Doctor-Patient Communication in Today's Digital Age

MS. DIANE REHM

10:06:56
Thanks for joining us. I'm Diane Rehm. When doctors see patients, they don't just listen to a list of symptoms. They also look at facial expressions and body language for clues to a health problem. The growing trend toward communicating with patients online raises concerns among some physicians and patient advocates.

MS. DIANE REHM

10:07:23
Joining me to talk about doctor-patient communication in today's high-tech world: Dr. Steven Schwartz of Georgetown University and Deven McGraw of the Center for Democracy & Technology, from WGBH in Boston, Dr. Joseph Kvedar of Harvard University, by phone from Tuba City, Ariz., Dr. Sam Bierstock of Champions in Healthcare. I'm sure many of you have comments to make. I look forward to hearing from you. Give us a call. Send us an email. Join us on Facebook or Twitter. And good morning to all of you.

DR. JOSEPH KVEDAR

10:08:14
Good morning, Diane.

MS. DEVEN MCGRAW

10:08:15
Good morning, Diane.

DR. STEVEN SCHWARTZ

10:08:16
Great to see -- great to be with you.

REHM

10:08:16
Good to have you all with us. Dr. Kvedar, if I could start with you, I know you think emailing with your patients is a good idea. Tell us why.

KVEDAR

10:08:30
Well, Diane, it is, after all, the 21st century, and health care may be the only service left on the planet where you have to go visit a person in a physical location to get that service. It only makes sense that we harness the opportunities that communications technologies give us, and email is one example. Video communication is another. They're all breaking out at the consumer level, and we just need to think carefully about how we implement them. But in health care, we should be harnessing all these primarily because it builds a better relationship with our patients.

REHM

10:09:11
Dr. Bierstock, on the other hand, you say that the doctor's office is where medicine should be practiced. Explain why.

DR. SAM BIERSTOCK

10:09:23
Yes. Well, actually, I'd like to qualify that a little bit, Diane, because the way this argument was originally framed was, should physicians use email to communicate with patients? And I think had that been worded, is there an appropriate role for email, I'd probably be sitting and agreeing totally with Joe. My problem with it is that I don't believe that this can be widely generalized, and there are elements of judgment that can't be standardized. Patients have varying degrees of the significance of their problems and privacy issues.

DR. SAM BIERSTOCK

10:10:03
And I think to generically make the statement that email should be a way to communicate is much too great a generalization and does not take into consideration the many, many instances in which you really need to be face to face with someone.

REHM

10:10:19
Give me an example, Dr. Bierstock, of where you believe seeing a patient in person is critical.

BIERSTOCK

10:10:29
Oh, sure. Well, you know, people have written to say, well, I sent a picture of a mole that's changing to my dermatologist by email, and it's wonderful. Or I monitor my own blood pressure, and I let my doctor know what it is. I think these things are great. That's one thing, but there's email and there's email. If you -- if I were to send an email to my doctor because I noticed I've been coughing a lot and there's a little bit of blood in it and I'm concerned, one of three things could happen.

BIERSTOCK

10:10:59
He may not answer me at all. He may be too busy or may take too long. He may send me what I think is an appropriate response, which is, gee, you know, we better look into that. Come on in, make an appointment. Or he may send me a note that says, gee, you know, you may just have some irritation in the back of your throat, or, on the other hand, it might be an early sign of lung cancer. Well, that's three different ways that I'm going to respond. Hopefully, he has the judgment not to do the latter, but we don't always know that.

BIERSTOCK

10:11:27
And if the doctor sent a patient a note that said we happened to notice a little spot on your lung on your last X-ray that we didn't see last time, please come in, the only thing that person is thinking is cancer. And they're going to be frightened to death until they get in. There are interactions that have to happen between the doctor and the patient directly so that they can be face to face, the doctor can manage the reaction, the fears, answer questions, develop plans, discuss options, et cetera.

REHM

10:11:58
So, Dr. Kvedar, would you agree with Dr. Bierstock's reservations?

KVEDAR

10:12:07
Well, I never meant to come forward and say that we should displace all in-person visits. Quite the contrary, as a clinician, I see patients a couple of times a week, and I'm very attached to those relationships, those interactions in the office. I do, however, find that people are coming into the office for a number of interactions that I would say are quite a rote and of low emotional value. And they're coming in simply because it's the only way they can avail themselves of a health care service.

