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The Emerging Role Of Online The Emerging Role Of Online Communication Between Communication Between
Patients And Their ProviderPatients And Their Provider
Steven Katz M.D. M.P.H. Steven Katz M.D. M.P.H.
Associate ProfessorAssociate Professor
Departments of Medicine and Departments of Medicine and
Health Management and PolicyHealth Management and Policy
University of Michigan University of Michigan
AgendaAgenda
MotivationMotivation Current online landscapeCurrent online landscape ChallengesChallenges Early ExperiencesEarly Experiences PrognosisPrognosis
Motivation Motivation
PatientsPatients Frustrated with between-visit access Frustrated with between-visit access Are increasingly connected onlineAre increasingly connected online
Providers Providers Are frustrated with between-visit Are frustrated with between-visit
communicationcommunication Current modes are burdensome, fragmented Current modes are burdensome, fragmented
and inefficient and inefficient There is enormous mismatch between There is enormous mismatch between
communication mode and taskscommunication mode and tasks
Why web is rightWhy web is right
It is asynchronousIt is asynchronous It has enormous reachIt has enormous reach It is robustIt is robust
exchange and store informationexchange and store information provide servicesprovide services connect peopleconnect people
Communication can be tracked, managed, Communication can be tracked, managed, documented, and evaluateddocumented, and evaluated
It is secureIt is secure
Great ExpectationsGreat Expectations
The Internet will have a profound effect on The Internet will have a profound effect on the practice and business of medicine. the practice and business of medicine. Physicians, eager to provide high-quality care Physicians, eager to provide high-quality care and forced by competition to offer online and forced by competition to offer online services, will introduce e-mail and patient-services, will introduce e-mail and patient-friendly Web sites to improve administrative friendly Web sites to improve administrative services and manage common medical services and manage common medical conditions. Patients will identify more health conditions. Patients will identify more health information online and will take more information online and will take more responsibility for their care. The responsibility for their care. The doctor/patient relationship will be altered...doctor/patient relationship will be altered...
Jerome Kassirer. Health Affairs 2000
Trends in internet useTrends in internet use
Type of use 2000 2003
E-mail/IM 57 63
Browsing 55 60
News 38 40
Information 36 37
Shopping 30 33
Any Internet 67 77
Source: http://www.digitalcenter.org
Source: http://www.digitalcenter.org
Digital Divide Digital Divide
Source: Pew Internet and American Life Surveys
Internet Use 2004Internet Use 2004
0
10
20
30
40
50
60
50-64 65+
Surfing
Buying
Banking
Pew Internet and American Life Project 2004 pewinternet.org
ChallengesChallenges
PatientsPatients Lack experience with useLack experience with use Cavernous digital divide Cavernous digital divide
ProvidersProviders Concerns about workloadConcerns about workload Uncertain value of online communicationUncertain value of online communication Little consensus about communication management Little consensus about communication management
Organization Organization Lack a coherent business model/ROILack a coherent business model/ROI No roadmap to building online communication tools No roadmap to building online communication tools
Dear Dr. Katz,
My name is XXX and I am a patient of Dr. XXX. While I am more than extremely pleased with the care that Dr. XXX provides my husband and me, it is our understanding that he is required to obtain your final approval before prescriptions can be written, or blood tests ordered, etc. Therefore, I thought I might eliminate the middle man, so to speak, and ask you about a concern I have had for over 20 years. In 1969 I had a cancerous tumor removed from my thyroid, and in 1978 I had a complete thyroidectomy as the cancer grew back in the same spot. After the surgery, I was placed on .2mg of Synthroid, and stayed at that dosage until about 1982-83. During this timeframe, I did not have any problems with fatigue, weight gain, lack of concentration, etc. The doctor I was seeing at the time ordered the normal barrage of thyroid blood tests and they all came back within normal limits, except for, I believe, my TSH, which was slightly elevated. Due to this fact he lowered my dosage to .15mg. Within a couple of months, my life ceased to exist as I had known it, and it has been that way ever since. Now that I am well into menopause, my symptoms have become more intense. One suggestion was to go to bed earlier and get 8 hours of sleep. I have been doing this for about 5 years and I still feel exhausted by about 3:00 p.m. every day and when I get home from work all I want to do is lie on the couch. I find myself falling asleep watching TV at about 8:00 p.m. every night. Lack of concentration is another real concern for me, especially during the day at work. I try to get up and walk around to see if that would help get the mental juices flowing again, and it does help in the short term, but not the long term. This is not from depression. I'm a pretty happy person. Another concern is my inability to lose weight. I have been on diets after diets and nothing works. I joined a women's only exercise group and that hasn't helped either. We eat well-balanced meals and I'm not a sugar junkie, so I'm very frustrated that nothing seems to work. All of these symptoms seem to me to be a direct result of a low dose of synthroid.
