Nino DiIullo, M.D., president of six Columbus, Ohio, urgent-care centers, is a self-confessed computer guy. DiIullo's Ambulatory Care Affiliates began keeping electronic medical records eight years ago, and his group spends about 4% of its $10 million in annual revenues on information technology. DiIullo says the centers' 25 physicians regularly use office computers to surf the Web for clinical information. In fact, he says, he won't even hire a physician who is not computer literate.
DiIullo now is working to develop a Web site for the centers. The site, which he expects to launch in the next six months, will provide basic information, such as office locations, hospital partners and accepted health plans. But DiIullo also intends for the site to provide patients with online health information, such as facts about allergies, bronchitis or pneumonia, and links to other sites with medical information. Eventually, he hopes to use the site for scheduling, patient reminders and alerts, and ultimately, he says, to give patients online access to their medical records.
DiIullo may be a bit ahead of the curve, but like many of the 800 other physician executives and group practice administrators who responded to Modern Physician's 1999 technology survey, he has begun to view the Internet as a tool to enhance the physician-patient relationship.
"Right now, a lot of patients have a lot of questions, but often they get in (the office) and forget half the questions," he says."If they come in already knowing their symptoms are related to allergies (because they have been doing research on the Web), then we can talk about it more, maybe discuss some of the antigens and they'll leave with more knowledge."
Tom Ferguson, M.D., editor of the Austin, Texas-based Ferguson Report, an online health newsletter, says online patient communications soon will be the rule, rather than the exception.
"When we look at patient services, I predict that in the next 10 years there is going to be a lot that will be provided online," he says. "Physicians need to be paying attention to the growing importance of online communication with patients." Ferguson suggests doctors who get on board early will be adequately prepared, but those who put use of the Internet low on their priority lists will have to scramble to catch up.
Why the Web?
According to the Modern Physician survey, having up-to-date information technology is increasingly important to many physicians. The survey, co-sponsored by the accounting firm PricewaterhouseCoopers, was sent to Modern Physician readers in June and included questions on technology spending and Internet use. An overwhelming majority of the respondents said they use information technology for the nuts and bolts of their office administration. A full 93% said they use information technology for billing, and 81% use it for scheduling. Those numbers are not too surprising, seeing as 90% of those surveyed said their initial investment in information technology was largely motivated by the hope it would improve business performance. Half of the respondents are spending between 1% and 3% of their total operating expenses on information technology.
Interest in the Internet appears to be on the rise, as well. Sixty-six percent of respondents said the Internet plays a part in their practices, up from 61% last year. Only 12.4% said physicians in their group or practice don't use the Internet at all.
Of the physicians who are out there surfing the Web, almost 30% reported they log on several times per day, 27.5% said they average once a day, 23.2% said twice a week, and just 0.4% said they use the Web only once a month.
The large majority, 91.5% of those who regularly use the Internet, are surfing for clinical information from medical journals, 68.5% are looking for access to clinical research and trials, and 68.3% are engaging in continuing medical education.
Increasingly, physicians are using the Internet for communication with their peers, partners and payers. Almost 35% of physician respondents said they use the Internet to communicate with specialists, 12.7% use it for consultations and referrals, and 30% use it to link to hospitals and payers.
Although the percentage of physicians using the Internet to communicate with patients is relatively small, just 17%, a large number expressed interest in more communication down the road. While 42.5% say they're already using information technology for patient reminders, 53.6% said they expect to use it for that purpose within five years. Likewise, only 25.5% of respondents use the Internet for treatment alerts now, but 63.1% expect to do so within five years.
Part of the reason physicians are inching toward online communications is that patients are beginning to demand it. According to a Harris Poll conducted in June, 70 million consumers have gone online in the past 12 months to look for healthcare information. According to our own survey, many of those who use the Web are bringing the information they find to their doctors. Almost 80% of our physician survey respondents said patients have talked to them about information they obtained on the Web.
David Chin, M.D., a principal in the Boston office of PricewaterhouseCoopers, says the explosion in Web use by patients is forcing physicians to reconsider their own Internet presence. "The physicians do not have any choice," he says. "So many patients are Internet (users); they are driving this movement."
