Elaine Zablocki


One of Christopher Crow’s patients was in Miami, about to leave on a week-long cruise, when his prostatitis flared up again. “He e-mailed me from his hotel room to ask for a prescription,” recalls Crow, whose Web site features secure e-mail messaging. “All he had to do was locate the closest drug store and pick up his medicine the next day. Imagine how difficult it would have been for him, trying to get an appointment with a doctor in a strange city before his ship sailed.” 

Crow practices at Village Health Partners in Plano, Texas. Crow says that the three-physician practice’s Web site, 

, attracts new patients and helps make the practice far more efficient. 

The same goes for the Office of Orthopaedic Medicine and Surgery, a three-physician practice in Washington, D.C. As patients leave after an appointment, they are handed cards with the practice’s Web address (

) printed on the front and their diagnosis written on the back. 

“We’ve just upgraded our Web site,” says Latisha Harrison, the practice’s marketing director. “Now it’s more interactive, and patients can submit forms to us online. We also added an educational guide so now our patients can look up reliable information about their specific condition. Our doctors were really, really adamant about including that feature in the upgrade.” 

These physicians are among the early adopters of Web-based technologies for medical practices, although many more are likely to soon follow their example. In today’s wired world, patients want the same level of service online from their physicians that they already routinely receive from companies selling them books, music, and camping gear. 

“Absolutely everyone should have a practice Web site,” says practice management consultant Judy Capko. “It’s a very reasonable investment, and it makes you more visible, not only to your existing patients, but also to people who are searching for a new physician in the area.” 

About three-quarters of U.S. adults would like to schedule their doctor visits via the Internet, and they’d also appreciate e-mail reminders from their doctors, according to a recent 

But only a small minority of medical practices offers such services, resulting in a paltry 4 percent of patients using them. Moreover, roughly two-thirds of patients would like to receive their lab results via e-mail, but only 2 percent currently do. 

It’s becoming increasingly apparent that the practices that invest in Web-based IT offerings will carry an advantage in the healthcare delivery marketplace. 

Some practice Web sites provide basic information about the practice, including short biographies of each physician, directions to the office, and forms patients can download and complete at home before arriving for scheduled visits. Other sites boast more sophisticated features, such as Crow’s secure e-mail and gastroenterologist Patricia Raymond’s Web movies.

), they find personalized videos available for viewing. Raymond, a solo practitioner in Chesapeake, Va., meets about two-thirds of her patients for the first time when they arrive for procedures. “The videos show me chatting in my living room, answering their most common questions,” explains Raymond. “My patients love them, and the Web site has streamlined, getting new patients in for their colonoscopies.” 

The specific mix of features your Web site should incorporate depends on the nature of your individual practice. A primary-care practice in which new patients are seeking long-term relationships with a physician should probably use its Internet presence to introduce its physicians and share some personal information about them. A specialty practice such as gastroenterology should focus more on the specific procedures it performs. Most physician practices start out with a basic Web site and then add new features over time as they perceive demand for them. 

One way to think about your Web site is to envision it in three developing stages, says Bruce Kleaveland, president of Kleaveland Consulting in Seattle. In the first stage, you offer a basic introduction to your practice. Then, as you expand the site and enter the second stage, you add administrative functions such as giving patients the ability to make appointments, pre-register, and complete downloadable forms. The third stage involves incorporating clinical interactions with patients, such as prescription refill requests and access to secure e-mail communication between physicians and patients. 


At this stage, you’ll be handling sensitive patient information, and so you must ensure your site is secure. To do so, employ the services of a company that offers encrypted e-mail messaging. When these companies receive a message from you, they then send e-mail messages to your patients. To access the messages, patients must have user names and passwords. These sites afford the same level of security as do financial services Web sites, such as banks. 

At this point, you may also want to set up a process to handle online clinical requests. If your practice has linked an EMR to your Web site, you can automatically call up a patient’s record, which you can view in conjunction with the request. 

In this case, responding to patients is so easy, physicians can do so with just a few clicks of a mouse. Paper-based practices that agree to field online requests may have to assign a nurse to screen and respond to basic clinical questions such as prescription refills and lab results. The nurse can forward more complex requests to a physician. 

The Web site for PeaceHealth Medical Group (PHMG), a 120-physician group in Eugene, Ore., exemplifies the sophisticated features a large practice can offer its patient base. This secure Web site (

) is available only to patients who have received a personal password. It gives patients the capability to schedule, reschedule, and cancel appointments; view and download lab results from current and previous visits; and exchange secure e-mail messages with their physicians. 

Bill Moshofsky, a family physician with PHMG, particularly appreciates his practice’s secure e-mail service. “Whenever I have two minutes between patients, I can just sit down and send off a couple of responses, and I couldn’t place a phone call in such a short time,” he says. “One of the things that’s kind of nice about e-mail is, you just send out the information and you’re done.” 

