Rise of the Online Doctor Visit

Sometimes, all a patient who’s already seen a doctor needs is a quick follow-up communication with his or her doctor, or a brief consultation on a healthcare problem. In that regard, leaders of patient care organizations nationwide are beginning to facilitate online communications between physicians and their patients for common, non-urgent medical matters and ailments.

One organization that is doing so is the 20-hospital, integrated University of Pittsburgh Medical Center (UPMC) health system in western Pennsylvania. Through the recently established e-visit program called HealthTrak, in which a patient engages with her or his provider online, eligible patients can have questions answered, conditions analyzed, and prescriptions written, without leaving home. The key to UPMC’s program is a secure patient website that makes use of a robust patient portal.

Grant Shevchik, M.D., a family physician and geriatrician whose suburban medical practice in Murrysville, Partners in Health, is a part of UPMC, is the medical director of HealthTrak, the program that has brought online visits to UPMC patients. Shevchik began developing the concept for the HealthTrak project in 2008, and brought a number of other physicians into the development work in 2009. Then later in 2009, UPMC Health Plan, the integrated system’s affiliated health plan, agreed to reimburse physicians for e-visits under the program, becoming the first health insurer in western Pennsylvania to reimburse for e-visits.

The program continued to roll out, and, at the time of publication of this article, 77 practices with 989 physicians, who care for 53,000 registered users, are active in the program. Of the physicians, 57 percent are primary care. Within the program, patients can get securely delivered medical advice, review their medical history and lab results, renew prescriptions, track blood glucose and blood pressure, request appointments, and ask billing questions, among other tasks.

Shevchik spoke recently with HCI Editor-in-Chief Mark Hagland about the program. Below are excerpts from that interview.

Healthcare Informatics: Please tell us a little bit about the origin of this program.

Grant Shevchik, M.D.: This started with an MBA course that I was taking in which you were supposed to come up with an idea for a new project in medicine. My idea was to come up with an e-visit for relatively minor, common issues, like urinary tract infections, sinus infections, and so on. And the idea was that there would be a questionnaire that would be filled out online, and the questionnaire would be embedded in the EMR. Fortunately, there is actually a CPT code for a non-face-to-face visit, under Medicare, code #99444, for an online medical examination.

So we got some physicians together in the summer of 2008, and began a project with the physicians at UPMC, and with people from Epic [the Verona, Wis.-based Epic Systems Corporation, the UPMC health system’s core outpatient EMR vendor]. Epicare is our outpatient electronic medical record; and within Epicare, there is MyChart, the patient portal, which we’ve branded as HealthTrak. We’ve done a number of customizations with the core system.

The key to how the whole thing works is the patient portal, where you can see your problem list, medication list, past history, and so forth. What’s more, we’ve built into the portal the clinical decision support needed to address over 20 areas, from sinus infections to pneumonia to vaginal yeast infections to erectile dysfunction, etc. So the patient goes into the portal, articulates their symptoms, and the branching logic in the system guides them forward through a detailed questionnaire. And the results of that questionnaire trigger the online visit with the physician.

HCI: What medical specialties are involved?

Shevchik: Currently, internal medicine and family practice. We have a physician in neurology working on some things, and one in cardiology, looking at something, but it’s mainly primary care.

HCI: What has the growth in volume or use been so far?

Shevchik: In September 2010, we rolled it out to 277 doctors, covering 12,000 patients. And that’s where it’s out to now. We went from having months where we might get 25 to 30 e-visits a month, to five or six visits a day. Our busiest day has involved 17 e-visits a day. We offer the service seven days a week, from 8 a.m. to 8 p.m.—the reason for those hours are that the pharmacy should be open to service those patients. But for patients, you can do this 24 hours a day; you feel bad in the middle of the night, you can fill out the questionnaire, and go back to bed.

HCI: How big will this eventually get?

Shevchik: It’s not so much the physicians who make it grow so much as the patients. So if you move to Pittsburgh, and you pick Dr. X, and that doctor has five people on HealthTrak; and he has a capacity limit. But he may have 1,000 or 2,000 people on HealthTrak. So 300 doctors may have 12,000 patients today, but may have 25,000 patients, as HealthTrak continues to roll out more and more.

HCI: What lessons have been learned so far?

Shevchik: From an IT standpoint, it’s this: that you can have the best of something, but patients need access to it. What’s more, patients are “splitters,” whereas doctors are “lumpers.” Patients think in terms of very specific conditions, such as, “I have a sinus infection, or I have the flu.” Doctors think more broadly.

HCI: In other words, patients don’t think clinically, correct?

Shevchik: That’s right. Also, being a good diagnostician, you can come up with a good diagnosis. You don’t have to come up with all sorts of crazy explanations. And in fact, 80 or 90 percent of the time, patients actually know what they have now.

HCI: Have the physicians enjoyed being a part of this?

Shevchik: When we started out, it was probably 20 percent ‘yes,’ 20 percent ‘no way,’ and all the rest in the middle, saying, ‘wow, this is really different.’ Some just couldn’t get comfortable without being able to ask another question or do whatever. But as it went on, I would challenge them, comparing their notes from a face-to-face visit with an e-visit; and I’d ask them, what did you learn from the face-to-face visit that you didn’t from the e-visit? And 95 percent of the time, they said, “nothing.” So most have really embraced this; and no one is saying it doesn’t work.

And on weekends, I cover for all 277 physicians myself, for the e-visits. The most I’ll get is 10 or 12 messages a day. But what is really interesting is that I’ll say, “Hi, I’m Dr. Shevchik, and I’m covering for Dr. X,” and they’re delighted.

HCI: Do you have any advice for our readers for those who might follow in your footsteps?

Shevchik: First, find a product that allows for a patient portal. What has changed was healthcare reform; healthcare reform said, ‘you’d better start paying attention to computers.’ And a lot of organizations had electronic health records, but didn’t have a way to attach a patient portal to their EHR. And patients are now starting to accept responsibility for their own chronic illnesses, and the first thing they want is a closer interaction with their doctor.

What’s more, I’ve learned about asynchronicity: patients send in messages any time of day or night, but they’re impressed if you can get back to them in a few hours. It’s different from a telephone call; we’re not putting you on hold for 10 minutes on the phone, which would be pretty frustrating. The other element is discrete data—the computer can read the different individual data elements. Let’s pick a simple example: a patient’s hemoglobin a1c. If it’s under 7, that’s good. And if it can read your a1c, and it’s high, it can read that data element, and you can build in a best-practice alert for a high a1c reading. That’s just one example.

But what happens to a lot of doctors is that they want to take their paper world and make it electronic, which is absolutely the worst thing to do, but if you’ve never been electronic, it’s a very difficult thing to do.

And the other thing this does is that it generates a source of revenue. Even if you do $30 a visit and do one e-visit a day, that’s over $10,000 a year. I was actually invited to do a presentation down at CMS [the federal Centers for Medicare and Medicaid Services], because they were so intrigued by what we were doing. And you can’t do an e-visit without an EHR. But it’s one of the things doctors are hesitant to do because they want to know what they’ll get out of it.