Nancy Finn submitted this guest post about the challenges facing doctors and patients who want to have clinical conversations online.

The quest for the right communication formula and balance that will satisfy doctors and e-patients who want to experience continuous care can be partially resolved with the spread of virtual clinical electronic messaging, or e-visits. The e-visit is a specific encounter between a provider and his or her established patient over a secure online connection. It is an asynchronous communication reserved for non-emergency issues.

A 2009 Manhattan Research study of 8,600 healthcare consumers found that a majority of these individuals were interested in having electronic online consultations with their physician. Patients who have engaged in e-visits claim that these encounters are particularly useful for monitoring chronic conditions such as diabetes, chronic bronchitis, and high blood pressure, or for discussing minor ailments that occur during the months following their annual visit, such as sore throats, stomach pains and colds. However, although 42% of US physicians report having discussed clinical symptoms with patients online, only 5% of physicians said that they were paid for these online consultations. This is clearly a barrier to advancing this digital communication technology.

In 2008, a billing code was approved (Current Procedural Terminology code 99444) that would enable doctors to charge for e-visits. But many online communications have not met the criteria required for the code. Several of the large payers such as Cigna, Aetna, a number of Blue Shield plans, WellPoint and Humana now recognize the value to patients and the cost savings to the system of paying for e-visits, rather than have the patient come to the doctor in the office and are reimbursing doctors for online clinical consultations. They require that the e-visit take place through a secure web portal with encryption and that the providers comply with Health Insurance Portability and Accountability Act (HIPAA) privacy rules. Payments average $30 per e-visit, about the same as the cost of a patient visiting a retail clinic as compared with $75 to $100 for an in-office consultation.
The Center for Medicare and Medicaid (CMS) is considering e-visit reimbursement. As a result of the healthcare reform law, CMS is reviewing innovations that would help facilitate doctors’ meeting with their patients through video chats, telephone checkups and in-home monitoring devices. This could prove to be a real game-changer for online remotely delivered healthcare.

There is another barrier to the expansion of the e-visit. There is a pervasive lack of sufficient infrastructure to provide meaningful online communications, including back-end technology to capture and store data from the visits, templates on how visits should be presented to patients; agreement on what interface will be best for doctors to use in delivering care; and questions about whether e-visits should be text-based, video, or IP video. There are also bandwidth issues for supporting the technology and a lack of resources to install the necessary equipment and train providers in conducting effective e-visits.

There are a few larger healthcare institutions and payer companies that have either developed their own infrastructure to handle e-visits or outsource those services to an organization such as the RelayHealth’s webVisit. Beyond those isolated examples, it is unlikely that e-visits will expand to the general patient population in the near term. I would argue that the e-visit can have a tremendous impact on a patient’s overall well-being and positively affect the cost of care. It behooves the medical establishment, public and private, to find the ways to make this happen sooner rather than later.