Medicine on the Net: If not now, when?

Next week I'm off to Toronto, Canada, to make a keynote address at the 11th World Congress on Internet in Medicine.  The Congress is being coordinated by the Centre for Global eHealth Innovation in Toronto and brings together several prestigious groups including the Society for the Internet in Medicine (SIM), the International Society for Research on Internet Interventions, and the WATI group (Web-Assisted Tobacco Interventions).  It promises to be a very informative event and an opportunity to network with colleagues from around the world on a topic that is near and dear to my heart.

More than a decade ago, I co-founded a company that did some pioneering work to improve communication and collaboration between community physicians and their patients using the Internet.  The solution we developed provided a trusted source of healthcare information, secure physician-patient messaging, scheduled audio-video "virtual visits" between physicians and their patients, and a business model to reimburse physicians for e-mail and virtual visit services with their patients via the Web.

Back then, some of the technology we used in building our solution was rather new, unproven, and a bit clunky.   Building a similar system today would be far less daunting.  Of course, it turns out that technology really isn't the issue.  Today, we could be delivering all kinds of healthcare information and medical services to people in their homes and offices using readily available, and now proven, web-based technologies.  The concerns that prevent more widespread adoption of Internet medicine are much more about legal, regulatory and reimbursements issues than anything technical. 

When you consider that somewhere between 25 and 40 percent of all primary care visits could be augmented or replaced with information and services provided on the Net, one might wonder why we don't see more of this?  Lack of reimbursement is likely the primary barrier.  Although some good work has been done by
RelayHealth, progressive employers and innovative insurers, by and large most physicians cannot get reimbursed by private health insurers or government for providing cognitive services to patients in venues other than face to face in a clinic or hospital setting.  If you are a physician and time is all you have to "sell", it's no wonder you won't waste time corresponding with patients via e-mail or tele-visits if you're not going to get paid.  However, one need only look at progressive healthcare organizations such as Group Health Cooperative in Seattle or the University of Pittsburg Medical Center to see how a well-planned and carefully implemented e-health strategy yields improved patient and provider satisfaction, greater efficiency, and a positive return on investment.

I hope very soon, the barriers will come down and providers who wish to provide e-health services to their patients can be rewarded for doing so.  I hope government will conclude that the provision of health information and certain kinds of medical services via the Web is not only reimbursable, but absolutely a cornerstone of modern healthcare delivery.  Only then will we see the rise of an Internet-enabled, global healthcare delivery system reaching its full potential. 

Bill Crounse, MD       Healthcare Industry Director    
Microsoft Corporation

Comments (3)
  1. In the VIP panel in at the conference:

    Robert Pretlow mentioned that an assistant to Rep. Jim McDermott:

    told him that it was illegal under Medicare to charge extra for email.  He was told that the Medicare fee for an office visit included all subsequent communications.

    Is this restriction as clear-cut as it was made to sound?  If true, does this disincentive to communication mean that people over 65 are relegated to have less communication with their doctors that those under 65?

  2. Jesse Kerns, senior legislative assistant for Congressman Jim McDermott ( ) confirms that indeed it is illegal for a physician to charge a Medicare eligible patient for email interaction, even if the patient agrees to the charge in advance.  Email interaction is considered as follow-up to an office visit, in the same category as telephone communication.  Reimbursement for all subsequent communications is included in Medicare payment for the office visit.  A physician may not charge additionally for a Medicare reimbursed service, per the "Ban on Balanced Billing".  Thus, even though a patient may enjoy the convenience of email communication with his/her physician, once the patient reaches age 65, the patient may no longer take advantage of this type of communication.  Mr. Kerns was not aware of this age inequity and acknowledges that it raises "a very interesting issue", and that email interaction could save time and offer convenience for all concerned.

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