The survey results support his claim: About 25% of respondents say patient demands are a primary motivation for their investment in information technology, and 37% list patient demands as a secondary motivation.
President and CEO of the McLean, Va.-based Global Telemedicine Group Jay Sanders, M.D., agrees that patients are pushing physicians toward more online communications. Sanders is past president of the American Telemedicine Association. "For a lot of physicians, they won't embrace (the Internet) and wrap their arms around it because of the logic of it or because of their love for it or the ease of it," he says. "They will do it out of necessity because their colleagues are using it and their patients are using it."
William Vederman, M.D., president of Sunrise Health Medical Group, a weight control clinic with 10 sites in Northern California, says patient demands led him to launch a Web site in January.
"People have come to expect that there will be Web sites for the businesses that they patronize," he says.
Harry Starnes, M.D., a solo family practitioner in rural Clinton, Ark., does not yet have a Web site, but he does communicate with about 20% of his patients through e-mail. He began collecting patients' e-mail addresses about six months ago and now uses e-mail to send patients their lab results and reminders for flu shots, and to answer general questions about their conditions or treatment plans.
"I would like to get rid of all the phone tag, and as everybody gets e-mail, we will," he says.
Kim Swanson, M.D., a cardiologist in solo practice in Newport Beach, Calif., communicates with about 30 of his 600 patients through e-mail. He says he usually replies to patient e-mails from his home computer after he puts his children to bed.
"I'm busy all day long and have very little time to return patient phone calls, particularly those that appear to be elective and could wait a few hours. They end up stacking up until the end of the day, but that's a difficult time to deal with phone calls," he says.
A typical exchange may involve a patient asking Swanson for more information about a test he has recommended. Swanson can reply with an explanation of an angiogram, for example, and suggest Web sites the patient can visit to learn more on his or her own.
Ferguson says it's important for physicians to know how much of their patient base would like to correspond through e-mail.
"If that number is less than 5%, there's no huge pressure, but if that number is 50%, you are probably already losing patients, and it should be a real top priority."
Although Swanson enjoys his online exchanges, many survey respondents are wary of giving patients e-mail access. Of the physicians who currently do not use the Internet, 14.3% say they don't because they are afraid they will be showered with e-mail. Smaller groups in particular seem fearful of e-mail overload. Only 3.7% of groups with 50 or more physicians responded that they worry about receiving more online correspondence than they can handle, but 11% of respondents in groups with fewer than 20 physicians say they are concerned.
Only 5.1% of those using the Internet, however, say they have been overwhelmed with communications from patients and others.
Swanson, who launched his Web site about a year ago, gets between 50 and 75 hits a month. "It started out at just 25 to 30 hits per month," he says. "Physicians are not going to be overwhelmed with the burden of having to deal with some new gigantic input from their patients."
DiIullo, on the other hand, would wecome a "gigantic" response as he believes an active Web site would only be a help to his staff in improving efficiency.
"We're already doing registration by fax, so it would make sense, as we gear up in the future, to do all the preliminary work we would do now here in the office over the Internet. So when patients come in, we can pull up their (registration information), instead of waiting for 10 or 15 minutes in the office while they fill out forms," he says.
DiIullo and Swanson agree that the Internet can enhance existing patient relations, and Swanson is hoping it also can help build new ones.
"This is a fairly competitive area, so one needs a high level of visibility both among patients and referring physicians," he says. "It's not quite advertising in the sense we perceive advertising. I felt comfortable from a professional standpoint with the visibility that a Web site offers me without feeling like it oversteps the bounds of being tacky and going beyond good taste."
Floss O'Sullivan, product manager for the healthcare Web site Medscape, says practices without customized Web sites will soon seem very old fashioned and behind the times. "A lot of physicians are becoming convinced that they need a venue like a physician Web site for a couple of reasons," she says. "One is to market themselves--we like to say 'to hang their shingle on the Web.' The other is that patients are savvy, and they're out there looking for information.
Some are looking to see if their doctors have a Web site as a measure of how 'with it' they are." To date, Medscape has built about 3,900 customized physician Web sites.
