Implications of the Internet in Medical Practice

1
Implications of the Internet in Medical Practice
Roshni Ghosh MD, MPH candidate Columbia
University Mailman School of Public
Health Arnold J. Rosoff, Prof. of Legal Studies
Health Care Systems, The Wharton School, and
Senior Fellow, The Leonard Davis Institute of
Health Economics, Univ. of Pennsylvania.
Legal Issues
Abstract
Potential Communication Linkages

• Like a telephone call, e-mail can be informal and
  responses are often spontaneous and without
  adequate thought. Specific concerns include
• Does an e-mail exchange constitute a dr.-patient
  relationship? 
• Telephone-based precedent is Miller vs.
  Sullivan, 625 N.Y.S.2d 102 (App. Div. 1995) If
  a doctor makes a diagnosis and prescribes a
  course of treatment over the phone but the
  patient doesnt follow it, no physician-patient
  relationship is established. 
• Permanent Documentation e-mail creates a
  permanent record that presents a potential source
  of liability or support for the physician
• Privacy Concerns e-mails can be forwarded,
  compromising physician-patient confidentiality

Over the past decade, internet communications
have transformed human interactions, potentially
altering physician-patient interactions in a
radical way. The internet facilitates
communication among all elements of the
healthcare system, offering new opportunities to
improve patient care and practice efficiency.
However, as with the advent of the telephone, new
technologies introduce complexities and raise
challenging questions about professional
practices and liability, in addition to other
legal and ethical considerations. This
presentation invites a dialogue on some of the
most pressing issues physician compensation,
practice standards, liability concerns, privacy
and security
Background
Guidelines Specific for Online Use

• Internet Usage
• 199,861,345 people use the Internet as of
  October 2004 (67.6 of the US population)
• Over 53 million people looked for health
  information online in 2003-2004
• According to a US Survey
• 90 would communicate with their doctors via
  e-mail.
• 56 stated ability to e-mail their doctors would
  influence their choice of doctor
• 37 would be willing to pay for e-mail access
• 65 are interested in engaging in online
  consultations with their physicians
• Harris Interactive Jupiter Research

• Doctor-Patient Agreement
• Turn-around time
• Permissible content
• Category subject headers
• Discreet subject headers

• How to Handle Messages
• Automatic reply to message
• Archiving of e-mail messages
• Awareness of tone
• Address book

Use of the Internet in Practice

• Privacy/Confidentiality/Security Guidelines
• Disclaimers for content usage
• Continuous updating of information
• Security guidelines/protocols
• Security mechanisms (SSL/encryption)
• Secondary call center for symptom evaluation
• Linkage to verified reputable sites

• In 2000, AMA issued guidelines for communicating
  electronically with patients
• 2003 HIPAA guidelines protect the privacy of
  medical information for patients and set a
  broader standard for hospitals, other healthcare
  providers, and insurers.
• Medem, created e-Risk Working Group, made up of
  liability carriers, medical societies and state
  board reps to address the issues and concerns
  associated with physician-patient interaction and
  communication via the internet.
• http//www.amaassn.org/ama/pub/category/2386.htm
  http//www.medem.com/phy/phy_eriskguidelines.c
  fm

Use of the Internet in Practice
Conclusions
Physician Compensation
In 2000, Medem found that reimbursement was a
top reason doctors avoided e-mail contact with
their patients. Two existing models for
reimbursement 1. Health plans pay 19 to 25
per online visit patients may co-pay 5 to
20. 2. Patients pay full cost as set by doctor.
Currently, Medem collects payment from patients
by credit card and submits a check to the
physician, minus a 2.50 fee, each time a
physician bills patients for an online
consultation. http//www.mdng.com/departments/
mar_apr2004/cover.htm http//www.amaassn.org/am
ednews/2004/07/12/bil20712.htm.
Convincing the medical community of the benefits
of online practice remains the greatest
challenge. With a careful and structured
implementation strategy, healthcare providers can
harness the power of the internet to improve
standards of care, increase efficiency, and
reduce costs. Successful use of the internet in
medicine requires that issues of confidentiality,
medical liability, privacy, and compensation be
continually addressed by medical and legal
organizations. Finally, a larger proportion of
managed care plans need to support the use of the
internet by developing payment plans to entice
physicians and compensate them for their added
responsibilities.
s
On January 1, 2004 CPT code 0074T was issued
under the aegis of the AMA, formalizing
reimbursement for online consultations http//ww
w.mdng.com/departments/mar_apr2004/cover4.