1. E-HEALTH@YOURPROVIDER.COM IMPLICATIONS FOR COST, QUALITY, AND ACCESS TO HEALTHCARE SHANNON C. SCOTT, DO HEALTH POLICY FELLOWSHIP 2012-2013 OSTEOPATHIC FAMILY PHYSICIAN

2. Patient Access The public wants access to e-health technology and the ability to communicate with their physicians via email. 2012 Harris Interactive Poll (n= 2,311)

3. E-Health Challenges Cost of health information technology (HIT) Work load changes Reimbursement State licensing requirements Quality of care issues Safety and security of transmitted information

4. What is E-Health? Over 50 different definitions – Creates health policy confusion Umbrella Term – Telemedicine – Telehealth – E-mail Synchronous (real-time) video, audio Asynchronous (delayed-time) e-mail, text msg

5. Electronic Health Records By 2012, 72% of physicians have an EHR 7% use email to communicate with patients EHR Costs: Implementation and maintenance Meaningful Use incentive programs assist but do not reimburse. As high as $80,000 over four years per provider Meaningful Use Stage 2 - Jan 2014 Requires “providers to use secure e-mail with patients” to qualify for incentive payments

6. Reimbursement of E-health Limited in both private and federal programs In some states Medicaid pays for Telemedicine Private payer CPT 99444 exists – Many limitations to use of code Cost of health IT ≠ reimbursement

7. State Medical Licensing Issues Policies differ among states regarding e-health Full license required to practice electronically – Limited to the state where the patient lives Unintended consequences – Expensive and time consuming to obtain multiple state licenses – Decreased access to care – Proposal of national medical license

8. Security Increased physician and patient risk when using e- health on unencrypted sites. Un-secure Messages – Manipulated – Forwarded – Read by unintended recipients – Contain protected health information (PHI)

9. Three Pilot Projects Group Health Cooperative 2003 “Shared Health Record” Online medical records Secure email messaging 235,000 (54%) of eligible adults accessed services 1,055 physicians engaged 23% of their encounters now occur via secure messaging Replaced 27% of office visits and 66% of telephone calls Kaiser Permanente Experience 2004-2010 “Suite” online services 2.3 million (64%) members enrolled by 2010 7,000 physicians had received over 5.8 million secure messages 35,423 patients who used secure messaging had a reduction in office visits and an increase in health quality outcomes Virtuwell/ HealthPartners Minnesota and Wisconsin 2010 Online health care service Medicare coverage Accessed by 40,000 patients Visits screened by nurse practitioners via protocol $88 savings per visit In-person office visits were displaced by 90% 94% patients satisfied

10. Pilot Project Feedback Critical to the success of each program included attention to provider work flow, reimbursement, and organization of the information transmitted electronically. Access Quality Cost

11. Recommendations: Payment Reform Traditional fee-for-service will not support e-health. Develop e-health business models for private insurers. Overhaul federal e-health incentive programs. – The MU program designed to run through 2016 should be lengthened instead of assessing penalties.

12. Recommendations: State Medical Licensing Develop uniform licensure rules among all states. State medical licensing boards retain control of all licensing fees and disciplinary regulation. Integrate all medical licensure into a national database. Establish clear definitions among electronic health subsystems for policy making groups. Prevent telemedicine or e-health from being singled out as a medical specialty or granted special license.

13. Recommendations: Security Secure confidential information through a patient portal. – Adhere to HIPPA and AMA medico-legal guidelines. National policy making groups collaborate regarding security. Educate physicians through CME on E-health best practices. – Recommend clear practice policies regarding: Message response times The amount of information transmitted electronically Types of conditions treated with e-health technology

14. Well-designed e-health systems have the potential to increase physician efficiency, patient engagement, and health outcomes. The full potential of e-health is yet to be understood; virtually every patient could be touched by this innovation.

15. Bibliography Harris Interactive Poll. (2012). Patient Choice an Increasingly Important Factor in the Age of the "Healthcare Consumer". Accessed May 24, 2013, from Harris Interactive News Room: http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/1074/ctl/ReadCustom%20Default/Defaul t.aspx http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/1074/ctl/ReadCustom%20Default/Defaul t.aspx Dixon, R. Enhancing Primary Care Through Online Communication. Health Affairs, 2010; 29(7), 1364-1369. American College of Physicians. (2008). Center for Practice Improvement and Innovation: Communicating with Patients Electronically (Via Telephone, Email, & Web Sites). Accessed May, 2013, from: http://www.acponline.org/running_practice/technology/comm_electronic.pdf http://www.acponline.org/running_practice/technology/comm_electronic.pdf Schroeder, S., & Frist, W. Phasing Out Fee-for-Service Payment. New England Journal of Medicine, 2013; (368) 2029-2032. Health Policy Institute of Ohio. (2013). Looking Ahead: Understanding Telehealth in Ohio. Accessed June 2013, from Health Policy Institute of Ohio: http://a5e8c023c8899218225edfa4b02e4d9734e01a28.gripelements.com/pdf/publications/hpio_telehealth_brief.pdf http://a5e8c023c8899218225edfa4b02e4d9734e01a28.gripelements.com/pdf/publications/hpio_telehealth_brief.pdf Kittler, A., et. al. Primary care physician attitudes towards using a secure web-based portal designed to facilitate electronic communication with patients. Informatics in Primary Care, 2004; (12) 129-138. Boukus, E., et al. Physicians Slow to E-mail Routinely with Patients. Health System Change, 2010. Accessed June 2013, from: http://www.hschange.com/CONTENT/1156/ http://www.hschange.com/CONTENT/1156/ American Medical Association. (2010). Report of the Council on Medical Service- Payment for Electronic Communication. Accessed June 2013, from American Medical Association: http://www.ama-assn.org/resources/doc/cms/a10-cms-rpt-1.pdfhttp://www.ama-assn.org/resources/doc/cms/a10-cms-rpt-1.pdf American College of Physicians. (2008). Position Paper: E-Health and Its Impact on Medical Practice. Accessed May 24, 2013, from: http://www.acponline.org/acp_policy/policies/ehealth_impact_medical_practices_2008.pdf http://www.acponline.org/acp_policy/policies/ehealth_impact_medical_practices_2008.pdf

16. Bibliography, cont. Federation of State Medical Boards. (2012). Telemedicine Overview Board-by-Board Approach. Accessed June 2013, from Federation of State Medical Boards: http://www.fsmb.org/pdf/grpol_telemedicine_licensure.pdfhttp://www.fsmb.org/pdf/grpol_telemedicine_licensure.pdf Courneya, P., et al. HealthPartner's ONline Clinic For Simple Conditions Delivers Savings of $88 Per Episode and High Patient Approval. Health Affairs, 2013; 32(2), 385-392. Rowthorn, V. White Paper: Legal Impediments to the Diffusion of Telemedicine. Journal of Health Care Law and Policy, 2011; Volume 14, pages 1-24. Federation of State Medical Boards. (2011). Telemedicine Conference: Balancing Access, Safety and Quality in a New Era of Telemedicine. Washington DC: Federation of State Medical Boards. Accessed June, 2013 from: http://www.fsmb.org/pdf/pub-symposium-telemed.pdf http://www.fsmb.org/pdf/pub-symposium-telemed.pdf Zhou, Y., et al. Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients. Health Affairs, 2010; 29(7), 1370-1375 Baer, D. Patient-Physician E-Mail Communication: The Kaiser Permanente Experience. Journal of Oncology Practice, 2011; 7(4), 230-233. LeRouge, C., et al. The Business of Telemedicine: Strategy Primer. Telemedicine and e-Health, 2010; 16(8), 898-909.