PHMG also hosts a site for the general public. Potential patients can search its Healthwise database for information about specific symptoms. Visitors can also use the site’s “ask-an-expert” function to submit their healthcare-related questions and view previously posted responses. PHMG has found this community service to be an effective way to attract new patients. 

Within the next year, PHMG is expanding its Web site to enable it to send personalized reminders to patients, telling them when it’s time to schedule a physical exam, a mammogram, or similar preventive services. The group is also planning to send personalized electronic newsletters to targeted patients with an interest in specific conditions; these newsletters will be available to nonpatient community members as well as established patients. 

In the future, PHMG hopes to link data from their patients’ home monitoring systems directly into their electronic medical records so that staff can keep a close eye on variables such as blood pressure and glucose levels for the chronically ill. The practice is also considering giving patients Web access to their personal health records. “For example, if a patient wanted to report that they’re cutting pills in half, or taking them every other day, this would give them an avenue for those comments,” says Chuck Broch, PeaceHealth’s systems analyst. 

Part of the reason PHMG can do all this is because it participates in a three-state healthcare IT collaboration. But smaller practices can also develop Web sites with similarly, advanced features, using sophisticated software and Web designers who specialize in helping physician practices. 

For example, one physician at Village Health Partners with a special interest in information technology supervises the practice’s Web site, while the others chime in with suggestions and comments on future directions. The practice uses software to link its EMR to a secure e-mail service, so physicians can respond to patient e-mail requests quickly and safely. 

The Office of Orthopaedic Medicine and Surgery called on iHealthSpot to create its new Web site. That company grew out of a partnership between a patient with a broken leg and a surgeon with an interest in Web technology. Today, iHealthSpot specializes in Web site design for small physician practices, also offering secure e-mail hosting, patient education materials, search engine optimization, and nightly backups. Its most complete package will set you back roughly $3,000. 

Clearly, patients value being able to easily access their physicians and take care of personal healthcare tasks via the Internet. And the physicians who understand this enjoy the enhanced efficiency highly developed practice Web sites can bring. But it’s difficult to quantify exactly how much time a well-run, multifunctional Web site can save the average practice. Simply posting your address, map, and directions on your site likely saves some phone time for your front-office staff - but exactly how much time? 

Village Health Partners can give you an idea: Named 

, this group is on the cutting edge of Web-based technology, with a seamlessly integrated EMR and secure e-mail messaging. “The national average for staff in a primary-care practice is just under five employees per physician,” says Crow. “We need less than 2.5 employees per physician.” 


When Crow arrives at work in the morning, lab results from yesterday’s patients are in their respective electronic charts. “I review them and then click a few times to e-mail those patients that their results are waiting on our Web site. The work flow takes seconds,” he says. “Compared to the old system with paper charts and lab reports, where you handed the chart to a nurse who sent the information to the patient … you are probably saving $5 or $6 each time you send out lab results.” 

is a writer who has focused on healthcare issues for more than 20 years. She is the editor of

and she contributes to many other healthcare publications. She can be reached via 

This article originally appeared in the May 2007 issue of Physicians Practice.

Articles

An effective Web presence can be a boon to your practice and your bottom line, and a great help to your patients. Here’s how to get started.

Web Surfing: If You Build It …

Crow practices at Family Medical Specialists of Texas (FMST) in Plano, a Dallas suburb. Crow says that the three-physician practice’s Web site, 

) printed on the front and their diagnosis written on the back. “We’ve just upgraded our Web site,” explains Latisha Harrison, the practice’s marketing director. “Now it’s more interactive, and patients can submit forms to us online. We also added an educational guide so now our patients can look up reliable information about their specific condition. Our doctors were really, really adamant about including that feature in the upgrade.”

These physicians are among the early adopters of Web-based technologies for medical practices, although many more are likely to follow their example. In today’s wired world, patients want the same level of service online from their physicians that they already routinely receive from companies selling them books, music, and camping gear. 

About three-quarters of U.S. adults would like to schedule their doctor visits via the Internet, and they’d appreciate e-mail reminders from their doctors, according to a recent 

/Harris Interactive poll. But only a tiny minority of medical practices offer such services, resulting in a paltry 4 percent of patients using them. Moreover, roughly two-thirds of patients would like to receive their lab results via e-mail, but only 2 percent currently do. It’s becoming increasingly apparent that the practices that invest in these IT offerings will be at an advantage in the healthcare delivery marketplace. 

Some practice Web sites present basic information about the practice, including short biographies of each physician, directions to the office, and forms patients can download and complete at home before arriving for scheduled visits. Other sites boast more sophisticated features, such as Crow’s secure e-mail and gastroenterologist Patricia Raymond’s Web movies.

), they find personalized videos available for viewing. Raymond, a solo practitioner in Chesapeake, Va., meets about two-thirds of her patients for the first time when they arrive for procedures. “The videos show me chatting in my living room, answering their most common questions,” explains Raymond. “My patients love them, and the Web site has streamlined getting new patients in for their colonoscopies.” 

