E-visit to the Doctor and TeleMedicine

There is a corollary argument popular among health care Internet companies and their backers that, even if the Internet does induce demand for more medical resources, the associated costs will be offset by various types of "remote doctoring" that the Internet will soon enable. Such remote doctoring falls into two categories: formalized e-mail-type physician "visits" by patients; and disease management systems that route patient clinical measurements from their home computers and/or medical devices to centralized nursing stations. If we believe that either of these new services will displace, rather than add new costs to the health care system, we should look, respectively, at the realities of medical practice and the sad fate of telemedicine over the past decade.

Many have argued that "e-visits" between physicians and patients have the potential to preclude entire office visits. The key issue associated with the supplanting of office visits by e-mail is not privacy, as many have argued. As recently as 1997, fear of electronic theft of credit card numbers was expected to be a major barricade to consumers purchasing of goods over the Internet. Rather, the key issue is bound up in the culture of medical practice: it involves the real reasons that people want to "see" their doctor, and the real reasons why doctors still insist on "seeing" patients when - long before the Internet reached critical mass - they could just as easily consult over the telephone.

Granted, my viewpoint tends toward economic determinism, but I always thought that doctors "see" patients to make money. A major impediment to "e-visits" with physicians is the same obstacle to the widespread acceptance of telemedicine: reimbursement. Because telemedicine represented a significant improvement in access and quality of care for patients in remote locations, it also represented induced costs for their insurers. With telemedicine, patients get to "see" leading specialists without onerous all-day drives across rural landscapes; without telemedicine, those same patients either make the drives, delay the encounter until they can, or forego the service altogether. Small wonder HCFA and the health insurers have not rushed to figure out a way to regulate and pay for the bulk of telemedicine services.

By contrast, HCFA and the managed care industry might be happy to figure out a way to reimburse for e-visits; unlike telemedicine, e-visits may prove to reduce total costs. This, of course, is exactly why physicians, then, will not embrace them as alternatives. Until reimbursement to physicians for providing an "e-visit" is worked out, they will continue to regard such alternatives warily, as yet another income-threatening burden. This impression of e-mail is the reason most commonly cited for physician reluctance to enter into e-mail communications with patients. (Miller, 1998; Goldsmith, 2000.) (This problem is already solved for patients covered by the disappearing reimbursement method of capitation, of course; an e-visit that pre-empts an office visit supplants a cost rather than revenue opportunity for the physician.) Will e-visits - even if adequately reimbursed and thus embraced by physicians - displace office visits demanded by patients? Or will they merely be one more service to be delivered and reimbursed by insurers? This leads us into one of the Internet's biggest health care challenges: if e-visits prove to add new services and costs, insurers will not want to pay for them; if they prove to supplant old services and reduce costs, physicians will not deliver them. This same exact conundrum will extend to the Web-based remote monitoring systems, which are really e-visits of another variety: if this extra IT-driven service is cost-additive, insurers will not pay; if it displaces physician visits, physicians will not authorize their use for patients for whom they retain ultimate liability.