KVEDAR

10:12:43
So I would say that -- very good thoughts on your part, Sam, and I quite agree that I shouldn't be telling someone they have a new diagnosis of cancer by email. On the other hand, there are a whole host of interactions that we could have more effectively in a variety of online communication modalities that we don't really do now simply because we're either behind the times or we have constraints on the system.

KVEDAR

10:13:12
The only other thing that I do want to emphasize because a lot of your argument has to do with nuances in terms of people's readiness to communicate or the -- how bright the doctor is in terms of noting his or her response. And I would just ask that we not place any more of a burden on our thoughts about online communication than we do face to face. All of those errors that you suggested can be made by a face-to-face doctor or a face-to-face patient. They're not unique to the online environment.

REHM

10:13:51
All right. Let me move on now to you, Deven McGraw. I know that you've got concerns about privacy. Lay those out for us.

MCGRAW

10:14:02
Sure. I do have some concerns, although I think -- I do think all of them can be managed. So, essentially, they're actually a little bit more concerns about security. I mean, email does need to be protected as a form of communication. It's actually a legal obligation on physicians, if they're going to use electronic technologies to communicate information to patients, that they have to provide some physical security for that communication, whether it's through encryption or through some other vehicle.

MCGRAW

10:14:33
Also, I think it's important for patients to really understand that when they're using email, depending on which email address they're using or how they're accessing it, it may not be a private email address. A lot of people misunderstand how they can use their work email -- for example, using it often for personal purposes, maybe the only email address they actually have -- and that email is not private to them.

MCGRAW

10:14:56
They may assume that it is, but, in fact, it's not. Some people use public computers to access email because they don't have email services in their home. And so I think it's important that there be a conversation with the patient so they understand that there could be some limits to protections on their email, depending on the email service that they're using and that they ought to be smart about how they use email.

REHM

10:15:20
And, Dr. Schwartz, you've recently begun using an encrypted form of communication with your patients. Is that correct?

SCHWARTZ

10:15:31
Yeah, that's right. In our practice, we've been using -- I first used some email, and then we've gone to secure encrypted email. And we just launched our patient portal. I'm in a medium-sized practice here in Montgomery County. And the move has been a good one because, using a patient portal, it is a direct one-to-one link. The communication is integrated into the electronic medical record, the patient chart.

SCHWARTZ

10:15:59
When I'm looking at the communication, I also have access to the patient record. I can add the communication to the patient record, and I can attach elements like lab results and notes and other things right back to the patient. So that's been a boon for us. The patients have loved it, and I've loved it.

REHM

10:16:17
You know, it's interesting, for the last three years, at least, I've had a private patient portal for my dog. I mean, are veterinarians ahead of the curve on this, Dr. Schwartz?

SCHWARTZ

10:16:34
Yes. I mean, I think, yes.

REHM

10:16:35
And that's the only answer.

SCHWARTZ

10:16:37
I think yes. I think doctors are slow to make changes. As a group, they have practiced a -- you know, a certain way for a number of years. They're good at what they do because they do it the same way over and over and over. And then to make a change in the workflow creates concerns that bad things will happen. And so I think they're slow to change because if you say, well, now you're going to change and do it differently, it somewhat implies what you've been doing isn't good enough or maybe wrong.

SCHWARTZ

10:17:09
And doctors, I think, don't like to hear that. And it's a change in the workflow. It is, to some degree, disruptive, and you need that concentration to make good decisions.

REHM

10:17:17
Does it save you time?

SCHWARTZ

10:17:20
Yes, it definitely has. A good example, yesterday, after having the same five messages in my inbox, playing phone tag, having left messages, getting return calls, calls back, I generated letters, printed those out and mailed them to patients who weren't on the portal. In the meanwhile, I knocked out several portal calls or portal messages very, very quickly. Because, when I have to make a phone call, I have to decide, is this call going to take me one minute, five minutes, 10 minutes? I'm 20 minutes behind.

SCHWARTZ

10:17:51
I only have a minute between patients. Do I make the call now? Do I wait till the end of the day? Now, I'm calling at the end of the day. The patient is on a commute, whereas, with the portal or an electronic message, it's asynchronous. The patient can send me the message at 10 at night. I can get it when I have it two minutes between patients. So it becomes much more efficient with time because I can do it when it's efficient for me, and the patient can send a message when it's efficient for them.

REHM

10:18:12
Efficient, but perhaps less accurate because it's moving so rapidly.

SCHWARTZ

10:18:19
I'm not sure about accurate, but, you know, it's in small pieces. You'd -- it's asynchronous, so you can't have the back and forth exchange.