At this stage, you’ll be handling sensitive patient information, and so you must ensure your site is secure. To do so, employ the services of a company that offers encrypted e-mail messaging. When these companies receive a message from you, they then send e-mail messages to your patients. To access the messages, patients must have user names and passwords. These sites afford the same level of security as do financial services Web sites, such as banks. 

At this point, you may also want to set up a process to handle online clinical requests. If your practice has linked an EMR to your Web site, you can automatically call up a patient’s record, which you can view in conjunction with the request. In this case, responding to patients is so easy, physicians can do so with just a few clicks of a mouse. Paper-based practices that agree to field online requests may have to assign a nurse to screen and respond to basic clinical questions such as prescription refills and lab results. The nurse can forward more complex requests to a physician. 


Bill Moshofsky, a PHMG family physician, particularly appreciates his practice’s secure e-mail service. “Whenever I have two minutes between patients, I can just sit down and send off a couple of responses, and I couldn’t place a phone call in such a short time,” he says. “One of the things that’s kind of nice about e-mail is, you just send out the information and you’re done.” 

PHMG also hosts a site for the general public. Potential patients can search its Healthwise database for information about their specific symptoms. Visitors can also use the site’s “ask-an-expert” function to send in their healthcare-related questions and view previously posted responses. PHMG has found this community service to be an effective way to attract new patients. 

In the future, PHMG hopes to link data from their patients’ home monitoring systems directly into their electronic medical records, so that staff can keep a close eye on variables such as blood pressure and glucose levels for the chronically ill. The practice is also considering giving patients Web access to their personal health records. “For example, if a patient wanted to report that they’re cutting pills in half, or taking them every other day, this would give them an avenue for those comments,” says Chuck Broch, PeaceHealth’s systems analyst. 

Part of the reason PHMG can do all this is because it participates in a three-state healthcare IT collaboration. But smaller practices can also develop Web sites with similar advanced features using sophisticated software and Web designers who specialize in physician practices. 

For example, one physician at FMST with a special interest in information technology supervises the practice’s Web site, while the others chime in with suggestions and comments on future directions. The practice uses software to link its EMR to its secure e-mail service, so physicians can respond to patient e-mail requests quickly and safely. 

Clearly, patients value being able to easily access their physicians and take care of personal healthcare tasks via the Internet. Physicians also enjoy the enhanced efficiency highly developed practice Web sites can bring. But it’s difficult to quantify exactly how much time a well-run, multifunctional Web site can save the average practice. Simply posting your address, map, and directions on your site must save phone time for front-office staff - but exactly how much time? 

FMST can give you an idea: Named Practice of the Year in 2006 by 

, this group is on the technological cutting edge, with a seamlessly integrated EMR and secure e-mail messaging. “The national average for staff in a primary-care practice is just under five employees per physician,” says Crow. “We need less than 2.5 employees per physician.” 

When Crow arrives at work in the morning, lab results from yesterday’s patients are in their respective electronic charts. “I review them and then click a few times to e-mail those patients that their results are waiting on our Web site. The work flow takes seconds,” he says. “Compared to the old system with paper charts and lab reports, where you handed the chart to a nurse who sent the information to the patient … you are probably saving $5 or $6 each time you send out lab results.” 

is a writer who has focused on healthcare issues for more than 20 years. She is the editor of 

, and she contributes to many other healthcare publications. She can be reached via 

This article originally appeared in the May 2007 issue of

It’s not as hard as you think to “wow” patients with a sophisticated Web site. And doing so can make life easier on you, too.

Communication: If You Build It …


So after months of searching, you've purchased and installed your new EMR. Congratulations: if all goes as it should, your practice will soon be saving time and money while improving the level of care you provide patients. Your staff, physicians, and patients will be happier once you're up to speed, and you're now in a much better position to demonstrate your clinical excellence and patient satisfaction in negotiating payer contracts and navigating the world of "pay for performance." 

But selecting and installing an EMR is just the first step in a major process that will transform the workflow within your office. You can't just flip a switch and expect the transition to take care of itself. Taking the time to visualize all the essential implementation steps will lead to a smooth, successful conversion. 

The first essential step is gaining physician support. If some, or even one, of your physicians remains firmly resistant to change, it could seriously damage your ability to move the rest of the practice onto the system efficiently. 

"Present this to your doctors as a quality project," says Joel Diamond, a family practice physician in Pittsburgh. "Don't focus on the technology; focus on the ways [an] EMR helps us practice better medicine. For example, it helps us identify people who need smoking cessation counseling or pneumonia vaccinations, and this information will become increasingly significant in a pay-for-performance world." 

Next, consider the varying personality traits and technical abilities of the physicians in your group. Some physicians can't type; for them, alternative ways to enter information into the computer, such as voice recognition software, will be extremely important. 

