E-health: Consultations down the wire

special report Organising and attending medical consultations can be a headache for both medical professionals and patients. Being able to -see" patients via phone or e-mail means doctors can squeeze in more consultation hours, and thus more revenue, and some can and do charge for phone and e-mail consultations.

special report Organising and attending medical consultations can be a headache for both medical professionals and patients. Being able to -see" patients via phone or e-mail means doctors can squeeze in more consultation hours, and thus more revenue, and some can and do charge for phone and e-mail consultations.

However many do not want to be bombarded with calls at all hours, have the hassle of setting up a 1900 number or an accountant to organise payment, or worry about keeping track of an e-mail inbox.

And for patients, there is no such thing as nipping to the doctors. For even minor ailments, a trip to the GP, let alone to a specialist, can take a huge chunk out of a working day. Once a patient has travelled, parked and waited, there isn't going to be much change out of two hours. It is almost entrenched in our culture to take a -sickie" or a half day in order to see the doctor and the cost to the community and business is widely either accepted or ignored.

TeleConsult, a start up company in Sydney, has created and launched a system which enables doctors to provide e-mail and phone consultations, including follow-up advice, changes in drug dosages, repeat prescriptions and referrals, test results, and generally deal with patients for whom a face-to-face visit may not be necessary. The differentiator is that TeleConsult handles the entire process, from registering patients and routing calls right through to tracking consultations and the reimbursement of doctors.

The phone system is based on an IVR voice response system. Patients register and request consultations via phone or on the Web site. All that's needed is a credit card number and a password and ID, along with some personal details. If a phone consultation is requested, the TeleConsult system phones the doctor on a nominated phone number, which can be a mobile. If the doctor is not able or ready to take the call at that time, the patient can request a call-back. An SMS is sent to the doctor with the patient's name and preferred time for a call back. This information is stored on the TeleConsult system and is used to connect the doctor when he or she calls back.

Patients can also request a consultation via the Web site using a secure email system, and doctors can then provide advice via secure e-mail and charge a pre-arranged fee.

Dr Jonathan Rutland, TeleConsult

The TeleConsult service has 50 doctors and 500 patients signed up to it so far, in NSW and across the country, and the company is aiming for 1000 doctors by the end of the year.

CEO Benjamin Rutland established the business last year with his father Jonathan, a thoracic physician who has over 20 years clinical experience treating lung disease. Jonathan Rutland had noticed that increasingly patients wanted to talk to him by phone but it was proving to be a bit of a nightmare. -If I gave my mobile number out to patients I wouldn't get a single other thing done during the day. But I began to think that maybe as doctors we should be facilitating these callers rather than turning them away," he says.

Rutland says he spends perhaps a third of his week in his consulting room, with the rest of his time being spent doing -other things. Ward rounds, teaching, committees, that kind of thing. Likewise a GP would spend some time doing house rounds. Taking calls randomly would drive them mad, so a service which allows us to call patients back at a convenient time is ideal," he says.

The TeleConsult system, he claims, allows doctors to get remuneration for an otherwise frustrating and time consuming part of their job. Doctors pay a one-off $150 registration fee and an annual fee of $50 to use the service. Rutland says doctors on average are charging between $3 and $4 per minute, or between $180 and $300 per hour via the service. TeleConsult takes 30 percent of the phone revenue and 20 percent of the e-mail revenue. There is no cost to the patient to register for the service and no charge if the call is not connected -One doctor charges quite a bit more for out of hours consultations, but he answers calls at two and three o'clock am, which is an excellent service," says Rutland.

It is economical for the patient, says Rutland, because the etiquette of phone calls and e-mail is quite different than a face-to-face consultation. -If a patient comes to the surgery they have to sit in the waiting room, and then the doctor makes polite conversation about the weather, or whatever, whereas it's not being rude whilst on the phone or in an e-mail to get straight to the point," he says.

Page II: A Sydney-based start-up is offering a way for doctors to track and bill their clients for consultations over the phone and by e-mail.

Rutland is a firm believer in establishing a rapport with patients prior to engaging them in TeleConsult consultations. -For diagnosis purposes you need to see a patient, but if you are discussing further investigations, therapies, referrals and so on it is useful to have a system in place that allows patients and doctors to interact securely and remotely when both agree that it is unnecessary to have a face to face consultation," he says.