REHM

10:18:27
Dr. Steven Schwartz, he is associate dean of clinical informatics and a family medicine physician at Georgetown University. Stay with us.

REHM

10:20:04
And if you've just joined us, how many times have you called your physician, hoping, waiting, waiting, hoping for a callback? We're talking this morning about the opening of electronic communication between doctors and their patients. Some are using this. Some have actually created private portals at a cost of what, Dr. Kvedar?

KVEDAR

10:20:40
Well, I think that the dilemma here is that email has become ubiquitous. Virtually everyone uses it, and we must, as Deven said and as Sam said. Everyone agrees we must be vigilant about privacy and educate people about the privacy concerns and what this means to them.

KVEDAR

10:21:04
On the other hand, when I say to someone, you have to log in, you have to create an account, you have to use this particular vehicle to communicate with me, and, oh, by the way, on the back end, typically, that goes to a staff person and doesn't go to the doctor 'cause those portals are often set up so that it is a workflow management tool for the practice, the patients just say, can I just email you?

KVEDAR

10:21:29
And it's hard to say no to that. I -- we use encrypted email. We use secure email for the reasons that Deven mentioned. But, frankly, it is a very ubiquitous tool and very easy to use.

REHM

10:21:43
It's interesting, Deven, because don't nurses, assistants -- don't they see the information in any case that may come out in a doctor-patient visit face-to-face?

MCGRAW

10:22:01
Absolutely. Absolutely, and there's nothing wrong with that. I mean, email is just one vehicle to facilitate the same communication that you have with your provider over the phone, if you can get them on the phone or the nurse on the phone. It's just, you know, there are some differences that you have to accommodate so that, you know, people understand that there might be some additional risks to this communication.

MCGRAW

10:22:24
But having said that, I think Dr. Kvedar is absolutely right. There are lots of people who say, I understand the risks. I would much prefer to just email you. And if they understand it and that's what they want to do, I think that's fine.

REHM

10:22:37
And, Dr. Bierstock, we have a message on Facebook from April, who says, "I feel email, texting, et cetera, would make the relationship with my doctor feel less professional and honestly make me feel extremely uncomfortable. Things like email update on day and time of appointments would be useful, but to discuss personal information that way would really hinder my respect for the doctor." Do you agree with that?

BIERSTOCK

10:23:17
Oh, I certainly see why a lot of people would feel that way, and it was to an earlier point I raised. And I certainly think both Joe and Steve lead some excellent points, which I fully agree. But, you know, Diane, I just feel that there are elements within this discussion that are deeper, and I would be interested in actually -- probably, Deven has something to say about this, but there are no parameters around expectations.

BIERSTOCK

10:23:45
If I were to get an email while I'm talking to you that one of my patients is having chest pain and I decide to finish this discussion with you and get back to them in half an hour and, in the meantime, something happens, is there a liability issue there? Have I abrogated my responsibility to that patient? I don't think we have any parameters around the length of time of response when we get information in real time.

BIERSTOCK

10:24:11
And we are in an age now when the data gets to the doctor as quickly as it's generated. So, you know, perhaps Steve would comment on that, too. But I think that we have an issue that needs addressing as to what the expectations are of physicians in terms of how they prioritize the information they get and act upon it. And if I just may make one other point.

REHM

10:24:33
Sure.

BIERSTOCK

10:24:35
The -- people don't realize the degree of granularity of analysis that comes with electronic health records. I mean, it's actually literally possible to see what information the doctor looked at, how long he looked at a screen, did he scroll down and read everything? And, you know, there's enormous scrutiny involved in that with -- which again, raises a great deal of medico-legal vulnerability.

BIERSTOCK

10:25:01
So this is a problem for doctors because, in the last 10 years, the reason they've been so slow to respond to EHRs or several, number one, the change in their workflow. It may slow them down. In some cases, it may speed it up. But if they want immediate information -- if someone has chest pain, they know what they want. They want a chest X-ray, they want a cardiogram, they want to see the tests to see if there's muscle damage to the heart.

BIERSTOCK

10:25:27
They don't want to click through seven screens to do it. And, similarly, they don't want to review a thread of emails if they can be -- if that information can be otherwise captured.

REHM

10:25:36
Dr. Schwartz, you might talk about emergency care in the kind of situation Dr. Bierstock outlined.

