Your first impression of Eugenia Marcus, M.D., is likely to be: kindly pediatrician, wise in the ways of primary care and exuberant about kids.
Sure, that's all part of her persona as a 25-year medical veteran in the driver's seat of a four-doctor office. But look under the hood of Marcus' Newton, Mass., practice and you'll see a custom-built communication engine that complements and streamlines operations, with a power assist from the Internet.
To Boston-area parents, the World Wide Web site www.pediatrichealthcare.com affords a way to request forms, read postings of advice, peruse education-session agendas and, significantly, pose questions for doctors and nurses without having to schedule office visits.
To Marcus and the other physicians and staffers, the Web site's ability to route incoming messages to the right person reduces routine phone traffic and other assaults on practice productivity while strengthening bonds with patients.
"I do a lot of e-mail with patients back and forth with questions about things like growth and development issues, nutrition issues, chronic illness problems -- things that are of a nonurgent nature," she says. "From the Web site, people can do things like request a school or camp (medical) form, request a referral, request prescription refills. And there's `Ask the Nurse,' `Ask the Doctor' and `Request an Appointment.' "
The healthcare Internet market has targeted physician-patient contact as a growth area during the past year, but Marcus had it figured out back in 1996, when the practice moved to a new location and she set a goal of a paperless office. That's still a work in progress, but the decision to open a two-way path to the Internet in spring 1997 was prescient.
"I wanted to have a presence on the Web, because I wanted to be out there to take advantage of things as they evolved," Marcus says. It wasn't easy at first. "A lot of the stuff was still in its infancy."
But it became a hit. "The communication with patients has been astounding. They have been so pleased with being able to get an answer."
Marcus has attached a promise of a response within 48 hours. "But because of my own commitment to making this work as a reasonable technology in the office, I go through and I answer the patient stuff right away. So if you send me an e-mail and you're not a patient, you go to the bottom of the list."
That may seem like more work, but overall the Web site has been a plus for the practice. "Much more is getting done much more efficiently," she says.
All communication is managed by a special computer called a proxy server, which is connected to the practice's Internet service provider -- which sorts messages according to the type of correspondence a visitor selects by clicking on Web-site choices. The messages are distributed to the computer workstations of the staffers designated to handle them, she explains.
"The proxy server dials out to the ISP once an hour, collects all the e-mails that are there, and they pop up on my screen. So all day long, as I'm in and out of my office and between patients, I'm constantly looking at what's come in on the e-mail."
Things are a little quieter in the office now. Marcus says she is getting many fewer phone calls, maybe five per day compared with 15 to 20 before the Web site caught on. "It gives me more time. It gets rid of some of the nitty-gritty stuff that has been invading the time."
And the shift to e-mail from the phone adds a benefit: proof of what was said. A question is on file exactly as the patient posed it, and an electronic swap of messages shows when the patient sent a correspondence and when the physician answered it.
After she sends a message, Marcus drags a copy of the message from the "sent mail" box to a folder with the patient's name on it. "I now have a complete documentation of what they asked and what my response was," she says. "In terms of medicolegal documentation, it is far superior to telephone conversation."
Patients are known to send her e-mail responses to others, which extends the reach of what would have been one-to-one advice. The e-mails also can be called up later for reference, she adds.
The e-mail route is no substitute for phone or face-to-face contact for situations that need quick intervention, however. "When you log on to the Web site (to) contact the doctor, there's an information block that comes up that says the use of e-mail is for nonurgent things," Marcus says. "If your child is sick and you need an appointment today, you need to call the office and make that appointment -- and there are phone numbers to prompt people to do that."
Even with more-routine problems, the limitations of e-mail are sometimes evident. "Sometimes the questions are too intricate, they're too involved. They don't lend themselves to a two- or three-(line) or even a short paragraph answer. And so at that point I pick up the phone and I call the patient and say, `You know, this is really much more involved and we really ought to sit down and talk face-to-face about it.'
"Maybe with one or two additional questions (over the phone) I can resolve it, and I don't want to wait for the e-mail exchange," Marcus says. "So (the e-mail option) really does help me to communicate better with my patients."
When the doctor talks about her patients, she usually means the parents who speak for her little charges. But the Web site has made it easier for kids to do their own talking.
"The best e-mail that I ever got was from an 8-year-old who said, `Dear Dr. Marcus: Thank you for piercing my ears. It didn't hurt as much as I thought it would.' I've been in practice now more than 25 years and I never got a phone call from an 8-year-old. It would be just so daunting for a kid at that age to pick up the phone, call the office, get through the front desk to reach me to say, `Thank you.' But it came through on e-mail."
Another child became a regular correspondent after getting a cast for a leg fracture. "Every day I had a progress report on what was going on with the cast," such as autographs on the plaster by schoolmates.
"I respond to the kids because I want to encourage them to use e-mail," she says. "If a kid takes the time to communicate with me, I think that's the best thing in the whole world."