-If doctors wanted to charge for phone consultations they would have to discuss money with the patient which I don't think is appropriate. A phone consultation typically costs between $15 and $20, so to send an invoice for that amount, once you've posted it and taken into account bank fees, is not an economical amount of money to collect," he says.

TeleConsult is looking into payment by other means than credit cad, but at the moment Jonathan says that even if a patient doesn't have a credit card themselves, a relative normally does. To make a call, the patient needs the doctors ID number, and whilst waiting to be connected a recorded message informs them of the charges or if the doctor is away on holiday or alternative contact numbers - anything the doctor wants the patient to know.

Kourosh Ghassemi, IDC
The patient then uses the keypad to request a return call if the doctor is not available. -We normally ask patients to give a generous time period when requesting a callback, say two to four hours, and we make it very clear that this is not an emergency service so if for instance you have chest pains, don't leave a message," says Rutland.

As well as saving time and generating additional revenue, another benefit of the system is the ability for doctors to document their online and phone consultations easily, which can't easily be done if the doctor is taking a call or checking email away from their consulting room.

A transcription system was developed with partner company OzeScribe, a company which offers, amongst other things, medical transcription services. -I can select to use the keypad as a dictaphone, for example I can press 4 for rewind, 3 for play, and I can dictate a brief note, whether it be to organise follow up care or refer the patient to a specialist," says Rutland. These notes appear on the TeleConsult Web site within 24 hours, and one hour if the doctor marks it as urgent. The Web site also allows doctors, and patients, to view statements from the last three months.

The service will be extended out to other medical professionals including clinical psychologists, dieticians and nurses, says Rutland. -To get advice from a dietician, do you really need to see them every time as long as you are honest about your weight?" he asks.

Kourosh Ghassemi, IDC's research director, SME, vertical markets and Infrastructure says he is sceptical about the concept overall, rather than the service itself.

-At state level the Government has introduced sophisticated web cam services to meet the medical needs of remote communities, but in the private sector there is nothing like this," says Ghassemi. -The service appears to be targeting city workers who do have access to GPs so I wonder why they would choose to get advice online," he adds.

Ghassemi believes it will be a big cultural shift for people, particularly the elderly who TeleConsult are also keen to target, to e-mail or call the doctor rather than visit in person. -It's very hard to ask questions over e-mail particularly, but if it was a web cam and instant messenger service it might be different," he says.

Page III: A Sydney-based start-up is offering a way for doctors to track and bill their clients for consultations over the phone and by e-mail.

According to Rutland, a spin off benefit of the service is its use as a kind of triage system. -If a patient rings and is coughing up blood, I can ring the emergency department and tell them what they need to know prior to the patients arrival. Or I might need to see the patient and request that they get a chest x-ray prior to coming into the surgery, which saves them coming in and going away again to get a chest x-ray. Or if the patient is traveling in India and runs out of medication, we can post it out," he says.

It also affords Rutland more flexibility when it comes to treating his patients. -If I attend a conference for a week I used to have to cancel all my patients but now I can keep the lines of communication open and ring or e-mail them during lunchtime or after the conference hours," he says.

Relatives of patients can also sign up for the service. -There is traditionally a limited amount of time you can spend talking to relatives, but if you've got elderly people going to see a geriatrician and middle aged parents who don't want to take time off work but want to find out how things went, we can do this via TeleConsult, with the patients permission," he says.

Rutland says it is a win-win situation. -It empowers patients by giving them better access to their doctor out of hours and it maintains my privacy whilst still making me available. It's a time management thing, meaning I can squeeze in an extra patient here and there," he says.

Furthermore, Rutland claims this kind of service will benefit the community too, by preventing unnecessary hospital admissions. -I've treated people who are at home on the understanding that if they deteriorate they will ring me or go to hospital. With a bed in a hospital costing the tax payer around $800 to $1000 per a day, the savings are considerable, he says. -It doesn't stop people needing hip operations, bit it might stop someone with chronic bronchitis being admitted to hospital unnecessarily," he adds.

Patients can also use the service if they want clarification about medical facts they may have researched on the Internet. Some patients follow up a diagnosis by going to the Internet to find out more, but after surfing several sites and finding contradictory information, don't know what to believe. -It's quite appropriate in these circumstances for the patient to phone or e-mail a doctor with the URLs for advice on which facts are correct," says Rutland. In the same way, if a new treatment comes onto the market, the patient can check with the doctor whether it is suitable, and gain advice on why it might or might not be, says Rutland.