SCHWARTZ

10:25:47
Well, Dr. Bierstock's exactly right. The concern right now is, because it's a new method of communication, the expectation, the rules of engagement are not quite clear what you can put with a portal or secure email. You can build in automatic responses, disclaimers and things like that, like your message will be returned within 24 hours. If this is an emergency, please call 911...

REHM

10:26:14
Call 911.

SCHWARTZ

10:26:15
...just like when you call the -- right, just like when you call the doctor's office. In reality, it is an unusual event that patients would say, I'm having chest pain, what should I do? And then common sense comes in. But the question is right. Is 24 hours reasonable? Is same day? Is a half day? And it's very hard to piece that out, and I think that will evolve in the standard of care to which medico-legal is judged, is based on what the standards are, what people begin to do.

SCHWARTZ

10:26:51
My experience has been, 'cause I've consulted on some medico-legal cases, there's been more cases were the patient hasn't received information and that was the grounds rather than they got information. So I actually don't think, you know, an extra means of communication would increase the liability. But I do agree if you ignore a phone call or you ignore a message, a digital message, there's some risk.

REHM

10:27:16
What about that, Deven? Also the careful scrutiny of material related to that patient, does a doctor pull a file before he or she answers an email and carefully go through all the information?

MCGRAW

10:27:37
Right. I mean, you know, obviously, the standards are evolving here, and it would never be smart to adopt email communications or portal-like communications without setting very clear expectations and then abiding by them, really, on both ends to say to a patient, here, I will return an email within a certain period of time. Please don't email me over the weekend. We don't look at them over the weekend.

MCGRAW

10:28:03
And then, of course, to abide by that because, if you start as a pattern of behavior, communicating with people outside of the boundaries of what you sort of agreed upon are the parameters, you could be in some trouble. In terms of sort of how much information you look at, how easy it is to obtain from the record, I certainly have heard these concerns from physicians. And I do believe it's both an issue of usability of the current systems and the need for some innovation to evolve so that they are more useful.

MCGRAW

10:28:31
But, inevitably, the standard of care will be the community standard of like practicing physicians, right?

REHM

10:28:40
And that's developing, and that's the point.

MCGRAW

10:28:42
And it's going to be developing. And, quite frankly, the expectation will -- over time, as more and more physicians adopt these technologies, if you are not using them, you could be outside of the standard of care.

REHM

10:28:53
Dr. Kvedar, give us some examples of how you use various technology to communicate with your patients.

KVEDAR

10:29:05
Right. I'll do that in two ways, Diane. First, I do want to respond to the thread that was going on a moment ago. And, I guess, I'll just say in my own experience, as a practicing clinician, who has face-to-face practice, in addition to all the virtual work that I do, my patients just haven't been that clueless, that they're very respectful of both the medium and the use of it. I honestly don't sit down with every single one of them and say do not email me for chest pain or things like that or an emergency.

KVEDAR

10:29:40
On the other hand, I'm not sure why it is. It may be that my experience is unusual, but people are very respectful and very thoughtful. And they use the technology wisely. I do think that we -- this is one theme of our center, the Center for Connected Health, is we really can't expect much more of our patients than we do now. So with that transition, let me tell you a little bit about some of the uses of technology that we're employing at the center. Our mission is to bring care out of the office, out of the hospital, and directly into the lives of patients and unlock a great deal of value in doing so.

KVEDAR

10:30:18
On one hand, we can educate you about your health in such a way that you can be motivated and be more healthy and take demand off the system, really become your own health care provider, and the other way we add value in using connected health is by giving providers more of a population view of real-time information that they can delve into and do care, what we call just-in-time care, rather than scheduled care, when you might or might not need it most. We've applied those tools -- monitoring, messaging -- to a variety of chronic illnesses and had really breakthrough results.

KVEDAR

10:30:57
But in terms of how we communicate, we certainly do a series -- we use text messaging a lot as a tool to communicate with populations of patients. The most popular one these days is women who are pregnant because during their prenatal care, we can send them very, very specific timely messages to engage them. And we've shown that they're more adherent to their care plan when they get those messages. So that's an example. We do virtual visits. We've studied virtual visits. We've found that patients are quite happy to have certain visit types done asynchronously in a vehicle like email.

KVEDAR

10:31:37
This particular study was done using a portal framework, so it wasn't email exactly. But it was acne follow-up care. Patients were very, very happy to be able to do that. If you think about, for certain health care interactions, the fact that you have to travel, park, wait for an hour, sit in a room with a gown on for another half hour, and if we could avoid all that by letting you do it from your living room, there's a power in that as well. So I think a lot of dimensions to this and a lot of really interesting threads to go through as we think about it.

