The Emerging Role Of Online Communication Between Patients And Their Provider Steven Katz M.D. M.P.H. Associate Professor Departments of Medicine and Health Management and Policy University of Michigan

Agenda Motivation Motivation Current online landscape Current online landscape Challenges Challenges Early Experiences Early Experiences Prognosis Prognosis

Motivation Patients Patients Frustrated with between-visit access Frustrated with between-visit access Are increasingly connected online Are increasingly connected online Providers Providers Are frustrated with between-visit communication Are frustrated with between-visit communication Current modes are burdensome, fragmented and inefficient Current modes are burdensome, fragmented and inefficient There is enormous mismatch between communication mode and tasks There is enormous mismatch between communication mode and tasks

Why web is right It is asynchronous It is asynchronous It has enormous reach It has enormous reach It is robust It is robust exchange and store information exchange and store information provide services provide services connect people connect people Communication can be tracked, managed, documented, and evaluated Communication can be tracked, managed, documented, and evaluated It is secure It is secure

Great Expectations The Internet will have a profound effect on the practice and business of medicine. Physicians, eager to provide high-quality care and forced by competition to offer online services, will introduce and patient-friendly Web sites to improve administrative services and manage common medical conditions. Patients will identify more health information online and will take more responsibility for their care. The doctor/patient relationship will be altered... The Internet will have a profound effect on the practice and business of medicine. Physicians, eager to provide high-quality care and forced by competition to offer online services, will introduce and patient-friendly Web sites to improve administrative services and manage common medical conditions. Patients will identify more health information online and will take more responsibility for their care. The doctor/patient relationship will be altered... Jerome Kassirer. Health Affairs 2000

Trends in internet use 1 1. UCLA internet report

UCLA Center for Communication Policy, 2003

Digital Divide Source: Pew Internet and American Life Surveys

Message Volume* University of Michigan Primary Care 2002 * weekly patient messages per 100 scheduled visits

Challenges Patients Patients Lack experience Lack experience Digital divide Digital divide Providers Providers Workload Workload Uncertain value of online communication Uncertain value of online communication Little consensus about communication management Little consensus about communication management Organization Organization Business model/ROI Business model/ROI Building and integrating online communication tools Building and integrating online communication tools No road map No road map

Dr. Katz: I am a patient of yours through Yellow Care Network. Generally, I am seen by Dr. Rufus T. Firefly but I have not been able to contact him nor have I been able to get an appointment to see any doctor in the Internal Medicine clinic. When I called I was simply told there were no available appointment times. I am currently experiencing intense pain when I urinate as a result of a bladder infection and would very much like to get a antibiotic to start treating this. The symptoms are constant urge to urinate and painful urination followed by blood in my urine at the end of the urination. Can you please facilitate an appointment to see a doctor in your staff or prescribe an antibiotic. I am not taking any other medicines at this time.

various news: 1) referral to Diabetes Clinic DOES NOT SHOW UP on their records yet (as of Friday 01/09)... was seeing Dr. Sugar 2) Am re-enrolled in Stop Smoking Program (she'll use your old referral) but WILL NEED anti-depressant script soon 3) scripts for imdur (120mg & 30mg) WORKED at pharmacy... 4) referral to Eye Clinic OK... appointment set 5) referral to Cardiology Clinic OK... Dr. Heart said "...see you in a year..." and "...are 95th percentile of her patients (for exercise level, walking 3-5 miles /day)". Walked 11 miles last Monday=01/12 6) next apptmt with you(??) 04/02 Thank You

Components of a patient portal Service-related features Service-related features Medication renewals, scheduling, forms, registration/billing Medication renewals, scheduling, forms, registration/billing A clinical communication tool A clinical communication tool Secure messaging Secure messaging A patient health record A patient health record Populated from provider and patient data sources Populated from provider and patient data sources Medical record Medical record Patient: current meds, immunizations, health status information (e.g. blood sugar or blood pressure log) Patient: current meds, immunizations, health status information (e.g. blood sugar or blood pressure log)

Yellow brick road Develop business model Develop business model Build or buy communication tools Build or buy communication tools Develop roll-out strategy Develop roll-out strategy Map relationships and workflow Map relationships and workflow Develop rules of engagement and exchange Develop rules of engagement and exchange Develop education and promotion strategy Develop education and promotion strategy Allocate provider effort during rollout Allocate provider effort during rollout Evaluate processes and outcomes Evaluate processes and outcomes

Emerald Cities

Start-up Experiences Patient uptake is slow Patient uptake is slow Patient online gap Patient online gap Resource offsets are uncertain Resource offsets are uncertain Clinician and staff acceptance is high Clinician and staff acceptance is high “Cultural Divide” between patients and their clinicians “Cultural Divide” between patients and their clinicians

Patient 1 and physician attitudes towards role of clinic staff in e-communication Patients: “ OK for clinic staff to handle my [ /Web] messages for my physician” Physicians: “OK for the clinic staff to handle patient [ /Web] messages for me” 1. Patients who reported regular use of

% Preferring Mode Physicians Patients Cholesteroltest Anxiety orsadness Rx sideeffect Back pain AbnormalPap/PSA Breast ortesticular Sore throat Normal PapPSA test

Prognosis: Good Patient facility and access is growing Patient facility and access is growing increase in broadband access increase in broadband access Better online communication tools Better online communication tools Better clinical data systems Better clinical data systems Beginning of the “J curve” Beginning of the “J curve” Uncertain business model Uncertain business model