Without the fanfare of an aggressive marketing campaign, Boston's Partners HealthCare System recently began offering second opinions via the Internet. The Cleveland Clinic will have its own service in place by the end of the year.
The two are joining the growing number of big-name medical organizations entering the world of online consultations. Others in this group include Johns Hopkins University in Baltimore and the University of Texas M.D. Anderson Cancer Center in Houston.
Some lesser-known operations also have opened up shop in cyberspace, raising some concerns among telemedicine experts about the wisdom of Internet-centered consultation services.
Partners, which includes Massachusetts General Hospital and Brigham and Women's Hospital and is affiliated with Harvard University, is not allowed to advertise its service to out-of-state patients. But it has been getting hundreds of inquiries per week since launching the program in June, says Joseph Kvedar, M.D., director of telemedicine for the health system.
"People are going to find us by linkage, not by an ad on MSN," Kvedar says, referring to Microsoft Corp.'s Internet portal. "Given that lack of marketing, the response has been good." He says prospective patients learn about the service through the hospitals' Web sites, Internet search engine queries and word of mouth.
Kvedar, also the vice chairman of dermatology at Harvard Medical School, reports that the Web page had 721 unique visitors during one week in August and that 55 patients had registered with the program since it began in June.
"We think that's a sign that there's something here," he says.
Others apparently agree. The Cleveland Clinic expects to have its system operational during the fourth quarter, though a spokesperson for the multispecialty physicians' group declined to provide further details.
A Palo Alto, Calif.-based company called MDExpert.com has been selling second opinions for cancer patients online for nearly two years. The price, at $450 each, includes a review of medical records, a radiologist's examination of images and a written opinion. Partners, which also has a pathologist test biopsy samples, charges $600 per case. The physician's share of the fee varies, depending on the complexity of the case and any expenses involved.
"But our activity has increased significantly in the last 12 months," says MDExpert.com founder Julian Schink, M.D., a professor of gynecologic oncology at the University of Wisconsin.
The firm now is handling about 20 to 25 cases per month, though it has the medical and administrative infrastructure to support "several hundred" monthly consultations, according to Schink.
In general, the various consultative operations follow similar processes: A patient or physician registers with the Web site and fills out patient and case history reports. Both patient and doctor must approve the release of medical records. The sites often request supporting materials, including laboratory samples and medical images.
After receiving payment, the service assigns a specialist to review the case.
The specialist then renders an opinion directly to the patient's personal physician.
"This is a physician-to-physician transaction," Schink says. That aspect helps shield the services from ethical and legal minefields.
According to Kvedar of Partners, "I don't see how it can be argued that the exchange of information between professionals can be ethically (wrong)."
Legally, the HIPAA privacy regulations, set to take effect in 2003, allow physicians to share patient records with the patient's consent when evaluating medical opinions. However, Kvedar says that online consultations may be illegal or otherwise inappropriate in some states. He says Partners looked at offering the service in 32 states. "We came up with 27 where we were comfortably, legally and ethically, in bounds," he says.
Still, the concept has its detractors. Robert D'Alessandri, M.D., dean of the School of Medicine at West Virginia University and an authority on telemedicine, cautions that consulting physicians run the risk of being implicated in suits or complaints about negative outcomes even though they never actually see the patients they are rendering opinions about.
"It's going to cause the recommendation to be less specific and more general. It may provide only a qualified recommendation and won't help the patient as much," he says.
D'Alessandri contrasts that with Mountaineer Doctor Television, or MDTV, a statewide program in West Virginia he helped create nearly two decades ago and now oversees as dean of the medical school.
"With our telemedicine program, there is a direct video link," he says. "We can do parts of the examination. We can provide the added information that these physicians can't."
Schink says that the medical community has begun to warm up to the idea of Web-initiated second opinions and that he has received "overwhelmingly positive" feedback from patients and their original physicians.
"Many physicians initially were wary about this service," Schink explains. But they changed their thinking once they saw the results. "We have the best academic docs in the country . . . and they know how to write an opinion."
Many of the online programs are tied to teaching hospitals and rely on medical professors. D'Alessandri takes some comfort in that.
"My advice to patients who decide to use a service like this is to use a site affiliated with an academic health center," he says.