Physician Electronic Availability and Expectation Creep

Physician Electronic Availability and Expectation Creep

Robert S. Miller, MD, FACP, FASCO

@rsm2800
Aug 28, 2010

Physician blogger Wes Fisher aka Dr. Wes, a cardiac electrophysiologist from North Shore in Evanston, IL, laments the “devaluation” of physician time in a recent blog post When the Doctor’s Always In:

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider's time, for that matter) - we're seeing a powerful force emerge - a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving.

He notes an increasing expectation that physicians will need to review tests results online and respond to patient emails in a time frame that will almost certainly mean that much of this workflow will be shifted to after hours in the office or at home. And for most U.S. physicians, this work is uncompensated as few insurers – and certainly not Medicare and Medicaid at the present – reimburse for any patient-related activities outside of an office or hospital visit.

Dr. Wes also asks the important questions about the impact this expectation creep has on the type of individuals entering medicine:

Increasingly the question becomes - if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation - will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care? For the doctors who accept this choice, what are the risks to patients when they interact with doctors who are "crackberry" addicts without personal or family boundaries? Should our medical students expect that their lives will be surrendered to their patients, free of charge, as they answer the never-ending bounty of health care questions online?

His post engendered a number of interesting comments that can be read on his site, and other physician bloggers chimed in as well. Bryan Vartabedian, a pediatric gastroenterologist from Baylor, who blogs at 33 Charts, echoed some of the same concerns in The Boundaries of Physician Availability, and Rob Lamberts, a primary care internist from Georgia who writes the witty and insightful blog Musings of a Distractible Mind, says that in his practice, despite employing an EHR for 14 years, he simply declines to deliver medical care via email with patients because of the impact on his financial viability. I encourage you to take a look at the post and in particular read the many blog comments from physicians and non-physicians for a flavor of this debate.

This issue resonates with me personally, and I suspect as more of us start using EHR’s and patient portals, this is something we all will have to resolve. As I write this on a Saturday afternoon, I was out of the office for four days this past week, two days to be with my mom who had minor surgery and two days to help my daughter move into her freshman dorm at college, but I was never really “off.” Like most of us, I received my usual dozens of emails (all of which I got in real time on my Blackberry), even though I was “protected” by the MS Outlook Out of Office Assistant. And even though I kept my promise to myself to let my colleagues handle things in my absence (ok, not entirely, since I emailed my NP for two patients since I knew I was the only one who could really answer the question), I didn’t feel particularly “unavailable.” I will spend much of the next two days this weekend reviewing labs and reports, answering emails from patients, generally catching up, and becoming truly available once again.

Of course, patients deserve us to be responsive and available to them, and electronic availability is an entirely reasonable and appropriate expectation. As far back as the IOM Quality Chasm report in 2001, electronic communication between patients and physicians was identified as a means to improve quality of care. More recent evidence from Kaiser has suggested that the use of patient-physician email may have been responsible for improvement in certain HEDIS measures for diabetes and hypertension. Still, electronic communication between doctors and patients is not common. I gave a session on patient-physician email at the ASCO Annual Meeting in 2006, and most of the barriers I cited are still issues today, even though rates of adoption have increased somewhat. The comments on the blog posts above touch on the major points, and the issue of reimbursement is probably the most important. Until our healthcare system moves away from physician reimbursement based exclusively on face-to-face visits and services delivered, the ability to incorporate electronic communication into the patient-physician relationship will be limited.

Even if we fix the reimbursement system – probably with the adoption of some variation on the patient-centered medical home model – the issue of expectation creep on the electronic availability of physicians will likely persist. I’ve seen this in my own career. When I moved from private practice to an academic medical center in 2009, I was grateful for the enhanced electronic access to patient records at Hopkins (even though we don’t yet have a fully-featured EHR). But now I find it is all too easy to spend time at nights and weekends looking up patient test results, responding to emails from patients (even though our system does not set this up as an expectation, since fellows cover our practice at night), and generally staying involved in clinical care. Medicine is hardly the only field where continuous availability is becoming the norm, but we owe it to our patients and ourselves to manage this prospectively and rationally.