REHM

10:32:11
Dr. Joseph Kvedar is founder and director of the Center for Connected Health in Boston. He's associate professor at the Harvard Medical School. And you're listening to "The Diane Rehm Show." We're going to open the phones now. We've got lots of folks on the line. 800-433-8850. First to Providence, R.I. and to Marie. Good morning to you.

MARIE

10:32:50
Good morning. I just wanted to make the point that, you know, doctors are under such a time crunch these days. I mean, I used to work for a doctor, and I know how short the slotted appointments are. And the opportunity for them to be able to address all of the patient's concerns and issues, very, very limited. And so this is a great tool for augmenting the doctor-patient relationship because patients can ask about preventive medicine questions. It can be wellness stuff. It can dealing with chronic illnesses, as Dr. Schwartz and Dr. Kvedar were pointing out.

MARIE

10:33:18
And it's just such a great opportunity for patients to talk to their doctors about things they generally -- get the chance to talk to them about, and those things tend not to get dealt with, whether it's in the context of prenatal care or a chronic illness, where scheduled visits aren't always very helpful because you don't get sick on schedules. You get sick (unintelligible), and waiting for appointments can be a problem. So I think a lot of this has to --payment schemes and how overscheduled doctors are and that this can be a real opportunity.

REHM

10:33:46
You've raised some good points, Marie. What about payment for time, Dr. Schwartz, that you spend on email with patients?

SCHWARTZ

10:33:58
Well, that's a concern. It's phone calls. In the current payment models, for the most part, phone calls are uncompensated. Email is uncompensated. Right now, you're essentially paid for visits, which is part of the reason that there's overuse of medical services, is the more you do, the more you get paid. And so there is a concern that -- am I going to take on more work that's uncompensated? And it is a challenge.

REHM

10:34:24
What about that, Dr. Kvedar?

KVEDAR

10:34:28
I'd say a couple of things -- and Steve alluded to this earlier -- that -- right. So non-visit work in the fee-for-service model is uncompensated. But we did say earlier how there is good evidence, Steve's anecdotal evidence -- there's also been published evidence -- that practices that adopt an asynchronous model, say a portal or an email, their phone volume goes down. It is a more efficient way to do what you need to do.

KVEDAR

10:34:56
Over and above all, our obligation as professionals is to our patients. It isn't to get paid. Of course, we have to get paid to make a living, but caring for someone is the obligation. And if we can do it more efficiently using this kind of a tool, and effectively, I would say it makes sense in that context. But even more importantly, what's really exciting in the coming wave -- and it was hinted at by Dr. Schwartz -- is the coming wave of new payment models.

KVEDAR

10:35:26
And the government is behind this with the accountable care organization movement. In Massachusetts now, we, with every single payer, have -- or are on the cusp of having contracts that hold us accountable for efficiency and quality as opposed to volume. And it's amazing how our doctors are waking up to concepts like virtual care and connected health as a result of that.

REHM

10:35:52
Deven, I know you want to respond.

MCGRAW

10:35:54
Yeah. No. I mean, it's just another way that technology can really be used to support where health care appears to be going, which is that, if payment is based on good outcomes and the patient either getting better or not getting sick in the first place, the ability to use the technologies to make sure this happen will pay off in the long run. But we are, at this moment, asking the provider community, the physicians, to up-front the cost of using these technologies as we transition out of a, you know, sort of pay for the -- per service into something that is more based on pay for outcomes.

MCGRAW

10:36:32
We're not -- we're evolving there, but we're not there yet. And yet we have to -- somebody has to pay for those up-front costs of the technology.

REHM

10:36:39
And before we go to a break, let me ask you, Deven: Have there been any lawsuits, as yet, regarding electronic communication between doctor and patient?

MCGRAW

10:36:53
We have not seen any. I mean, they're hard to monitor 'cause they largely take place in state courts across the country. There's plenty with respect to missed telephone communications, whether it's the call didn't get returned or the call didn't get triaged quickly enough or appropriately, or the person who responded to the phone call misread the communication and underestimated the seriousness of it. There are lots and lots of those. And so you can certainly see that if you don't manage email appropriately, the same thing could happen.

REHM

10:37:25
Deven McGraw. She is director of the Health Privacy Project at the Center for Democracy & Technology. When we come back, more of your calls. I look forward to hearing from you. 800-433-8850.

