Unseen and online: What are the limits for patient care?

Having clinicians diagnose and treat patients over the Internet, without their ever having seen those patients in person, is making a comeback.

In the early 2000s, a state medical board shut down one attempt to make such online care legitimate. But today, in an age of greater comfort with telemedicine and delivering care over the Internet, the strategy is getting a closer look, as health leaders try to find ways to reduce costs and help expand patient access. Regulations generally don’t declare explicitly that treatment of previously unknown patients over the Internet is wrong. This provides an opening for an activity once associated mostly with online pill mills to be embraced by mainstream medicine.

Patrick Courneya, MD, a family physician and medical director of the health plan for the Minnesota-based hospital system and insurer HealthPartners, is not merely a supporter of the idea of treating simple cases online by having patients fill out questionnaires and having those documents reviewed by clinicians. His organization started a company, Virtuwell, to do just that, using nonphysician clinicians.

In the February issue of Health Affairs, HealthPartners executives got a chance to state their case for Virtuwell, which uses nurse practitioners to make clinical decisions, including writing prescriptions, for about 40 conditions, such as colds, flu, allergies, urinary tract infections, acne and some sexually transmitted diseases. The executives, including Dr. Courneya, wrote that, based on HealthPartners claims data, Virtuwell reduced costs by $88.03 per case compared with care in traditional physician office settings. It costs $40 for a Virtuwell interaction, which can be covered by insurance.

Ninety percent of Virtuwell interactions were made in place of in-person visits, with users reporting that they saved 2.5 hours per visit. Virtuwell has treated 40,000 site users. An additional 56,000 were referred for in-office visits, because their symptoms were beyond the scope of the company’s services. The company’s business is mostly in Minnesota, although it also is available to patients in Michigan and Wisconsin.

HealthPartners’ report did not get into clinicians’ comfort with the concept of online care delivery. But “we observe anecdotally that physicians in HealthPartners are generally supportive of Virtuwell, at least in part because physicians helped create it and continue to participate in its operation.”

HealthPartners isn’t the only company treating patients online without seeing them. Another Minnesota-based company, Zipnosis, has physician assistants or nurse practitioners available for online treatment and prescriptions for patients in 12 states: Alaska, Colorado, Connecticut, Illinois, Kentucky, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Washington and Wisconsin.

The use of nonphysician clinicians is intentional. Virtuwell says that’s in part what makes its system so much less expensive than an office visit — and a help for doctors.

“If you ask primary care physicians, ‘Do you have enough to fill your day?’ they will say they have more than enough,” Dr. Courneya said. “We [as primary care physicians] have gotten beyond looking forward to that ear infection to break up the day. We have a lot more complex cases. I want to use my skills to the highest and best use. I want to use my time for more serious challenges and let someone else take care of the other stuff.”

The definition of “seeing” patients

In 2002, the Illinois Dept. of Professional Regulation ordered that physicians not be allowed to treat patients online through a venture owned by drug company Roche Diagnostics called MyDoc.com. The company offered consultations with board-certified primary care doctors in Indiana and Illinois for patients who filled out questionnaires online. Like Virtuwell and Zipnosis, MyDoc.com was designed for people seeking treatment for “simple” conditions. Soon after the medical board order, Roche sold MyDoc.com, which quickly ceased to exist.

When Illinois made its pronouncement, it didn’t have a rule stating explicitly that online care was illegal — and it doesn’t have that today. Telehealth is allowed in all 50 states in some form, said Gary Capistrant, senior director of public policy at the American Telemedicine Assn.

All states require physicians, nurse practitioners and physician assistants to be licensed in their home states and the states in which they treat patients. But from there, states have a wide variety of rules governing online care — or have no regulations at all. Illinois made its original ruling on MyDoc.com based on other parts of state law. Meanwhile, the state has allowed Zipnosis to operate.

The policy of the Federation of State Medical Boards states that physicians who engage in telemedicine are expected to have access to patients’ exam evaluations, said Lisa Robin, the federation’s chief advocacy officer. These evaluations don’t need to be performed by these physicians, and patients answering questions about their medical histories online would not count as acceptable evaluations, she said. But FSMB policy does not always translate into state regulation, Robin added.

Some states require there to be prior relationships with physicians and other clinicians or that doctors have access to patients’ medical records before treatment. And there are other rules that allow online care but essentially require an in-person follow-up. For example, Texas says health care clinicians treating patients online can’t prescribe more than three days of medication unless there has been a previous relationship. Or states could disallow online care based on interpretations of other rules, as Illinois did.

Other states have few restrictions. For instance, Wisconsin laws and medical examining rules don’t address telemedicine, said Jeff Weigand, legislative liaison at the Wisconsin Dept. of Safety and Professional Services. In Michigan, physicians can practice telemedicine as long as they are licensed in the state, said Jeannie Vogel, a spokeswoman for the Michigan Dept. of Licensing and Regulatory Affairs.

So far, states have accepted setups in which a physician “sees” a patient via a video screen. Individual insurance companies have systems in which doctors are paid to see any member through an online video link. Some plans allow physicians to see their established patients during off hours through a similar hookup. Cleveland Clinic offers a second opinion service in which patients can send their medical records online and have them reviewed by one of its doctors. TelaDoc is a company with doctors in all 50 states who will do phone- or Internet-based care, although it requires patients to buy a membership and create an electronic health record that physicians can review. It also has added video consultations.

Where does that leave doctors?

As there’s more acceptance of online technology, it’s being viewed as a more cost-effective way to treat a certain subset of patients, said Capistrant, of the American Telemedicine Assn. He said most patients who use telehealth services fall into two categories: uninsured, young, transient people who don’t have chronic health problems, and patients who live in remote locations where physicians are in short supply.

In Minnesota, where Virtuwell and Zipnosis are based, the state medical society is not lining up behind the idea of treating patients through online questionnaires.

Marilyn Peitso, MD, a board member of the Minnesota Medical Assn., said physicians and nurse practitioners shouldn’t engage in telemedicine in any form unless they have access to patients’ medical records, even for what seems like an uncomplicated issue.

“These simple problems aren’t always so simple,” she said.

In 2003, the American Medical Association House of Delegates passed policy regarding online care. It didn’t explicitly forbid teleheath services, but did attach a number of conditions for anyone considering implementing them. The policy reads: “The provision of diagnostic or therapeutic services through interactive online sites, including advice to online users with whom the physician does not have a pre-existing relationship or the use of decision-support programs that generate personalized information directly transmitted to users, should be consistent with general and specialty-specific standards. General standards include truthfulness, protection of privacy, principles of informed consent, and disclosures such as limitations inherent in the technology.”

At the 2012 Annual Meeting, a resolution asked the AMA to urge the U.S. Dept. of Health and Human Services to review telehealth initiatives being implemented by insurance carriers and others. The resolution requested that HHS assure that proper standards of care are maintained, and that the agency give regulatory guidance regarding the “essential requirements of Web-based telehealth technology and health care initiatives, and the requirements of physicians and health care providers who engage in the delivery of such services.”

Based on the wide variety of testimony on the 2012 resolution, the AMA house referred it for further study. A report on telehealth initiatives is expected to be presented at the Association’s Annual Meeting in June.

Whatever happens, Virtuwell expects that its model is here to stay. “We are going in a direction where we want accountable care organizations and better support for people with complex medical needs,” said Kevin Palattao, vice president of clinic patient care systems at HealthPartners and vice president of Virtuwell. “A physician who is treating a simple bladder infection is not working at the top of his license.”