Some physicians prefer standardized templates for common health conditions, so they can enter data for a typical patient with just a few clicks. Others prefer to work with a trained assistant who sits at the computer and enters data during the patient encounter. "The larger your group, the more diversity there is among your physicians, and that increases your need for flexible, customizable software," says Rodney P. Lusk, MD, director of the Ear, Nose & Throat Institute at Boys Town National Research Hospital, in Omaha, Neb. 

Have realistic expectations for the implementation process. It's not as straightforward as buying Microsoft Word and installing it on your computer, says Ronald B. Kuppersmith, an otolaryngologist in private practice at Texas ENT and Allergy, in College Station. A couple of years ago Kuppersmith's practice was working with separate vendors for a practice management system and an EMR. "They gave us conflicting advice about the hardware we needed. In the end, it came down to a judgment call," he says. "Someone from the practice has to be thoroughly involved in the process. All our vendors were really helpful, but you can't let them take over." 
Once you've chosen your vendor, software, and hardware, budget time and energy for an intensive period of preparation. eClinical Works, of Westborough, Mass., a well-known supplier of EMR and practice management software, sends its clients a 12-week timeline listing all the essential steps between signing the formal contract and the "go-live" date. 

During this preparatory phase, all physicians and employees should have a chance to become familiar with the software. Many vendors supply audiovisual training materials, so employees and physicians can start learning various features of the software even before it's been installed. 

In addition, expect to work with the software vendor to customize the system and develop templates that match the forms you currently use. Build upon your current style of practice, instead of forcing doctors and other clinicians to adapt to the new software. 

Some practices have sought to mollify technology holdouts by maintaining a separate paper-records system, just for them, even after installing an EMR for everyone else's use. That, says Lusk, is a recipe for disaster. "You double your costs, and you're never sure which system has the most accurate information." 

To successfully implement an EMR, you need several key people in place. 

For starters, you should have a physician champion who can sell the other physicians on the value of having an EMR in the first place. Your champion should be a physician, because no one else in the practice has as much credibility with the other doctors, or is able to speak to them on their level. 

"That means someone who does this as a labor of love, who lives it and breathes it, who can demonstrate the benefits to his peers," Diamond says. The ideal person may not be the most computer-savvy person in the office. Instead, seek out a physician with a strong commitment to quality of care. 


You also need a project manager, who probably shouldn't be a physician, says Rosemarie Nelson, a principal with the Medical Group Management Association Health Care Consulting Group. "They could be a nurse or any midlevel provider. The reason I recommend against a physician in this role is that doctors need to continue seeing patients, so they usually don't have enough time to monitor all the details of the project." 

The project manager will be responsible for ensuring that hardware has been ordered and is being installed on schedule. She coordinates the training process. When there are separate vendors for practice management software and the EMR, the project manager monitors both vendors to ensure that the two systems will interact properly. As the rollout date approaches, the project manager helps develop templates to meet the practice's specific needs. 

During the start and end of the implementation process, the project manager may spend only a quarter to a third of her time on the EMR. But just before and after rollout, expect it to be a full-time job. Nelson estimates that six months after the go-live date the project manager will be down to half time. However, she'll always need to spend some time maintaining the system as a whole, installing new software releases, and monitoring new functions that can improve the way the practice operates. 

Finally, you need at least one person, and often more than one, to train as a "super user." These people will become thoroughly familiar with the software; they can help train and support staffers in a real-life environment after the formal training period ends. In a small practice, the project manager may fill this role, but in a larger practice, with two or more work sites, you need at least two people who can help other staffers learn and remember key software details. 

By the go-live date, all systems should be installed and operating correctly. This is the moment when practice sessions end and real use begins. Your software vendor will supply onsite training for all your staff during this period, usually for one to two weeks, depending on the size of the practice. 

When you go live, it's a good idea to schedule fewer patients than usual. Ideally, allow double the usual appointment time. 

Many practices follow a gradual implementation strategy. For example, a practice with several locations may implement an EMR at one site, then another. Or a practice may implement one module of the system at a time. 

Diamond, whose practice followed this latter strategy, estimates it took about two months until everything was up and working correctly. At that point, some aspects still felt a bit strange and unfamiliar, like a pair of new shoes, he says. But by the end of six months, everyone was comfortable with the new system. 

How much should you budget for the implementation process? Nelson advises practices to plan on $20,000 to $35,000 for EMR acquisition costs for each full-time physician (or full-time equivalent). That includes hardware, software, initial training for the physician champion and super-users, and onsite support for the whole practice during the "go-live" period. Vendors generally charge $100 to $180 per hour for on-site consulting, she says, and you may be able to negotiate a daily or weekly rate. Her estimate for acquisition costs includes about $7,500 per physician for the software license fee; after the first year, you can expect to pay 18 percent to 22 percent of that fee annually for software updates and continuing phone support. 