REHM

10:40:04
And we're talking about new technology, its effects on the relationships between doctors and their patients. Here's an email from Catherine, who says, "I'm not surprised if doctors move away from traditional face-to-face visits. I'm shocked and dismayed about how little they're reimbursed by insurance companies. Recently, our pediatrician spent 25 minutes with my son who had injured his arm. My co-payment for the visit was $35. Our insurance company paid the doctor an additional $10.

REHM

10:40:52
"The doctor earned a total of $45. Patients should examine their explanation of benefits and see just how little their primary care physicians are earning." Dr. Schwartz.

SCHWARTZ

10:41:09
Well, I'm a primary care physician. Fortunately, we're doing, you know, a little better than we used to. But -- and, look, doctors, in general, are compensated more than the average salary. But primary care doctors do make significantly less. And that's one of the reasons that fewer medical students tend to go into primary care. But, again, adding efficiency and adding new payment models that, you know, compensate quality rather than quantity, I think, is the way to go.

REHM

10:41:39
And, Dr. Bierstock, here's one for you. This individual says, "I was recently traveling in Bulgaria, starting to get serious pains. I debated my options for treatment in a Bulgarian emergency room. I could not call my doctor in the U.S. because of the time difference, so I emailed him. I never got a reply. Upon my return to the U.S., I visited him, told him I had sent an email to which he had not responded.

REHM

10:42:19
"He said he and his staff laughed about it, that, of course, he could not respond via unsecured email, and it was illegal anyway. Trust me," our emailer goes on to say, "when you're having medical issues overseas, it sure would be nice to be able to get some sort of advice from your doctor." Dr. Bierstock.

BIERSTOCK

10:42:50
Yes. I mean, I could not agree more that -- and this sort of speaks to my point about being too general about the use of email. I think everything that's been pointed out this morning is, you know, largely very positive. But it's not always a reliable way to communicate in a situation such as this gentleman was in. I'm sure it was very frustrating, and probably the response by his medical team when he got back, you know, added to that. It isn't always a reliable way.

BIERSTOCK

10:43:22
You don't know when your doctor is going to check. It sounds like Joe and Steve are very conscientious about it, and that's appropriate and very helpful, I think. I would like to make one other point about the compensation if I can go backwards for a second.

REHM

10:43:34
Surely.

BIERSTOCK

10:43:35
There are models of very successful email communications and practices where the practices charge a fee on a monthly basis to their patients because they're not being compensated by third-party payers, and that might be $20 or $30 a month for the ability to communicate with their doctors. Because there is currently no compensation model, I think that's probably reasonable. And they claim that they have great many patients who are signed up and enjoying that a great deal.

BIERSTOCK

10:44:07
I think there are codes from some of the third-party payers for telephone time, but I don't think many of them are paying. And I also don't believe there are codes -- maybe somebody will correct me on this -- for Medicare and Medicaid for telephone time.

REHM

10:44:21
Deven, what about that?

MCGRAW

10:44:23
Well, you know, if a patient is insured and the communication flow that improves care is sort part of the whole package, it seems to me that shifting that cost onto the patient is less desirable. If you're dealing in what are now being called concierge medicine practices, where it's essentially self-pay, then, certainly, the email service would be sort of part of what you're paying for.

REHM

10:44:48
All right. To Fort Lauderdale, Fla., good morning, Sharon.

SHARON

10:44:53
Hi. Good morning. Excuse me. My husband was an internal medicine primary care physician. I guess he was trained in the last of the doctors who actually learned physical diagnosis. But I'm concerned because it seems that this is basically being addressed to primary care, that assuming doctors still know how to look at a person's body and make some -- base -- some diagnosis based on symptoms, whether it's fingernails that are yellow or eyes or whatever or things on the face, where you can even diagnose some types of underlying cancers, that's going to be eliminated.

SHARON

10:45:35
So I'm concerned about that particularly when we are trying as a society to get more people to go into primary care. And, yes, it's underpaid. And when somebody -- one of your speakers made the analogy, well, they still make better livings than most people. But this is -- they don't start working for 10 years, and they're always confronted with the possibility of a lawsuit if they make a diagnosis, are pretty sure of it and yet don't go on and order a series of expensive tests.

SHARON

10:46:12
So that's a dilemma that, I think, in addition to whatever privacy issues some people are concerned about in this age of no such thing as privacy, I think you're going to be eliminating an important step in that diagnostic process. And, basically, what you're going to be asking physicians to do is become Web MD.