My husband and I have appointments with Dr. XXXX tomorrow and I will discuss these issues with him as well. Again, let me reiterate that this is in no way a reflection on the care that we receive from Dr. XXX.
I would greatly appreciate your advice and counsel regarding these concerns. Thank you for your time.
Regards,
Dr. Katz:
I am a patient of yours through Great Care Network. Generally, I am seen by Dr. Rufus T. Firefly but I have not been able to contact him nor have I been able to get an appointment to see any doctor in the Internal Medicine clinic. When I called I was simply told there were no available appointment times. I am currently experiencing intense pain when I urinate as a result of a bladder infection and would very much like to get a antibiotic to start treating this. The symptoms are constant urge to urinate and painful urination followed by blood in my urine at the end of the urination. Can you please facilitate an appointment to see a doctor in your staff or prescribe an antibiotic. I am not taking any other medicines at this time.
Components of a patient portalComponents of a patient portal
Service-related featuresService-related features Medication renewals, scheduling, forms, Medication renewals, scheduling, forms,
registration/billingregistration/billing A clinical communication toolA clinical communication tool
Secure messagingSecure messaging A patient health recordA patient health record
Populated from provider and patient data sourcesPopulated from provider and patient data sources Medical recordMedical record Patient: current meds, immunizations, health Patient: current meds, immunizations, health
status information (e.g. blood sugar or blood status information (e.g. blood sugar or blood pressure log)pressure log)
Three solutionsThree solutions
E-mailE-mail Application Service ProviderApplication Service Provider Integrated Clinical Information SystemIntegrated Clinical Information System
E-mail E-mail
Advantages Advantages Seamless Communication Seamless Communication Enormous reach Enormous reach Asynchronous messagingAsynchronous messaging
DisadvantagesDisadvantages Security concernsSecurity concerns Unstructured free-text Unstructured free-text Cannot track messages Cannot track messages Messages cannot be automatically routed Messages cannot be automatically routed Cannot be easily documentedCannot be easily documented
Application Service ProviderApplication Service Provider
Hosted by vendorHosted by vendor Secure messagingSecure messaging Rx renewal, schedule requestsRx renewal, schedule requests
AdvantagesAdvantages Low start-up costsLow start-up costs Bridges clinical practicesBridges clinical practices Quick startQuick start Vendor is responsible for updatesVendor is responsible for updates
DisadvantagesDisadvantages Limited integration with CISLimited integration with CIS Data moves offsiteData moves offsite Requires ongoing service contractRequires ongoing service contract
CIS applicationCIS application Hosted by providerHosted by provider
Secure messagingSecure messaging Rx Renewal, schedulingRx Renewal, scheduling Portal recordPortal record
DisadvantagesDisadvantages High start-up costsHigh start-up costs Limited bridging with other clinical practicesLimited bridging with other clinical practices Slow start-upSlow start-up Provider partners with vendor on updatesProvider partners with vendor on updates
AdvantagesAdvantages Robust integration with CISRobust integration with CIS Data stays onsiteData stays onsite Does not require ongoing service contractDoes not require ongoing service contract
Summary Of Experiences With Summary Of Experiences With Online CommunicationOnline Communication
Patients Patients Slow initial uptakeSlow initial uptake Patients will follow the rules Patients will follow the rules Digital divide exists in clinicDigital divide exists in clinic
ProvidersProviders Staff don’t like E-mailStaff don’t like E-mail Doctors warm up to online communicationDoctors warm up to online communication Doctors and patients view E-mail differently Doctors and patients view E-mail differently
Organization Organization Resource offsets?: Cost-saving vs Cost-effectiveResource offsets?: Cost-saving vs Cost-effective Clinical processes and outcomes? Clinical processes and outcomes?