Nelson advises practices to budget for an additional period of onsite vendor support, three months after the go-live date, and again six months afterwards. "What usually happens with technology is that we learn just enough to get today's job done," she points out. "Often we don't learn about all the functions we could use to make our jobs easier." She recommends an onsite visit so the trainer can observe people at their workstations, and note bad habits they may have developed, or shortcuts they aren't using. 

eClinicalWorks president and CEO Girish Kumar Navani agrees that practices need to develop their software skills on a continuing basis, since some features of the software become more relevant over time. For example, if you see a patient for a recurring ear infection, the software remembers which antibiotic you used last time. These special features are difficult to demonstrate when the system has just been installed. 

However, Navani doesn't think additional onsite visits are the most appropriate way to teach these additional skills, since most new functions are best learned in short training sessions. Instead, eClinical Works invites practices to sign up for its training Webcasts, of which it hosts eight weekly. 

Installing EMR and practice management software means a major change in work processes for everyone who works at the practice. It's not surprising that this degree of change can be intimidating. 


But the change is inevitable. Navani, who has observed 1,800 practices implement an EMR, says, "don't allow small issues to become show stoppers. Take a positive approach. Even if there is a feature you wish had been designed differently, don't let that slow you down." 

MedPeds, LLC, in Laurel, Md., a five-physician practice, installed eClinicalWorks in May 2004. Since then, total practice overhead has declined by more than 15 percent, overdue accounts have been cut in half, and income per visit has increased due to improved documentation, according to practice manager Heather Lynch. 

Once MedPeds decided to move to an EMR, the practice acted decisively. It sent all active charts out to be scanned and, "after that day, we never used paper again." Lynch's advice to other practices is, "make your decision, and then implement it 100 percent." 

This article originally appeared in the January 2006 issue of

So you've finally decided to get that EMR. It's a big investment, and you're convinced it will help you be a better doctor - that in the end it will pay for itself. Great. But how do you get past all the implementation hurdles after you've made your choice? Expert advice on making it happen.

'Go Live' Without Going Nuts

Use E-mail to improve care, boost efficiency - and, sometimes, enhance revenue.

Karen Ilika, MD, is an e-mail pioneer. A gynecologist in Kirkland, Wash., Ilika offers patients e-mail access through a secure Web site. They post their questions online; when a response is ready they receive an e-mail alerting them to go to the site to read her answer. About 350 patients have signed up for the service.

Ilika, who shares office space and support staff with three other gynecologists, gets one or two e-mails a day. If the exchange reaches the level of a clinical consultation, Ilika charges a fee of $30, and she has found patients are willing to pay out of pocket. "It’s a subjective decision. If I think I’ve saved the patient a trip to the office, then there’s a charge for an e-mail consultation," she says.

Surveys show that increasing numbers of patients use e-mail in their everyday lives, and they want to use e-mail to contact their doctors, too, especially for routine administrative questions. A survey released by the Wall Street Journal this spring found that a large majority of online adults would like to use e-mail to schedule appointments, get test results or prescription refills, and ask questions.

E-mail can boost patient satisfaction. A study of pediatrician e-mails in the May issue of Pediatrics found that 98 percent of parents were "very satisfied" with physician e-mails and 80 percent felt that all pediatricians should use e-mail.

Physicians who use e-mail with patients report that such exchanges are more efficient than phone calls, and can create a written record that is easily added to the patient’s chart. 

Undoubtedly, though, there are stumbling blocks to widespread physician adoption of e-mail. Physicians’ biggest worries are that they will be inundated with questions, their communications won’t be secure, and perhaps most important, they won’t get paid for them. In fact, that same Pediatrics study found 63 percent of patients thought they should not have to pay for e-mail. 

But as the experiences of Ilika and David Ives, an internal medicine specialist in Boston, show, real progress is being made in overcoming these obstacles. Like Ilika, Ives has been using e-mail with patients for several years, and he is now participating in a pilot project with an insurer that is reimbursing some online patient communications. 

Insurers are beginning to pay for "online consultations," which they clearly distinguish from routine e-mails; these are considered similar to phone calls, which are not reimbursed. Consultations, in contrast, are seen as replacing an office visit. During a "Web visit," the patient typically responds to a detailed series of questions, similar to those they’d be asked during an office visit.

Ives, whose practice, Lexington Internal Medicine, is affiliated with Beth Israel Deaconess Medical Center of Boston, is piloting an online consultation program through PatientSite, the hospital’s existing secure Web site. The pilot uses software developed by RelayHealth Corp., of Emeryville, Calif., which includes clinical algorithms that guide established patients through a disease-specific online clinical interview, summarizes their answers, and sends the interview to the physician for a response. 

