Problem Addressed

• Dissatisfaction with lack of access to care: Only about 25 percent of adults report being satisfied with their current level of access to care. At the same time, many clinicians report they no longer enjoy their work, feel they provide inadequate care, and struggle with "productivity fatigue"¹ due to the combination of declining reimbursement and high overhead costs (which consume roughly 60 percent of revenue). To combat these trends, physicians feel pressured to see three or four patients an hour, which can result in decreased patient satisfaction, increased patient turnover, and inappropriate prescribing.²
• Unmet demand for access-enhancing measures such as telephone and e-mail access: Many providers will not guarantee their patients same-day appointments, and physicians have historically been reluctant to share their home phone numbers with patients, fearing they will be called continually. Although many patients are eager to use e-mail to communicate with their doctors,³ providers have been slow to adopt this practice. For example, a study of 4,203 physicians found that only 16.6 percent had used e-mail to communicate with patients, and only 2.9 percent used e-mail with patients frequently.⁴ Providers fear they will be overwhelmed with e-mails from patients,⁵ and most health insurers currently do not compensate physicians for electronic or telephone communication with patients.

Description of the Innovative Activity

• Virtual visits via secure e-mail: After at least one inperson visit with Dr. Eads, patients can initiate a virtual visit at any time via any computer with Internet capability, which enables patients to communicate with their doctor without having to miss work, arrange for child care, or travel to the doctor's office. These communications can include both written questions and descriptions of problems, along with attachments such as images or audio files that might help in communicating with the doctor. At present, Dr. Eads conducts about 200 virtual visits each year, mostly with younger, computer-savvy patients. (Older patients prefer telephone or inperson visits; see below for more details.) A survey of roughly 120 Kaiser Permanente members in her practice found that roughly one-half of them use the virtual visit option, with 60 percent of these users making multiple virtual visits during the year.
  • Introducing the virtual visit option to patients: When a new patient meets with Dr. Eads, she explains the virtual visit option and encourages the patient to visit her secure portal, create an account, and select a password. Patients are also reminded about the virtual visits option when they call the office for an appointment.
  • Initiating communication: Any patient who wants a virtual visit can access Dr. Eads' secure Web site portal and click on the "virtual office visit" link. To log in and make a visit, the patient enters his/her information and provides a credit card number. (The patient is billed $85 for the "virtual visit," although some local insurers do reimburse the patient for the visit.) Patients are also asked to select their preferred pharmacy.
  • Describing symptoms and complaints: The patient enters information, such as current medications and vital signs, and is presented with a drop-down list from which to select a chief complaint. The patient then answers a series of questions related to the complaint. For example, if a stomach ache is the primary complaint, the patient answers a series of questions about appetite and digestion (e.g., Have you had any changes to your appetite? Do you have trouble eating, drinking, or swallowing?). Patients can provide additional narrative descriptions beyond what the form requests by writing comments in a separate free-text area and/or attaching a document/chart (e.g., a blood pressure log), image (e.g., of a suspicious mole or rash), or audio file (e.g., of a cough).
  • Physician alert and electronic review and diagnosis: When a patient initiates a virtual visit, Dr. Eads receives an e-mail alert. She typically receives the alert quite quickly during the regular workday (because she checks e-mail often), and she also checks her e-mail daily during weekends or holidays and encourages patients to call her during weekends and holidays to notify her if they need a rapid response to a virtual visit. Dr. Eads reviews the chief complaint and concise medical history, which has been converted into medical terms (in contrast to the layperson's terms that appear on the patient side), and opens any attached files. If Dr. Eads is not in her office, the patient's medical history is accessible remotely through a Web-based electronic medical record (EMR), which aids in rapid diagnosis and treatment.
  • Electronic response to patient: In rare instances, Dr. Eads may ask the patient for more details or "abort" the virtual visit and suggest that the patient come into the office for an appointment (this has occurred twice in the last year, with the patient not being charged for the virtual visit). In the vast majority of cases, however, Dr. Eads will complete the virtual visit by responding to the patient's query electronically, providing her diagnosis and recommended treatment, including information about over-the-counter remedies and/or any medications she is prescribing, links to educational Web sites, other relevant information and attachments, and/or other advice about what to expect going forward. To streamline this process, Dr. Eads uses customizable response templates that are available through the software, which save time and simplify documentation through use of cut-and-paste functions. This approach also reduces the risk of medication errors, because all instructions are typed rather than handwritten or given verbally. If a prescription is made, it is sent electronically to the patient's pharmacy of choice.
  • Patient access to response: The doctor's diagnosis, treatment plan, and instructions are securely saved at the site for the patient to review at his or her convenience. Patients receive an e-mail notification when the doctor's response is available, after which time they can log in and review her findings and suggestions.