In terms of medical indemnity issues, most doctors already talk to patients on the phone and if they don't, then TeleConsult might not be for them anyway, says Rutland. -Each doctor has to be satisfied with his or her own medical defence system," he says.

Tony Andrew runs a General Practice which has 5,700 patients in Cremorne in Sydney, and has been trialling the system for a year.

-John's (Rutland) mother had a bypass operation at the same time as I did, and we were in hospital together. John came across to me and said 'you're a GP aren't you' and outlined his idea for the service, asking me if I'd find it useful. I told him I would," says Andrew.

Andrew says he used to feel -angry" when taking phone calls from patients, but now takes less calls and is -comfier" with the arrangement. -Prior to this I would have to have sent an invoice for $10 or $15 for a call which once posted and processed is not worth my while. TeleConsult happens seamlessly, and the only accounting I get is a piece of paper at the end of the month telling me how much money they've put in my bank account," he says.

-It's not for everything, but for things like follow up results, blood tests, and x-rays for instance, patients don't want to come into the surgery, and it reduces the number of times a patient has to come back to the practice," he adds.

Andrew's patients are informed of the service when they call to speak to him, and he says the service is generally well received. -I don't say, 'you used to ring me for free, but now you have to pay for it', I say 'there is no medicare rebate for this' and that tells them it is going to cost," he says.

According to Dr David Rivett, Chair of Australian Medical Association (AMA)'s Council of GPs, doctors may be put off this kind of service by the fact that Medicare does not offer reimbursement for phone and e-mail consultations yet.

He believes, however that once MediConnect, the government-initiated national electronic system which aims to improve the information about medicines are shared, comes into full swing, it is only a matter of a couple of years before prescriptions are being e-mailed out to patients.

-It will be a huge time saver and make life a lot simpler, but from a consultation point of view a consultation in the flesh is worth a thousand e-mails. Patients tend to put on a hardy front in the flesh even if we can see that they are half dead and it's hard to evaluate that from a written message," says Rivett. -A phone conversation is better because we may be able to hear the pain in their voice or other signals," he adds.

Andrew says the biggest problem at the moment is getting patients into the system. -To do it online is fairly quick but a lot of people are unsure of this still, and to register over the phone takes a while," he says. At the moment when a patient rings up, perhaps in the middle of the night and perhaps not feeling their best, is when they are told they must register with TeleConsult, which involves them ringing another number and registering.

-The best way to do it would be to join everybody up front, as they come into the surgery, as a matter of routine, and that is what we are looking to do," he says.

Andrew charges $4 a minute for a TeleConsult. -It's the same rate as a face-to-face consultation, only it usually takes a shorter time," he says. Patients signed up to the service are mainly senior people in the city, he says, people who don't want to take an hour and a half out of their day to visit the doctor.

-E-mail communication is wonderful," says Andrew. -E-mails could sit in my inbox unanswered for days, but now I get an SMS each time I receive a new request, and I can deal with it at anytime anywhere," he says.

The phone can be disruptive, admits Andrew, but he puts that down to his own failure to record a voicemail which informs patients of the hours he is able to take calls. -If I can't take the call, the patient is asked to leave a message using their keypad, and I get an SMS informing me that a call is waiting and the timeframe within which the patient would like to hear back from me," says Andrew. -It will get better and better as I and the patients get better at using it," he adds.

Richard Harris, Gartner Asia-Pacific vice president, says that if doctors want to offer a paid-for phone or e-mail consultation service, the outsourced or hosted model makes sense, particularly for small clinics and GPs.

-It's quite interesting because for most GPs and small practices, the administration involved with handling phone and e-mail requests is handled by front office staff, who are already pretty well pushed answering phones and dealing with patients in the surgery. A service that systemises, simplifies, and keeps track of calls and e-mails and reimburses doctors automatically, on the face of it, is very attractive and the hosted model is a good way to go," he says.

Harris says that some medical professionals do have a reluctance to hand over things to an outside party but TeleConsult, if marketed right, could be onto a winner. -If the marketing taps into the doctor's network, word of mouth sets in, the company ensure that the system is simple to use, and doctors don't have to think about the base technology, then the likelihood of ramping the service up is good, but it might be a slow ramp," he says. -However I think the hosted model is attractive and we are close to the time when this sort of approach is more palatable to doctors," he adds.