Ives will be paid $30 for each of these online consultations, through a combination of insurance and self-pay. Patients who have coverage from Blue Cross and Blue Shield of Massachusetts, Inc., will pay their usual copayment, while the insurer has agreed to reimburse the difference between the copayment and $30. Other patients will be asked to pay a $30 fee by credit card.

"The key to this service is that when the patient has a simple question, and can pay their usual copayment, they’re much more likely to use an online visit than drive to the office, find parking, and spend half a day seeing the doctor," Ives says. 

Other insurers are also experimenting with payment for e-mail. Blue Shield of California is currently testing, and paying for, Web visits using RelayHealth’s structured online clinical consultations. Capitated physicians receive a member copayment equal to the member’s standard office visit, but capped at $10. PPO physicians receive a $25 reimbursement, minus the member copayment. 

The California pilot program currently includes nine medical groups and 750 physicians. About 11,000 members are using the process to communicate with their physicians. "So far we’ve gotten very positive momentum," says Sejal Hingrajia, project manager for Blue Shield of California. "Both physicians and members really seem to like the process. We want to look closely at utilization before rolling this out systemwide. We suspect online consultations will cut utilization of office visits, but right now we don’t have enough data to reach significant conclusions either way."

E-mail with patients has come a long way. Technologically, communications are much more secure, and as patients become more comfortable with e-mail, they are beginning to seek help for medical conditions, rather than simply wanting to schedule an appointment.

Five years or so ago, when Ilika practiced in Virginia, e-mail from her patients was routed through a call center, a receptionist, and a nurse before reaching her. "The process took so long I was frustrated, and I began giving my personal e-mail address to specific patients I really wanted to hear from. I got quick, short messages from them that were just what I needed."

These days, she uses a secure Web site provided by Medem, Inc., of San Francisco (www.mygyn.com). Most of the e-mail queries Ilika gets are "things my nurse can handle, such as appointments, prescription refills, or dates of annual exams," she says. Occasionally she receives a clinical question. "In gynecology only a small portion of visits can be replaced by e-mail, because we like to see everybody. But when I get a question from a patient I’ve seen recently who’s just started having hot flashes, or has questions about bone density screening, I can handle those issues via e-mail." 

Ilika finds that sometimes patients prefer to come in for a visit, because the charge for e-mail may exceed a patient’s copayment, which ranges from $15 to $30. "But most busy people don’t mind if it costs them an extra $10, because e-mail saves them so much time and is so convenient," she says. 

Currently Ives’ patients can use PatientSite to check lab results, seek prescription refills, appointments, and referrals, and ask Ives clinical questions, all without charge. Physicians with access to PatientSite can decide how much data their patients can obtain via the site, and Ives has opted for broad access.

Within his own practice, however, one physician uses e-mail but not the Web site, while another doesn’t use e-mail at all. Some physicians are simply uncomfortable with an unfamiliar technology, according to Ives. 

"Most are afraid they’ll be overwhelmed if they open the door," he says. "But when they actually try it that never happens. That’s just an urban legend. And the patient satisfaction level is unbelievable. No patient ever says to me, ‘Gee, I’m sorry you’re on e-mail.’ I find I get substantially fewer phone calls than the physician who doesn’t use e-mail. I get fewer requests for lab results, because patients can look them up themselves."

Ives has 2,500 patients using PatientSite. During a typical month, he gets 100 e-mails for prescription refills, 100 for appointments or referrals, and about 400 clinical messages, which equates to about 20 per workday.

"I have to decide whether I feel comfortable managing each problem without seeing the patient," says Ives, "and that depends on the specific question, plus our pre-existing relationship. The big advantage is that I can respond to e-mail at my convenience." He estimates that e-mail has replaced about three-quarters of his telephone work.

John Halamka, an emergency medicine physician at Beth Israel whose titles also include chief information officer for the hospital and for Harvard Medical School, among others, sees an evolution in e-mail among physicians, payers, and patients.

"Generally speaking, patients feel that if phone calls are free, then e-mails should be free, too. But an online consultation that replaces an office visit - that’s different. Patients value the convenience of online communications. Handling a non acute problem remotely saves a lot of time, and that’s especially important for folks who may have a hard time getting around. Is this a widely adopted [philosophy]? No. Is it an emerging trend? Absolutely."

Physicians such as Ilika and Ives, who answer their own e-mails and conduct online consultations, represent the cutting edge of this practice. But you can start out by using e-mail for routine, nonclinical communications, with an administrator, rather than a physician, responding to messages. 

If you’re not ready to set up a secure Web site or don’t have access to one through your group or hospital affiliations, consider using conventional e-mail to communicate with patients on administrative subjects, such as appointment times or billing questions. Just keep in mind, and make sure your patients understand, that without encryption, sending e-mail is like sending a postcard. Anyone can read it.


Among the biggest threats to e-mail confidentiality, Halamka notes, are misaddressed messages, messages inadvertently forwarded to others, and those on computer screens when someone forgot to log off. You need to disclose your privacy and security policies as required by HIPAA, including how you safeguard e-mail exchanges.