Swanson launched his site with the assistance of another company that builds physician Web sites for free, Salu.net, a Portland, Ore.-based Internet company that helps physicians create personalized Web pages and secure medical e-mail.
Salu.net's own Web site welcomes physicians with the challenge: "Patients will be on the Internet today. Will you be there to greet them?"
Facts, but little knowledge
Swanson's Web site provides information on his practice and links to educational sites such as the American Heart Association.
While the AHA provides credible, peer-reviewed information, some Web sites do not. Although 37.5% of respondents say the Internet has made patients more knowledgeable about their conditions, 31.6% say patients come in with misinformation about their conditions. A recent study in the journal Cancerreported that as much as 40% of the medical information obtained on the Internet is inaccurate and misleading.
"It's apparent by what patients ask us when they come in that people are surfing widely, and for better or for worse, getting all sorts of information from the Internet," Vederman says.
According to the Modern Physician survey, 82.6% of the patients who bring information they've obtained from the Internet to an office visit bring general disease information; 69.2% bring information about alternative or complementary therapies; 69% bring drug-related information; and 51.8% bring information about treatment protocols.
Houston OB/GYN Rod Turner, M.D., hopes that his Web site, which was built by Medscape and includes links to all Medscape databases and libraries, will steer patients towards credible online information and serve as a reliable educational tool.
"Hopefully we can establish better communication so the patients will be more informed about what to expect and better educated about whatever we're talking about in the office. It's sort of like in class. The teacher can only teach you so much. You have to do some of the research on your own," he says.
Getting patients to online information and then empowering them to use that information to improve their health is the ultimate goal in physician-patient online communications, says Dick Gibson, M.D., medical director of information services at Providence Health System in Portland, Ore. The 170 primary-care physicians at Providence's Portland-area clinics are piloting a MedicaLogic product that will allow patients to view their own medical records, including some of the physicians' notes, and track their health progress online (see related story, page 60).
Cardiologist Swanson has his more Web-savvy patients creating and e-mailing spreadsheets that track their blood pressure levels. "I have a number of patients who live at some distance, and that's been a nice way to take care of them," he says.
A feature on Medscape-developed sites allows patients to track their weight, sugar levels and drug therapies. "The visit is so short today; the Web site extends that visit for patients so they can continue to receive help," O'Sullivan says.
A new partnership between WellMed, a Portland, Ore.-based provider of online health management tools, and Healthdirectory.com, a Missoula, Mont.-based Internet healthcare company that partners with medical societies, will allow physicians to deliver customized health information to their patients.
Healthdirectory.com has worked in tandem with 28 medical societies to create online directories of 50,000 physicians. Those physicians now will have an opportunity to create personalized Web pages that include WellMed's Online Health Management System.
The WellMed system provides patients with a 27-question health survey to complete, from which it creates a personal health profile. The program identifies risk areas, such as high blood pressure, and then automatically gives patients relevant, peer-reviewed medical information, such as information about smoking cessation programs.
MedicaLogic, Healthdirectory.com, Medscape and WebMD, which is building DiIullo's site, are just a few of the many companies eager to help physicians establish Web sites and communicate with their patients--all for free or very little cost. In doing so, they're not only facilitating physician-patient communications but also gaining access to some of those 70 million consumers who are out there surfing for healthcare information.
"If you can control or influence the physician, that is the key to e-commerce, because it is the physician who is ordering the test or who can direct patients to online content," says Jim Ackerman, a healthcare information technology analyst with the Arlington, Va.-based investment banking firm Friedman, Billings, Ramsey & Co.
"It's still the personal physician who is the ultimate authority that people look to. So I think we're going to continue seeing a nominal cost or no cost to physicians (by Internet companies) to set up Web sites."
Regardless of the motivation behind online communications, Global Telemedicine Group's Sanders says such communication is ultimately in the best interest of both physicians and patients.
"The biggest problem we have in patient care is effective communication," he says. "We have a $100 billion a year problem in this country in terms of noncompliance on the part of the patient. Patients either don't understand the information given to them or have totally forgotten the information given to them by the time they get home.
"I am passionately in favor of the Internet as another means of communication between doctor and patient."