  • Payment: When the doctor concludes the virtual visit, she authorizes the $85 credit card charge. She also provides the patient with a form to submit to the insurer for reimbursement for the virtual visit.
• 24/7 phone access: The doctor gives her home and cell phone numbers to all patients and asks them to use their best judgment when calling her after hours. Dr. Eads is rarely called at night, and no patients have abused the privilege, because they know her well and respect their relationship with her. During a recent 6-month period, only one patient called at night.
• Same-day appointments: Patients can get same-day, face-to-face appointments during regular work hours. To provide this service, prescheduled appointments are generally scheduled during morning hours, which leaves about two-thirds of her day open for same-day visits. The doctor is also willing to stay late if patients need to see her that day.
• Extended appointments: In contrast to the typical 15-minute office visit, about 45 minutes are allocated for each inperson visit. (Because Dr. Eads has relatively low overhead, cares for a small panel of 400 patients, and sees many patients virtually, she is able to allocate additional time for inperson visits.) The longer appointments allow her to provide more indepth education to patients with chronic conditions, with the goal of establishing a stronger collaborative relationship with the patient and enhancing the patient's role in self-care and disease management.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• High levels of patient satisfaction among those with chronic illness: Each year, 60 percent of Dr. Eads' patients submit surveys that evaluate the quality of their medical care at http://www.howsyourhealth.org, a patient survey sponsored by FNX Corp. and the trustees of Dartmouth College. The following are results from Dr. Eads' hardest-to-treat patients who have chronic diseases:
  • Sixty-four percent report that they get exactly the care they want and need, compared with 28 percent nationally.
  • Seventy-four percent report having "very easy access to medical care," compared with 45 percent nationally.
  • Eighty-eight percent report they receive very good overall chronic disease information, compared with 65 percent nationally.
  • Seventy-nine percent report that they "are confident with self-management of any conditions," compared with 43 percent nationally.
• Improvements in chronic disease outcomes: Patients with hypertension and diabetes who are seen by Dr. Eads have better-than-average outcomes, and these outcomes have been improving over time.
  • Hypertension: During her first year of practice, 91 percent of patients with hypertension had achieved normal blood pressure (compared with 71 percent nationally). During year 2, this figure rose to 92 percent (compared with 73 percent nationally); by year 3 it reached 98 percent (compared with 62 percent nationally); and, by year 4, 100 percent of patients had achieved normal blood pressure (compared with 52 percent nationally). (Between years 2 and 3, the definition of "normal" blood pressure was reduced from 135/90 to 120/80. As a result, the percentage of hypertensive patients achieving normal blood pressure nationally dropped.)
  • Diabetes: Dr. Eads' patients with type 2 diabetes are much more likely than the typical diabetes patient to have healthy hemoglobin A1c levels (a test that measures long-term blood glucose levels, with healthy levels being 7 percent or less), and the percentage of her patients with healthy levels has been increasing over time. For example, in her first year of practice, 87 percent of her type 2 diabetes patients had healthy blood glucose levels, compared with 17 percent nationally. By her third year of practice, 95 percent of her diabetes patients were at goal (compared with 56 percent nationally), and by year 4 that figure had risen to 98 percent (compared with 49 percent nationally).
• Lower costs: Kaiser Permanente of Colorado Springs, CO, conducted a pilot study of patients treated by Dr. Eads through virtual visits, which were reimbursed at a rate of $50 per visit. Preliminary figures from 2006 showed that Kaiser saved between $70 and $120 on each of these visits (as compared with the cost of an inperson encounter).
• Anecdotal reports of efficiency gains: Dr. Eads reports that virtual visits save her time that she can now spend caring for patients who truly need extended, inperson care. The typical virtual visit takes between 2 and 10 minutes of her time. Because they address less complicated medical issues, they would typically correlate with a 15- to 30-minute in-office appointment.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Purchasing the EMR: Dr. Eads selected an EMR with built-in practice management software to facilitate remote access to patient records and to simplify coding and billing procedures, which are jointly handled by Dr. Eads and her assistant.
• Developing initial model: After setting up her practice, Dr. Eads began offering same-day appointments and initially charged her patients $50 per year to have access to her via phone (she provided both her home and cell phone numbers) and e-mail. Nearly all patients quickly agreed to pay the out-of-pocket expense, which was not covered by insurance. She encouraged patients to contact her anytime they felt it was necessary and had patients sign a consent form advising them that e-mail communication may not be completely secure.
• Upgrading to a secure portal to allow virtual visits: Three years later, Dr. Eads purchased software and created a secure patient–physician communication portal that allows patients to make confidential, virtual visits. At this point, she began charging $20 for each virtual visit, and dropped the $50 annual fee for phone and e-mail access.
• Securing insurer coverage: In a unique pilot project, Kaiser Permanente agreed to reimburse Dr. Eads $50 per virtual visit. Recently, other insurers have also begun providing reimbursement for their members' virtual visits with Dr. Eads.
• Offering phone visits to patients: In 2007, Dr. Eads began offering telephone visits, charging $50 per phone consultation. Some of Dr. Eads' older patients, who do not use computers, prefer the phone visits. Currently, none of her patients' health insurers covers the cost of phone consultations.