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This is my first blog post on the new ASCO Connection site, and I am grateful to ASCO for allowing me to join their stable of bloggers. I started blogging on the ASCO EHR social networking site a few years ago, and some of my posts were migrated to this site as you can see. The ASCO EHR social networking site, which was initially hosted on a third party site, was ASCO’s first experiment with social media, and it was quite a success, with over 800 members participating. I hope to blog here on a semi-regular basis on a variety of oncology and health IT-related topics. I really encourage your comments to my posts and those of the other ASCO bloggers. The best blogs (one of my favorites is here) develop an ecosystem of their own, with a lively community and interaction between bloggers and the people who comment on the posts.  It would be great if that develops on ASCO Connection.

Disclaimer: 

The ideas and opinions expressed on the ASCO Connection Blogs do not necessarily reflect those of ASCO. None of the information posted on ASCOconnection.org is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice on ASCOconnection.org does not constitute an endorsement of any kind by ASCO. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

Comments

L. Michael Glode, MD, FACP, FASCO

Aug, 30 2010 5:44 PM

My good friend Dr. Miller makes great points, especially regarding the "always on call" aspects of email. Having faced the choice on several vacations in recent years of returning to literally a thousand or more emails (many patient related) versus logging on daily and dealing with them, I, too have chosen to keep up on a daily basis. It is unclear to me whether this results in better or worse patient care. However, another issue that deserves watching is the ongoing opposite trend in post-graduate education. Residents and interns are now so restricted in their "allowable hours", that a colleague of mine was called to task because one of his trainees had violated the work hour rules. He was required to send an email each day to the program director documenting the hours spent at home and in the hospital for each of the trainees on his team. However, he stated that it might be better when I am on service later this year, since they might be pulling ALL of the residents off oncology to cover other services as the rules become even more draconian. I guess this means that I will be staying late and coming in early to write all of the notes by myself.... Perhaps Dr. Miller has only begun to scratch the surface of increasing demands.

Jeffrey Kan

Aug, 31 2010 1:40 PM

As Dr. Miller mentions, other industries have faced this issue as technology has become more wide spread. During the record snowstorm this year in DC, many companies here decided to operate as usual - as many of their employees could use VPN or other electronic items to connect. And many of my friends with internet-connected phones are constantly answering emails 24/7. Having said that, most industries do not face possible life or death situations, and people can voluntarily stop the encroachment of work. Having more responsibility and moral expectations, it will be interesting how physicians and other care givers respond to these pressures. Dr. Lambert mentions the possibility of charging for an e-visit. While understandable and potentially inevitable, it also sounds somewhat similar to help desk support line - is that medicine's future?

Robert S. Miller, MD, FACP, FASCO

Sep, 03 2010 5:58 PM

As I implied in my main post, it seems like the expectation of continuous availability is becoming the norm for many industries outside medicine as well. The senior accountant from my former practice was an excellent young woman starting out her career, with a newborn at home, and she would seem never to let more than an hour go by before answering one of my emails, nights and weekends included. I tried to tell her many times that I didn't expect immediate replies, but I think that was an expectation she put on herself, or perhaps our administrator did. I think many companies are remiss in not addressing this prospectively. Particularly in regards to junior staff, I worry that they are being set up for early burnout if they think that just because they get an email from a more senior person at 11:00 pm on a Saturday night, that means it has to be addressed at 11:00 pm. I used to tell my person, "Just because I don't have a social life doesn't mean you shouldn't have one either." As Jeff Kan said in the comments, in clinical care it is a little bit different because the stakes are higher. That is not to say that the physician should be responsible for monitoring his or her email address 24/7, but in larger health systems a web portal could be staffed by advice nurses during the daylight hours and providers at night. When I was in private practice and would cover on weekends, we would get a fair number of calls from patients who were worried about something that they felt just could not wait until Monday. In many cases all they needed was brief reassurance. If we had the infrastructure to deal with some of those problems electronically via email/secure messaging, I bet it would have minimized the number of long rambling phone calls and would probably have made patients more willing to contact us in the first place.

Unfortunately, the reimbursement issue is going to stay a thorny one for physicians when it comes to email or really any type of care delivered outside of the exam room or hospital. If I was a real estate agent, and my pay came from my commission, you better believe I would make it easy for clients to find me after hours. And even if I were a salaried physician, and it was an expectation that some of my work would be done after hours answering patient emails, that would be fine. But if I am a private practice oncologist paid fee for service, and patients started bypassing the office and emailing me to solve problems, even fully recognizing that many problems CAN safely be handled that way, well that is not a sustainable business model for very long. Of course, there are degrees of this, and even in the usual private practice model, physicians deal with patient care issues on the phone and email all the time. But my point is that it could be done in a more equitable way, and that would ultimately be better for patient care.


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