University of Michigan ContextUniversity of Michigan Context
Integrated multi-specialty provider groupIntegrated multi-specialty provider group Clinical Information SystemClinical Information System
robust electronic medical record since 1999robust electronic medical record since 1999 encrypted e-mail system since 1999encrypted e-mail system since 1999 no online patient order entry no online patient order entry
Substantial enthusiasm for a patient portalSubstantial enthusiasm for a patient portal
Yellow brick roadYellow brick road
Develop the business modelDevelop the business model Prioritize functions and featuresPrioritize functions and features Build or buy communication toolsBuild or buy communication tools Identify organizational enablersIdentify organizational enablers Develop Develop roll-out strategy roll-out strategy
Map relationships and workflowMap relationships and workflow Develop rules of engagement and exchangeDevelop rules of engagement and exchange Develop education and promotion strategyDevelop education and promotion strategy Allocate provider effort during rolloutAllocate provider effort during rollout Evaluate processes and outcomesEvaluate processes and outcomes
Katz SJ, Moyer CA. J Gen Intern Med. 2004 Sept;19:978-983.
Prescriptions
Patient-Provider PortalPatient-Provider Portal
Personal Health Record
Send/receive a secure message
Prescriptions
Appointments & Scheduling
Referrals
Patient Sign-on
Health Record & History
Lab/Test Results
Reminders
Disease Management
Education & Cross Promotions
Pre-Registration
Account Info
Maps & Directories
Referring Physician
MCARE Services
Communicate with my provider:
Portal Account:
Self-Help
Access to my records:
My insurance:
Maintain my own records:
Prescriptions
Patient-Provider Portal- Phase Patient-Provider Portal- Phase 11
Personal Health Record
Send/receive a secure message
Prescriptions
Appointments & Scheduling
Referrals
Patient Sign-on
Health Record & History
Lab/Test Results
Reminders
Disease Management
Education & Cross Promotions
Pre-Registration
Account Info
Maps & Directories
Referring Physician
MCARE Services
Communicate with my provider:
Portal Account:
Self-Help
Access to my records:
My insurance:
Maintain my own records:
Prescriptions
Patient-Provider Portal- Phase Patient-Provider Portal- Phase 22
Personal Health Record
Send/receive a secure message
Prescriptions
Appointments & Scheduling
Referrals
Patient Sign-on
Health Record & History
Lab/Test Results
Reminders
Disease Management
Education & Cross Promotions
Pre-Registration
Account Info
Maps & Directories
Referring Physician
MCARE Services
Communicate with my provider:
Portal Account:
Self-Help
Access to my records:
My insurance:
Maintain my own records:
Emerald CitiesEmerald Cities
Early ChallengesEarly Challenges
Variable staff acceptanceVariable staff acceptance Perceived additional work Perceived additional work No clear reimbursement planNo clear reimbursement plan Delayed roll-outsDelayed roll-outs Uncertain budgeting Uncertain budgeting Scope creepScope creep No single system solutionNo single system solution
Prognosis: GoodPrognosis: Good
Patient facility and access is growingPatient facility and access is growing increase in broadband accessincrease in broadband access
Better online communication toolsBetter online communication tools Better clinical data systemsBetter clinical data systems Beginning of the “J curve” Beginning of the “J curve” Uncertain business modelUncertain business model