Resources Used and Skills Needed

• Staffing: As noted, Dr. Eads works about 30 hours per week, caring for a panel of 400 patients.
• Costs: Dr. Eads uses Medfusion^® software to manage the practice and to run the secure patient–physician communication portal. The initial software cost was $2,000 and the maintenance for the Medfusion software costs $500 a year.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Ask patients what could improve provider–patient interactions: A survey can help determine what is important to patients in the care process and identity which specific enhancements may be desired, such as same-day appointments, 24/7 phone access, or virtual visit capability. Younger, computer-savvy patients are likely to prefer the virtual visit option, while older patients may prefer phone or face-to-face visits.
• Engage staff in the review process: Incorporate feedback and observations from practice staff in the evaluation process. In larger practices, the introduction of same-day appointments and virtual visits may require changes in patient care processes and staffing responsibilities.
• Look for ways to reduce overhead through technology: Lower overhead reduces productivity pressures and makes it easier for providers to spend more time with patients. Low-cost EMRs and practice management software may help to reduce overhead and improve efficiency.
• Monitor the program's impact: Some practices use a structured assessment tool, such as http://www.howsyourhealth.org, to assess patient satisfaction with the care process and new initiatives (e.g., same-day appointments, virtual visits, telephone access to the physician). Ongoing evaluations can help identify opportunities for improvement.
• Be conscious of the revenue implications: Even if insurers and/or patients agree to pay a fee for each virtual visit, the revenues from such visits are likely to be less than what would have been received in a face-to-face visit. (Dr. Eads receives $50 per virtual visit reimbursement from insurance, compared with $60 to $120 for an inperson visit.) However, virtual visits take less time, which frees up capacity for additional patient care (including the potential to handle more overall visits, if desired). In addition, in some cases, virtual visits bring in incremental revenue for services that do not require an inperson visit. For example, if a patient calls a doctor complaining about a sinus infection or urinary tract infection, the physician may simply phone in a prescription to a pharmacy and thus receive no additional reimbursement. When this communication occurs through a virtual visit, the doctor can charge for the service.

Sustaining This Innovation

• Advocate for insurance coverage of virtual visits: Although some patients may be willing to pay for virtual visits out of their own pockets, others may not be. Thus, insurance coverage is critical to sustaining the innovation over time. A handful of insurance companies are beginning to reimburse providers for virtual visits. This precedent can be used by providers to encourage local health maintenance organizations and other payers to provide reimbursement for this service.

Additional Considerations and Lessons

• Offer virtual office visits only to established patients: The initial patient visit should always be conducted in person, with the virtual visit option explained during this initial encounter. Because Dr. Eads has a small patient panel and established relationships with her patients, she is generally comfortable treating them through virtual visits. (As noted, if she is not comfortable after reviewing the submitted information, she asks the patient to come in for an inperson visit.)
• Explain that virtual visits are not for emergency situations: Doctors should inform patients upfront and in writing that virtual visits are not for urgent matters, such as chest pain. Patients should be instructed to call 911 if they experience an emergency situation.
• Set appropriate expectations as to response time: Although physicians should respond to virtual visits promptly, patients should be advised of the average response time, which is typically 24 hours.
• Phone consultations will no longer be free: It may be necessary to retrain patients to understand that services they had received for free may no longer be given away.

Use By Other Organizations

• At Fairview Health Services, a Minneapolis-based integrated health care system, more than 5 percent of its 34,000 patients have signed up to use the MyChart^® secure portal that allows for virtual visits. Fairview is reimbursed roughly $35 per virtual visit by local insurance companies.
• See also the AHRQ Innovations Exchange profile of GreenField Health in Portland, OR, which makes extensive use of virtual visits, at http://www.innovations.ahrq.gov/content.aspx?id=1785.