	How does today’s connected, “always on” world translate to your medical practice? Should you be e-mailing your patients? Performing online consults? Telephone consults? What about telemedicine? The 

 defines telemedicine as “the use of medical information exchanged from one place to another via electronic communications to improve patients’ health status. This includes providing direct patient outreach and services and use of the Internet and other technologies for tele-consultations, patient medical education, remote patient monitoring, online medical records, specialist referrals and much more.”

 that as many as 70% of all doctor visits are for information only or for matters that can be easily handled over the phone. Data shows that more than 36 million Americans have been treated successfully through 

telemedicine, telephone, or e-mail consultations

. In addition, there is also a growing population of patients who can’t travel to the doctor easily, compromising their health and increasing their incidence of medical complications. Therefore, physicians and patients are gradually turning to electronic communication as a supplement to traditional visits. This technological step forward raises concerns about time, cost, liability, privacy, and security, remembering that communications need to be HIPAA compliant. But what if you could set up a system in which patients could receive e-mail and telephone consultations, including diagnosis and treatment for the more minor issues that don’t require office visits? What if for chronic patients you could set up a telemedicine system with secure video visits, with the ability to take vitals, obtain pertinent history, and measure important variables? What would systems that address all these concerns look like? What, if any, are the technical, liability, and ethical issues? “There is a whole move toward consumer-oriented healthcare: Your time, your place, your way,” says Jonathan Weiner, professor of health policy, Johns Hopkins Bloomberg School of Public Health.

	Since a variety of modalities and technologies now make it possible for physicians to exchange information, from brief messages to complete patient records, with each other and with patients—including tools as simple as e-mail and as sophisticated as two-way secure video with biometric patient monitoring&mdash; many physicians are integrating them into their practice. A host of services are becoming available at various levels of service, both to physicians and directly to patients.

	Physician adoption of electronic communication, particularly with their patients, has grown slowly in recent years; an estimated 38% of physicians reported using online communication with their patients in 2008, up from 31% in 2007, and 25% in 2006, according to 

. While the telephone appears to remain the channel of choice for urgent contact, many physicians are discovering that e-mail is a more efficient means for eliminating phone tag and documenting transactions.

	So what services are available? Some physicians have begun to offer patient access via e-mail. Although convenient, e-mail correspondence does raise the concern that a physician won’t be able to respond in a timely fashion to a barrage of messages. Many physician users say this has not been the case and that the bulk of patient correspondence tends to be regarding setting appointments, refilling prescriptions, and transmitting lab results, which would probably have been more time-consuming through traditional methods.

, the number of physicians who offer online patient consultations might increase in the wake of several developments in 2008:

 for online evaluation and management services provided by a physician (formerly Category III CPT Code 0074T.

		Large medical malpractice insurers will offer premium discounts to physicians who e-mail with patients.

	Brad Rostolsky, Esq., healthcare associate, ReedSmith, LLP, Philadelphia, PA, 

 that physicians who use standard e-mail that is not encrypted should take as many practical safeguards as possible in order to minimize liability exposure. Such measures include displaying privacy and security disclaimers at the bottom of every e-mail; requesting patient permission prior to responding any further via e-mail; and limiting medical detail in the messages. It is also a good idea to password-protect e-mail access on all desktop and portable computers, including PDAs and cell phones, which could easily be lost. Consideration should also be given to secure e-mail programs or e-mail encryption programs, wrote Guadagnino.

	These are great steps for the individual physician or practice, but what if patients want access to a more sophisticated assortment of online options and not just their own personal physician, or what if someone doesn’t have their own physician? Several existing services, each fulfilling a different niche, are available. Let’s take a look at a few examples.

 is an information-only service for patients who can sign up either individually or through their employer if the company they work for has an agreement with eDocAmerica. Once registered, users can obtain answers to their medical questions through Web-based e-mail or call a nurse hotline for a more immediate response. eDocAmerica provides boardcertified physicians who are guaranteed to respond within 24 hours, and there’s no copay for patients who have unlimited access to the service. After completing a simple, onetime registration and brief medical profile, participants submit their questions to an eDocAmerica physician using a unique, selfselected password. The process is online, simple, and secure. Because eDocAmerica is Web-based, participants can access the service anywhere, anytime, making it ideal for anyone who travels and for college students who are away from home. All of the patient’s medical information, questions, and replies remain completely private and confidential. No prescriptions or medical treatment are provided. eDocAmerica isn’t meant to replace the family doctor; it's designed to provide fast and convenient service and access to information on healthcare matters. If a patient does not have access to a computer, he or she may call a nurse hotline for information and speak with a registered nurse who will discuss the medical concern or problem, then provide a recommended course of action, which may range from home care to immediate emergency care.

	Commonly asked questions sent to eDocAmerica by participants include:

	•Do I need to see the doctor for this condition or do I have other options?

	•Where can I find additional reliable information about this issue?

	•What kinds of questions should I ask my doctor when I see him for this particular matter?

	•Can you clarify some of the information my doctor shared at my last visit?

	•What should I watch for when taking this medication?

	•What kind of doctor should I be seeing for this condition?

	In addition to the ability to ask questions to nurses, licensed psychologists, and board-certified physicians, eDocAmerica provides a BMI calculator, a searchable medical library, and a weekly health newsletter.

 is a slightly different service in that patients can call and get a doctor on the phone immediately and, if necessary, obtain treatment for minor concerns or chronic conditions. Consult A Doctor’s mission is to “improve health and reduce health care costs by creating innovative consumer-driven healthcare solutions for employers and individuals that meet their health care needs of today and tomorrow." They “believe that physician-provided health information economically provided via telephone medical consultations and secure e-mail medical consultations is fundamental to the decline of healthcare expenses.”

