It starts out like any> other visit to the doctor for a sore throat. First we have to wait 15 minutes. Then we meet the doctor, a grandmotherly type who asks us about medications and how long we ve had our hacking cough. Finally, she asks us to open wide and things get a little weird. She is, after all, not in the room with us but on the other end of a webcam connection, 100 miles away. So we ll need to awkwardly straddle our desk to give her a glimpse of our gullet.
It might sound funny to people used to wearing paper gowns and feeling a cold stethoscope on their chest, but to an unprecedented degree, a host of doctors are stepping into the brave new world of virtual medicine. Some are using secure Web site services or setting up virtual offices where patients can input health data like blood pressure readings or request prescription refills without leaving their desk or sofa. Others are emulating middle school students, using Web chat programs to gather information on patients symptoms and firing back diagnoses from their keyboard. And then there s the webcam: Already the enabler of Skype conversations with far-flung family members, it s now playing a starring role in virtual office visits that have an eerie likeness to the real thing.
Once limited mostly to rural areas where large-animal veterinarians outnumber family doctors, digital medicine is breaking into the mainstream. Manhattan Research, a tech-focused firm, recently reported that in 2009 about 40 percent of physicians were communicating with patients online, up from about 15 percent five years before. Meredith Abreu Ressi, a VP of research with Manhattan, says most of the doctors are deploying the computer to discuss clinical symptoms and often to make real diagnoses. Insurers have taken note too. Aetna and Cigna now routinely cover virtual visits, and UnitedHealthcare will be rolling out its own nationwide site offering chat and webcam features later this year.
It s another weird ingredient in the strange cauldron of the health care system. Medical costs already average more than $7,500 annually per American, and with most people s out-of-pocket costs continuing to rise, any way to save money is looking good to patients right now. And of course, in a still shaky job market, many employees would rather avoid skipping work for a trip to the clinic. To not have to schlep out in the snow to see the doctor, that s the dream, isn t it? asks Thomas Weida, a family-practice doctor in Hershey, Pa. But Weida and other physicians worry that online medicine could compromise patient privacy or worse, lead to diagnoses that are flat-out incorrect or harmful the kind of thing that could turn the digital dream into one of those going-to-school-naked nightmares.
Cheaper. Faster. Better?
Without a doubt, virtual medicine looks enticing to penny-pinchers. Studies have found that Web visits cost $25 to $50 for patients who aren t going through their insurance network, compared with the $100 to $125 they d pay for the same service in a bricks-and-mortar office. To sweeten the deal for people who do have coverage, insurers like Hawaii s Blue Cross Blue Shield offer the sort of copays not seen since the 1980s $10 for online visits for straightforward conditions like ear infections or sinus pressure. And a quick e-mail to the doctor for a prescription refill is usually gratis.
Just as important in the era of the impatient patient, many online services offer appointments within the hour. That s a far cry from the 20-day wait that s now the average for a routine physical in many large U.S. cities. In specialties where waits can stretch even longer, Web medicine is catching on even faster. Instead of queuing up for the dermatologist, for instance, some patients get their skin conditions diagnosed by flashing their rash at a webcam. Skittish pregnant women can get quick-hit answers to their concerns directly from gynecologists instead of bozos on a message board via live chat. And doctors can easily monitor patients with chronic conditions like diabetes by having them input data like daily weight and blood-glucose count via a Web site designed to spot aberrations. Some doctors say they benefit from the convenience as much as their patients do. Lisa Rankin, a primary-care doctor in Port St. Lucie, Fla., says she s often able to do Web visits while sweating away on the stationary bike in her basement, saving her office hours for more serious cases. Compared to playing phone tag with patients, she says, the computer is easy as pie.
The pie started looking tastier to Antoinette Steinert when she and her husband recently moved. Steinert, a hospital nurse, didn t want to give up her primary-care doctor but figured it would take three hours per visit out of her day if she kept commuting back to him for appointments. So she now uses RelayHealth, an online Q&A program used by Aetna and Cigna, to consult with him about occasional minor health issues, including a suspected urinary tract infection and an upper respiratory illness. She says the doctor s diagnoses have been on target, while she has been able to avoid getting stuck in a waiting room with, well, sick people. And in practice, she thinks an e-mail chat with a doctor is more thorough than what a doctor has time to ask you when you re sitting there in the office.
