell visit immediately and see their doctor. A box then comes up on the screen explaining that symptoms lasting more than seven days can be a sign of a more complicated infection and that they will need a urinalysis and examination of the abdomen and kidneys to make sure nothing serious is going on.

If a pediatric patient has a sore throat and no other symptoms, Virtuwell will stop the questioning and recommend a doctor’s visit because the child may have strep, the diagnosis of which requires a throat culture.

Data from both systems are being monitored to ensure against overprescribing of antibiotics. Kevin Palattao, vice president of patient care systems for HealthPartners and vice president of Virtuwell, says they monitor prescribing patterns on a weekly basis. “What we are finding is that we are not prescribing antibiotics for viral upper respiratory infection, and that is the standard metric in the community right now,” he says.

Rebecca Hafner-Fogarty, M.D., chief medical officer of Zipnosis, and her colleagues reviewed providers’ prescribing patterns around sinusitis, one of the most common conditions treated by their clinicians. “When we initially reviewed the Zipnosis sinusitis visits, we found that there were episodes where the clinician prescribed antibiotics outside the guidelines,” she says. “We gathered this information and presented it in aggregate form to the clinicians. We also reviewed our guidelines with them and added reminders to our sinusitis pages.” When they reviewed the data again four months later, they found compliance with the guidelines approached 100 percent.

Each Friday, Virtuwell holds a provider forum at which primary care physicians from HealthPartners Medical Group convene to discuss cases from that week and look for ways to improve the system. Throughout the week, team members also exchange emails about problems that arise. “This week, even before the meeting, we were able to solve some issues around how to improve our acne treatment protocols,” says Patrick Courneya, M.D., medical director for HealthPartners.

Courneya says they noticed that patients were not responding appropriately to questions about the appearance of their skin. So the Virtuwell team changed the questions and added sample images showing different types of lesions. They also added a feature that allows the patient to upload images of their own skin to give the provider more information.

The fact that every element of the online experience is documented and audited is a key safeguard, says Jon Pearce, cofounder of Zipnosis. “So if and when a discrepancy arises, it’s easy to identify the failure point.”

What the Data Say

Administrators of Virtuwell and Zipnosis are analyzing data to learn more about how the systems are being used and by whom, whether they are reducing providers’ workloads, and whether they are improving patients’ access to care.

Vituwell would not disclose the exact number of patients it has served but claims it is in the thousands. Zipnosis has treated 2,300—both Park Nicollet patients and others. Forty percent of its patients are from outside the Twin Cities, “showing a strong demand in rural areas, where it’s harder or more expensive to get medical care,” Bylander says.

Of 423 Virtuwell patients who have completed satisfaction surveys since October, 99.3% indicated that they would recommend the service to friends or family, 99.1% said that Virtuwell addressed their health concern, and 97.4% said it was worth the cost.

Claypool says convenience is a factor. “If a patient has to take time off work, drive downtown, park in the parking ramp, pay for parking, sit in the patient waiting room for 15 or 20 minutes, then finally get to see the doctor, their attitude is, ‘I better get something from this,’” he says. “But if they do a quick Zip visit, and they get the message, ‘Good news, you have a cold, you don’t need antibiotics,’ they are likely to be much more accepting.”