Patients of Bluegrass Orthopaedics, in Lexington, Ky., which has eight surgeons, can e-mail nonclinical questions using a form on the practice’s Web site. Administrator Cindy Dunn, RN, estimates she receives about a dozen e-mails per week, usually concerning appointments, medical records, and billing; she expects this number to grow as more patients become familiar with the service.

) states that the site is not secure, and the e-mail form isn’t designed to convey sensitive information. The practice also posts a warning message next to the e-mail form in red capital letters: "If this is an emergency call 911 immediately!" 

Dunn, who also is a consultant for the Medical Group Management Association, advises medical groups that are interested in e-mail to develop a "practice" Web site and test online services by first offering educational materials, online bill-paying, and appointment scheduling.

Start slowly, as her office has, Dunn says. "See how your patients respond. I wouldn’t bring the physicians on board and have them receive e-mails directly until you first have the whole process worked out for nonclinical questions."

When you’re ready to use e-mail for clinical concerns, you should maintain a secure, encrypted Web site, if possible. You send patients an e-mail saying there’s a message waiting for them on the Web site; your responses, and their personal information, never leave the Web site. "This is similar to models used in the financial services industry," Halamka notes. 

In addition, Halamka suggests discussing guidelines for appropriate use of e-mail with your patients. You can summarize the main points on a handout, or put them on the back of your business card. Document this discussion, and make it part of the patient’s record. 

Halamka recommends that your guidelines for patients say:

Please include your full name and medical record number in each e-mail. 

Use e-mail to request information and ask nonurgent questions. 

Never rely on e-mail for urgent or sensitive messages. 

Use the telephone or go to the emergency room for emergencies. 

E-mail communications become part of your medical record. 

E-mail messages may be shared with my office staff or with consultants. 

E-mail sent from work can legally be read by your employer, so you may want to consider getting a personal e-mail account. 

If you don’t get an e-mail response within a reasonable period of time, please call the office, since I may be out of town.

Elaine Zablocki is a writer with 18 years of experience focusing on healthcare, contributing to publications such as Group Practice Journal, Managed Healthcare News, and many others. She can be reached at ElaineZ@ezab.net or via 

This article originally appeared in the September 2005 issue of

E-mailing patients is more efficient than a phone call, and may even generate income.

Tap Into Your Inbox

First impressions count. Registration is an overlooked process at many practices, but it's most patients' first face-to-face contact with you, so it influences their feelings about you from then on. A welcoming, efficient registration process means happier patients, higher retention, and reduced claims denials.

First, by hiring warm and friendly staff and training them to do the job right. 

Cindy Dunn, RN, FACMPE, believes that hiring knowledgeable people is key. "Usually this is a fast-paced role, with few breaks," she says. "In the past, registration was frequently handed over to low-paid staffers who had the highest turnover rate in the practice. Instead, we should seek out experienced, intelligent people, and pay them well." Dunn is the administrator of Bluegrass Orthopaedics, a group of eight orthopedic surgeons in Lexington, Ky. 

When registration is a bottleneck, you can see the signals. Patient complaints. Exam rooms standing empty while patients slog through registration. Rejected claims. 

"If you have more than 2 percent insurance denials based on eligibility, it suggests you have some kind of problem in your registration process," says MGMA senior consultant Rosemarie Nelson. While it's difficult to give exact figures, she estimates one staffer should be able to register 60 new patients per day.

Nelson believes one of the best ways to limit registration problems is to get more information in advance. Some practices mail out registration forms before the first visit, while others post the forms on their Web sites. Patients can complete the form at home, fax it to the office, or bring it with them to the practice.

"When patients fax you the information in advance, that means you can verify insurance and check eligibility before they come in," Nelson says. And this doesn't require extra security for your Web site, since all you post is the empty form.

But if you like, you can create an interactive form on your Web site, which patients can complete and submit online, provided your site is secure. A secure Web site is very economical right now, Nelson says, and it's easy to find external technical assistance if you need it. 

In fact, you might even be able to take information from the online form and import it directly into your practice management system, so it doesn't have to be entered a second time by hand. 

Bluegrass Orthopaedics has found that posting a registration form on its Web site gets a better response than mailing it out, and it pleases patients. 

"More and more people have Internet access, and they demand this kind of service," says Dunn. "They want to access the form at any time that suits them, even if it's midnight." 

Another reason to gather registration information in advance is that waiting until they arrive means it will take them longer to see the doctor, or so they assume. Patients worry about how long they're going to have to wait, so they tend to rush when filling out the forms; thus the information may be incomplete or illegible. 

However, if you do in-person registration, Nelson suggests at least separating the insurance information from the medical history. "In other words, hand the patient one clipboard with the demographic questions. When they hand in that clipboard give them another, with questions on medical history and current problems. Whenever the exam room is ready they can go there. If necessary, they just take the second clipboard with them and continue filling it out in the room." 