REHM

10:46:33
Dr. Schwartz.

SCHWARTZ

10:46:35
Well, I think that -- and I don't know that I can speak for all of us, but I think I can speak for all of us -- that we've all said that electronic communication fills a role for certain visit types and encounters and follow-up that wouldn't require an office visit. So any kind of complaint or concern that would require physical diagnosis -- an abdominal pain complaint, a chest pain complaint, bleeding, even rashes -- 'cause even the issues of sending high-enough-resolution pictures would not be appropriate for electronic communication.

BIERSTOCK

10:47:11
But, you know, a follow-up -- I started my medicine, I've taken it two days later, I'm having nausea, should I continue or should I not -- is a perfect opportunity, whereas, before, the patient might just stop taking it. And if I can comment on the prior caller, I think, actually, one of the groups of patients I originally started with emails are people who do do a lot of international travel because it's extremely hard. They don't maybe speak the local language. They don't trust the local health care.

BIERSTOCK

10:47:38
And they do want your input. Now, you can't provide that care, but you can provide advice, like get on a plane and get home now or see the local person or adjust your medicine. But as Sam said before, I mean, the issue is you do have to have some standards and protocols in place of how you will respond to email, what happens when you're away, what's your turnaround time. You can't do it willy-nilly.

REHM

10:48:02
Your office also has a routing system. Talk about that.

SCHWARTZ

10:48:08
That's right. So this is -- you know, we've just recently turned on the portal, which has been a good thing, and so different types of messages get routed to the different members of the team. So a request, electronic request for a referral will go to the person who processes referrals. The person who wants to schedule an appointment online goes to an appointment scheduler. If you want to message your doctor directly, that message will go to a doctor, but it also will go to the -- part of the team.

SCHWARTZ

10:48:38
We have maybe a physician assistant or a nurse practitioner with the physician so that there's two people getting that message. So if one person's out, someone else can see it. So the messages get routed to the appropriate person who can handle or will handle that service in the most efficient way for the patient, and it gets to the most -- to the right person.

REHM

10:48:57
Dr. Kvedar, what about sitting there with one patient and emailing another? How often does that happen?

KVEDAR

10:49:11
Oh, not at the same time. I'll say again how precious the time I have with patients face to faces, and I never want to convey otherwise. I also want to emphasize that I'm in no way advocating for forming a new relationship with an individual as a provider via electronic means. That is to say, some random individual that I've never met before sends me a mail for evaluation, I probably wouldn't respond to that other than to say, this isn't something I can do for you, if I even responded to it.

KVEDAR

10:49:48
So this really is about when you have an established relationship and follow-up care. I do think, vis-à-vis the caller, though, there are two sides to it. It's a really interesting -- what you raised is fascinating. And clinical judgment, there's no substitute for it. We're not suggesting that people become robotic about their use of these tools, but I have heard on the other side a number of -- and it always seems to be frustrated young mothers.

KVEDAR

10:50:14
There are few examples of this, but probably the best one is a frustrated young mother who "knows" when their child has an ear infection and has to go in for a visit so the doctor can look and this and that and -- can I just call and get my antibiotic over the phone? And, of course, the pediatrician is saying, well, I want to make sure the child doesn't have meningitis or a number of other things.

KVEDAR

10:50:36
So it cuts both ways. Sometimes people feel inconvenienced by having to go in for an office visit when they feel they know exactly what's going on. And so I just think it's an interesting dilemma.

BIERSTOCK

10:50:48
Diane, may I just make one...

REHM

10:50:50
Certainly.

BIERSTOCK

10:50:50
…that, I think, is important. If I might, you know, the one reason I think it's so important that we sort through this -- it's such an important debate -- is I think that we have a pretty good certainty -- regardless of what ends up with the ultimate decisions with respect to health care reform, we have pretty good certainty that we're going to have 30-, maybe 40 million more people entering the health care system.

BIERSTOCK

10:51:12
We already have a shortage of primary care doctors, and many people are resorting to emergency rooms as their primary care. And with this amount of people coming into the system more, the burden on our primary care doctors is going to be even higher. So if we can sort our way through this and find effective use to maximize the use of our technology, it's going to be very important to the way we deliver care.

REHM

10:51:38
Deven, I would think that associating email technology with mental health professionals and their patients would be a very different situation.

