In early February, my new patient was a middle-aged woman from here in Silicon Valley with a self-discovered 2 cm right breast mass. Her internist was all over this. She quickly had a core needle biopsy, was evaluated by one of our breast surgeons, and was referred to me for an opinion regarding pre-operative (neo-adjuvant) chemotherapy. I saw her and her husband on one of my non-clinic days to accommodate her schedule. I described the various options available to her — pre-op, post-op chemotherapy, surgery only with its various permutations — and used Adjuvant! Online to illustrate the potential benefits and risks of the various options.
Since we didn't know her lymph node status, and she, like most patients at this stage, was overwhelmed with information, I sent them off for a lymph node ultrasound and needle biopsy of any enlarged nodes. Adjuvant! Online — a regression model of survival and recurrence risk — has various options for tumor size and lymph node status, so I sent her home with several printouts showing a range of predictions. I also asked if they were comfortable communicating electronically, as that would accommodate our schedules best, and should minimally interrupt her family life.
Making it convenient for the patient
Here's where it gets interesting. I have physically seen her thrice since her diagnosis. Most of our communications have been via EPIC's secure email (which we call MyHealth) and by telephone. I called to tell her that the ultrasonographers had determined that her axillary lymph nodes were invisible, and was about to suggest that the Oncotype DX might help her decide which part of the "three percent club" — as my friend Dan Hayes calls it — chemotherapy or hormone therapy she would fit. Before I could make my recommendation, she told me that her social network had told her about Genomic Health, and she wondered if their product would be appropriate. We arranged (unfortunately, I still had to sign several paper-based orders) for her specimen to be shipped across town to their facility in Redwood City, and then we waited.
The following Friday, I received an email that the result was available, I signed on as a "customer" and found her Recurrence Score (RS) was 20 — smack in the middle of the intermediate risk range. The report confirmed the estrogen and progesterone receptor results, as well as the absence of HER2 over amplification, by their PCR methods.
I called her with the result on Friday afternoon, sent the .pdf that I downloaded from the Genomic Health results site to her email account using Stanford's secure email, and arranged to call her back when I finished teaching my two-hour workshop. She agreed, and when I called her back she told me that she was in a car, being driven by one of her friends, and asked that I wait while she conferenced-in her husband. We had a 40-minute, three-way conversation, in which we came up with a plan of action — one which should accommodate her family's vacation plans this summer.
She had a lumpectomy and sentinel lymph node biopsy. Fortunately the tumor was small, was excised with clear margins of resection, and none of the three lymph nodes identified by the sentinel procedure were involved with cancer.
Starting adjuvant chemotherapy
I met my patient again (in-person visit number two) when we planned her chemotherapy after her surgery. We reviewed the risks and benefits, and otherwise went over what to expect. I have seen her once during her thus-far three cycles (of the four planned) and she has been seen other times by my nurse practitioner colleague. She is doing well.
Fortunately, in my current setting — where my primary duties aren’t high-volume clinical care and most of my job is administrative — I have some time to experiment with communication methods.
The initial management illustrates how we can use available informatics tools to maximize decision-making and minimize the time spent waiting in the doctor’s office, and how we are beginning to personalize her care. Our subsequent electronic visits, (or e-visits) as they are sometimes called, have been convenient for me and for her.
It’s important that we have an established patient-physician relationship to make this work, and all parties are comfortable with the technology. Technology use allows me to connect with her at off hours and down time. I can release her laboratory results to her, and respond to simple queries. I cannot push out her pathology and other results of her cancer-related tests to her by California statute (more about that later).
This is the way I've been treated when I am the patient. I can’t help reflecting on my own experience with my new internist. I’ve seen her once to establish care, and then used MyHealth to communicate with asking for prescription refills, lab tests, and other small things. My doc has been very timely and gracious in responding to my requests.
The major flaw I see is the compensation model. Many docs are reluctant to engage in e-visits in the current fee-for-service or productivity model. I’m certain that though it’s convenient, this communication model doesn’t scale well. However, it is mutually convenient, so let’s hope that we can find a way to make it work for patients.
Rakesh Bhutani, MD
Apr, 28 2011 4:56 PM
I am surprised by your last comment about scalability
We do this everyday on large scale at Kaiser -Permannte nationwide
Douglas W. Blayney, MD, FASCO
May, 05 2011 8:55 AM
Kaiser’s integrated care delivery system has done great work on “e-visits” -- using scheduled telephone visits and secure email communications -- as reported in Health Affairs: http://content.healthaffairs.org/content/28/2/323.full In person (face-to-face visits) decreased. “Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.” I mentioned this illustration above, as well as in a previous ASCO Connection post, "EHR and Secure Messaging," http://connection.asco.org/Bloggers/BlogView/tabid/65/aff/34/aft/265/afv...
My sister, who is a Kaiser member, tells me that she loves to receive her test results using e-visits and their patient portal. Similarly, her husband (who is a Kaiser Permanente internist) has time set aside in his day specifically to respond to patient secure email and “e-visits.”
My concerns about scalability are two fold:
1. Since my initial meeting with my patient, we (her surgeon and I) have responded to twenty-five emails in the last three months, in addition to seven telephone calls between office visits. In a busy practice, I question whether this level of effort can be sustained. In a competitive environment, patients will want their questions answered in a timely fashion. There are only so many hours in a day. Kaiser’s integrated delivery system has been successful in converting visits to e-visits in a captive population of employed people who can change providers once per year at open enrollment time. In practice settings with more patient choice, it’s an open question whether physicians and their support team can meet the patients’ needs before they take their business elsewhere.
2. The second scaling-related concern revolves around the computer-literacy and health-literacy of the patient. In a population of employed workers and their dependents, the e-visit system works well, as Kaiser’s experience demonstrates. Effective scaling of the e-visit to patients who are insured by government programs such as Medicare and Medicaid, and the un-insured (which are under-represented in the Kaiser system) is also an open issue.