Indeed, a little distance seems to improve some doctor-patient relationships. Experts say that e-mail-like online services can be good for patients who get flustered during appointments in the actual office. There s a real problem with what we call the door-handle question, or the phenomenon of patients asking critical questions right as the doctor heads for the exit, explains Boston-based health care consultant David E. Williams. RelayHealth asks patients a series of simple, prompted questions, such as what part of their head hurts, and then allows them to pen their own notes to the doctor. If it takes you 20 minutes and two calls to your spouse to get all your symptoms just right, Williams says, that s just fine.
Potential for Bad Connections
Just because patients are more comfortable doesn t mean doctors are. State medical societies already have restricted digital docs from conducting business across state lines, and some are also trying to stop physicians from working online with patients they don t already have a relationship with offline. These regulators and their allies say they re mainly concerned about medical accuracy. There are a lot of important nuances that are captured when a doctor is talking to a patient he knows, says Ronald Dixon, director of the Virtual Practice Project at Massachusetts General Hospital. Although experts say they know of no lawsuits yet over computer-based medicine, doctors like Thomas Weida caution that online doctors could easily make missteps like diagnosing strep throat instead of a more serious infection of the epiglottis.
Some medical-policy experts also fear that there could be a downside to too much convenience. With the doctor just a few clicks away, some patients might be tempted to ping the doctor to evaluate every twinge and tummy ache. That could drive up health insurance premiums, which already top $13,000 per family. What s more, some online services allow doctors to prescribe medicines like antianxiety drugs or sleeping pills that are prone to abuse. Elliot Justin, founder of SwiftMD, says he sometimes writes busy, professional road warriors prescriptions for short courses of insomnia drugs. Indeed, he sees that as one of the virtues of online medicine; there are enough checks in place, he says, to make sure we are not running a pill mill. For now, in a nod to such concerns, big nationwide insurance carriers are mostly paying doctors only for online interactions with their own patients. Other big players, like Boston-based firm American Well, ban their doctors from writing prescriptions for controlled substances, like Xanax or Oxycontin.
Champions of digital medicine say most of the fears about misdiagnoses are overblown. Justin and other doctors point out that many office diagnoses are made primarily by listening to the patient s description of symptoms and following by-the-book guidelines for example, if a person can bear weight on a foot alone, her ankle isn t broken. Those factors, they say, translate just as well digitally as they do face-to-face. One study published last year, in fact, found that when patients had a videoconference appointment with one primary-care doctor and then a regular visit with another, their diagnoses agreed 84 percent of the time. Diagnoses from two face-to-face visits agreed in only 80 percent of cases.
If only the connections themselves were as consistent. Anyone who s fought with their cable company knows there s no such thing as infallible Internet service, and some start-ups have their share of logistical headaches. During our own Web explorations, on a visit to MDLiveCare.com, we paid a $15 enrollment fee only to find out there wasn t a doctor available in the entire state of New York who could see us. Later, after the service tracked someone down, that doctor s computer froze up just a few minutes after she booted up her webcam. (Robert Smoley, CEO of MDLiveCare, says the site is expanding its network of doctors and adds, we didn t invent broadband technology...there can be dropped connections. ) Even some virtual doctors themselves seem reluctant to fully commit to 21st-century technology. On SwiftMD, we made an appointment via the Web and said that we were webcam-enabled, but our assigned doctor reached out to us by phone instead something that SwiftMD says many of its customers prefer.
For now, at least, many patients are willing to take the virtual plunge even as digital medicine works out its kinks. Eric Baum, a computer scientist, says he s been a satisfied online customer. But last year, when his 20-year-old son Nathan came down with a 103-degree fever on a Sunday, his call to a digital doctor hit a roadblock because the cell phone pictures Baum sent of Nathan s throat weren t clear enough for a diagnosis. Baum eventually had to dig up the family s high-powered LED flashlight to illuminate Nathan s mouth. Not your typical doctor s visit, Baum says.