MCGRAW

10:51:55
Well, you know, for many people it is a more sensitive aspect of health care, and, in fact, there are often are more stringent privacy laws, largely at the state level, that apply to information that indicates a mental health condition. Certainly, there are at the federal level if it's dealing with substance abuse recovery. So -- but I would say, as is always the case, you know, there's no reason to say what we -- I'm sure we can't use this tool in mental health because of the privacy concerns. I actually believe they can all be managed.

REHM

10:52:28
Really?

MCGRAW

10:52:29
Yes. But you have to manage it. You have to -- the patients -- first of all, you have to be dealing with a patient population that is actually interested in using email as a means of communication. Then, on the provider side, the providers certainly have to manage -- here's what you can email me about and here's what -- please don't use email to tell me that you're contemplating suicide, for example, right? Call 911. In fact, I have a friend who's in the mental health field. And when you call her, her voicemail says, if you're experiencing a medical emergency, please dial 911.

MCGRAW

10:53:01
So it really is -- there are no sort of absolutes, yes or no. It is about managing expectations. And if mental health care can be made better and more valuable to the patient through the use of these tools, I'm not going to say don't use it.

REHM

10:53:12
Deven McGraw, she is at the Center for Democracy & Technology. And you're listening to "The Diane Rehm Show." Dr. Schwartz, explain informatics to us and how you're training new doctors to use this communications technology.

SCHWARTZ

10:53:34
Well, to try and define informatics, simply, it's kind of the interface between computer science, information management science and biomedical information to optimize problem solving and decision making. So it's using computers to manage the information to deliver -- for clinical informatics deliver better care. At Georgetown, we've been using it for a while. We have been putting handhelds, initially Palms and iPhones, in students' hands to get point-of-care reference to answer questions.

SCHWARTZ

10:54:03
We're starting to have them use those in simulated patient encounters and then real patient encounters. We've recently added electronic prescribing curriculum. As they're learning pharmacology, they're learning how to prescribe electronically. We've now added that so they're working with the -- what we call the -- it was recently coined the triad of trust -- doctor, patient, computer in the exam room -- the communication skills with patients and doctors and computers in the room and prescribing in between.

SCHWARTZ

10:54:33
We've not started doing communications with electronic, but there are other folks have -- I saw a presentation of a family medicine group. I know the folks in Ann Arbor published a study on -- in pediatrics, not the journal but the Department of Pediatrics on teaching medical students how to communicate with email for content, for tone, for non-jargon and so forth.

REHM

10:54:55
Yeah, I would think that would have to be very carefully done.

SCHWARTZ

10:54:59
Yes. So what -- that particular study they -- it was simulated emails. They created simulated emails from patients, and the students had to respond with emails. And then they used a -- you know, a grading rubric on the email responses to teach how to respond electronically. And, in fact, what they showed in a nutshell was that you -- it's not intuitive. You would think it's intuitive 'cause we all use email. But as other users said, it's -- one of the caller said, it's very informal.

SCHWARTZ

10:55:29
This kind of messaging can be trained of how to be non-jargon, how to address the patient's concerns and so forth. So it was trainable. There are folks doing it at the residency level and doing it at the fellowship level as well, both primary care and specialty level. There was another article from some rheumatology folks in Missouri, I think, and they've been doing it with rheumatology fellows.

REHM

10:55:49
So one of the things I think you would teach them not to do is use all caps to communicate?

SCHWARTZ

10:55:56
Correct. All caps conveys urgency, and...

REHM

10:56:00
Urgency.

SCHWARTZ

10:56:01
...some of the examples given before, you know, you don't kind of just say, it looks like you have cancer, come in and talk to me.

REHM

10:56:07
Yeah.

SCHWARTZ

10:56:08
You know, there's ways of structuring messaging so that's -- that it is professionally appropriate.

REHM

10:56:15
Well, we're going to end this program with a very positive tweet from a woman who says, "As a stay-at-home mom, I love the idea of email rather than dragging my healthy kids to a germy office with me." So there we are. Thank you all so much, Dr. Steven Schwartz of Georgetown University, Deven McGraw, the Center for Democracy & Technology, Dr. Joseph Kvedar of the Center for Connected Health in Boston, and from Arizona, Dr. Sam Bierstock. He's founder and president of Champions in Healthcare. Thanks for listening, all. I'm Diane Rehm.

ANNOUNCER

10:57:09
"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Denise Couture, Monique Nazareth, Nikki Jecks, Susan Nabors and Lisa Dunn, and the engineer is Tobey Schreiner. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org, and we're on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.
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