	Consult A Doctor is able to reach people in rural and under-served areas, as well as those who have no health insurance and hence no personal physician. Consult A Doctor provides affordable care to individuals and is also partnered with many companies as an employee benefit to cut down on the number of missed work days for doctor visits that could be handled by telephone. Consult A Doctor provides both immediate phone and by-appointment contact with physicians, allowing for an interactive exchange that isn't possible via e-mail. If it is felt to be necessary, medication can be prescribed; however, Consult A Doctor physicians never prescribe controlled substances. This is a great service for travelers who accidentally leave their medication at home, the chronic patient who lives far from his or her doctor, or the patient with an embarrassing problem who would rather speak on the phone.

	Patients' medical records are stored online in a secure HIPAA-compliant format so that the physician has access to all medical records when speaking to the patient. Members of Consult A Doctor also have access to a personal health manager, which includes services like a complete health library, risk assessments, tools to promote healthier lifestyle, a prescription reminder, health alerts, and help with their medical records. A physical exam and lab service is also available. Consult A Doctor is an impressive service, even for those who have a personal physician. Patients may not always want to bother you with questions, especially at 2:00AM, but they can always reach a doctor at Consult A Doctor.

 is a service that offers live video medical consultations via webcam between patients and a network of physicians who are US-trained and board-certified in many specialties, including internal medicine, family medicine, dermatology, OB/Gyn, neurology, physical medicine, GI medicine, psychiatry, and ophthalmology. The service allows patients the opportunity to interact with physicians from their home, office, hotel, or anywhere they can set up a computer. MDLiveCare is intended for those with non-urgent, healthcare-related matters. The ability to order lab tests and prescribe medications is available. The system also allows for follow-up visits and second opinions. Like the services described above, it saves the time and expense of going to the doctor’s office in person. Video sessions are recorded, allowing physicians to review patient interactions, verify medical information, and provide the basis for re-examination of diagnosis. The site stores patients’ medical records, sends prescriptions digitally to reduce errors, and coordinates lab work through Quest Diagnostics, where all results are appended to patient records. Their goal is to provide complete healthcare to a modern, mobile society, where busy lifestyles can mean that routine medical care is often delayed. Whether patients are busy, housebound, or unable to go to a medical office for any reason, they can see a doctor online, anytime, from the safety and comfort of their office or home. Televideo consultations are conducted in a private, secure, HIPAA-compliant environment, and the service supplies webcams and headsets free of charge to patients.

 differentiates itself from the above services by providing technology and expertise in creating clinically based solutions for a wide range of patient populations and telehealth organizations. According to American Telecare’s website, recent studies show “proactive monitoring with telehealth technology serves as an extremely useful healthcare delivery tool that improves quality of care for those living with chronic diseases that require close monitoring by their health care provider.” Doctors and nurses can monitor patients who are at home on a regular basis who might not come in for scheduled visits, thereby risking deterioration leading to hospitalization.

	A two-way connection allows healthcare providers and patients to engage in live, secure audio and video encounters through which they can see and hear each other. Through regular telephone lines, the patient and provider engage in live, secure audio and video encounters through which they can see and hear each other. Through regular telephone lines, the patient and provider engage in virtual check-ups, using such medical instruments as telephonic stethoscopes, vital sign equipment, glucose meters, pulse oximeters, and digital scales. The patient goes through an automated collection of data before the doctor visit so that time spent with the doctor can be focused on the checkup. Questions asked by the computerized program are dependent on the answers to previous questions, so each interview is tailored to how the patient is doing on that particular day. The peripheral equipment connects to the patient station, and readings are downloaded to the provider’s central station, where he or she can monitor the patient’s progress, assess their condition(s), and make recommendations in the plan of care.

	The uses for the technology include monitoring patients who have chronic illness who can’t travel easily to the doctor, are on post-operation home care, have diabetes, are obstetric patients on bed rest, or are HIV patients with complicated medication regimens. Physician-to-physician consultation and physician specialist consultation to remote area clinics and offices is also possible.

	Although telemedicine offers benefits, obstacles remain that must be overcome before the technology becomes part of mainstream medicine —one being reimbursement; although Medicare and some insurance companies pay for diagnostic services like teleradiology, most do not yet pay for other consultative telemedicine services. Medical licensing is another potential problem. Because telemedicine can cross state lines, some states could require a state license for an out-of-state doctor whose use of telemedicine crosses into their jurisdiction, even if the doctor’s practice is physically located elsewhere. Medical liability is an issue as well. For example, a remote specialist who does not perform a hands-on examination could be regarded as delivering less-than-adequate care. Or if compressed digital images are not reconstructed well&mdash;causing loss of valuable diagnostic information&mdash;a doctor could possibly face a malpractice suit. These technical problems notwithstanding, telemedicine is here to stay and will only improve. If 20 years ago, someone said you could carry a wireless phone in your hand and talk to anyone in the world, you might have been a bit skeptical; but like cell phones, telemedicine will eventually be accepted too. Taking in the big picture, it is hard to dispute the time and cost savings and the health benefits to patients.

	Dr. Tice is a psychiatrist practicing holistic medicine at Arena Oncology, a private practice in New Hyde Park, NY, and an 

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How does today's connected, "always on" world translate to your medical practice?

By Nany Tice, MD

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