Some practices gather registration information when patients call to schedule their first appointment. This conversation is also a good time to introduce the practice to the patient in a friendly, informal way. You can discuss parking options or practice policies, or offer the practice's Web address for additional information. 

Capturing complete registration information over the phone "allows us to do pre-appointment verification of benefits, and confirm whether the patient has coverage for orthotics and prosthetics," explains Brenda Archer, an administrative specialist for Hanger Prosthetics and Orthotics, a 600-office chain based in Bethesda, Md. "If someone gives us inaccurate information, we can correct it before they even come to our office." 

Archer encourages Hanger P&O offices to do real-time data entry during the initial call. This information must be documented at some point, she argues, and it turns out to be more efficient to do it during the initial contact. When the information is entered into the system and a chart prepared before the first visit, it dramatically speeds the process of preparing written cost estimates for patient approval during that visit. 

As she trains people across the country to do phone registration, Archer finds she's getting a mixed reaction - and she's not surprised. "From a trainer's perspective, promoting enhancements to workflow requires changes in behavior, and that's one of the most difficult things you can ask an adult to do. They're used to doing things a certain way, so change naturally makes them feel uncomfortable at first."

You might get the same sort of resistance from your own staff. However, through frequent repetition and positive reinforcement, Archer finds that workflow processes can be improved. "When people start trying new behaviors, and discover that they really are more efficient, that strongly reinforces continued change."

Many practices reach out to new patients by sending them an introductory information packet. It may include a welcome letter, a brochure, a map to your office, information about financial policies, or a description of a typical first visit. While this information can be posted on your Web site, some patients don't have Internet access, so it's a good idea to mail out an attractive package. 

As you gather advance information, remember to ask your patients for a cell phone number, just in case they're late, Nelson says. When should you call them? It depends on your practice's expectations about time. If you're often running 20 minutes behind schedule, you might call when they're 20 minutes late. If your policy is "after 15 minutes, we reschedule," then you might give them a courtesy call when they're five minutes late. It's essential to discuss this subject in a warm, friendly tone: "I just wanted to check, since we do have you on our calendar today. Are you on your way? We're looking forward to seeing you."

Don't forget about the look of your office. What do your patients see when they arrive? Are your walls empty and colorless, your furniture ratty, your carpet worn?

Liven it up a little. Put attractive paintings on the wall, or post photos of patients and letters of praise on your bulletin board. The reception area should be clean, neat, and attractive, with current magazines and newspapers. Check it throughout the day to be sure it stays that way. 

The reception area should meet the needs of your particular patients. A family practice won't put a coffee pot where a child could topple it. An obstetrical practice needs large chairs, while a gerontologist needs chairs with sturdy arms. Pediatricians often set up two separate reception areas, one for routine visits and one for illness, so healthy and sick children don't have to play with the same toys.

If possible, the receptionist shouldn't answer incoming phone calls. Too often she ends up talking on the phone while a patient stands waiting patiently in front of her. Instead, encourage front-desk staff to look up from their work, make eye contact with patients right away, and smile. 

Don't put a glass wall between the receptionist and your patients - that isn't very welcoming. 

HIPAA now requires you to share policies on privacy and confidentiality with patients, and get their acknowledgment. This is another item you can post on your Web site. 


Some practices have responded to HIPAA by blacking out each patient's name on the sign-in sheet, so the next person just sees a black line. That isn't necessary, Nelson says, calling it "HIPAA paranoia." In any case, she asks, if you have a receptionist and it's her job to warmly welcome each patient, why should anyone have to sign in?

When established patients come in, it's always a good idea to ask for their current address, and check it against your records. Don't just ask, "Has your information changed?" since few people recall exactly what they said last time. 

How often should you look at someone's insurance card? If you're seeing a prenatal patient every two weeks, you needn't ask for her card at every visit. But in today's mobile economy, people change insurers frequently, so you should check every six months or so. "Scan insurance cards, and make that image part of your onscreen record. When the patient comes in and shows their card you can tell at a glance whether it's the same card they had last time," advises Nelson. "If you simply photocopy the card and file it in the chart, you'll spend too much time looking for it."

Finally, it's always a good idea to train people to do more than one job, so they can fill in during lunch breaks or emergencies. It's especially smart to cross-train your back-office billing staff and your front-desk registration staff. "It helps each of them appreciate both sides of the process," says Nelson. "Sometimes billing people feel registration staffers don't do a good job, but they don't have the practical experience to appreciate what it's like to interact with patients one-on-one all day long. When registration people work in the back office, they see the practical consequences when you don't register a patient accurately. Both will benefit from cross-training."

This article originally appeared in the June 2005 issue of 

Registration is an overlooked process at many practices.  A welcoming, efficient registration process means happier patients, higher retention, and reduced claims denials.