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Another specter raised by Miller is fee-splitting. If a physician gains patients through on-line commerce and receives compensation either indirectly through equity investment or directly from patient billing and collection, he is subject to state and federal self-referral and anti-kickback legislation. Direct payment from the site may violate the federal prohibition against corporate practice of medicine.
These legal opinions notwithstanding, an AMA survey found 27% of responding physicians have a web site promoting their practice and providing patient education. I’m one of them. Those who haven’t made the transition certainly have access to lots of advice. I get offers for web site design assistance every month. Recently I got a brochure from Aspen Publishers advertising E-Healthcare, a book guaranteed to provide "Internet strategies and e-solutions that help reduce overhead costs, find new business and improve patient care!" Chapter headings included "Meet the Empowered, Interactive SuperNet Woman", "e-Communication and Interactive e-Care: The Next Generation of Disease Management", and of course "e-Health and the Law".
I didn’t see a chapter on "How to shorten patient waiting times" but one might be helpful to Americasdoctor.com. Marilyn Chase’s August 23, 1999 The Wall Street Journal column discussed 36 people logged-in ahead of her in the virtual waiting room for the site’s Physician Chat Room. "Just like a real doctor’s office, without the old magazines!" Chase finally got to converse e-chat-style with AmDoc 8, who spoke in generalities about treatment of migraine headaches with the disclaimer that "(b)ecause I cannot evaluate your medical problems on-line, I cannot discuss your case." Maybe AmDoc 8 had previously enjoyed a telelaw consultation with attorney Miller.
David Toub, MD, discussed his own experience with medical chat sites in the August 1999 issue of Medical Economics. He initially expected general medical questions on his web health forum but was surprised to receive twice as many requests for medical diagnoses or second opinions. It’s easy to see how a well-meaning physician might be tempted to dispense a little free medical advice in such a situation but he reminds us that this could create a de facto doctor-patient relationship, recommending instead the use of disclaimers and avoidance of online referrals. "Medical Web sites are thriving because patients no longer have easy access to physicians," according to Toub.
American Medical News in its November 22-29, 1999, issue reported on the phenomenon of virtual house calls. Health Hero Network markets Health Buddy, an electronic device that monitors cardiac patients for congestive failure by transmitting weight, diet and medication usage data via telephone to a monitoring site. Similarly, Alere Medical, Inc., has developed an electronic scale that monitors cardiac patients. The University of Southern California has a pilot program for homebound multiple sclerosis patients allowing physician contact via the Internet. It’s hard to criticize obviously good intentions, and undeniably these patients benefit from expert medical care that they might not otherwise receive, yet critics fear the loss of face-to-face interactions may erode the physician-patient relationship plus encourage dangerous diagnostic and therapeutic shortcuts.
Perhaps the scariest medical Internet problem is record confidentiality. A fair amount of medical information is provided via e-mail even though such transmissions may be easily intercepted. Several recent articles such as Kevin Taylor’s "The Clinical Email Explosion" in the January 2000 issue of The Physician Executive and Cheryl Moyer et al’s "’We Got Mail’: Electronic Communication Between Physicians and Patients" in the December 1999 issue of The American Journal of Managed Care attempted to define guidelines for medical e-mail usage. Several start-up companies like ehealthline.com in addition to larger concerns such as PCS Health Systems and Healtheon-WebMD are moving rapidly toward on-line collection of, maintenance of and provision of access to confidential medical and pharmaceutical records by physicians and patients. Some propose that patients should be able to access and edit their medical record on-line. According to Dennis Streveler of Healtheon,
| "The ‘working medical record’ that each of us uses to become our own most important caregiver will be with us on the ‘Net, in our pockets, or both. We will share the data as we see fit, and the whole notion of a ‘personal health record’ will help mitigate the patient confidentiality battles which no doubt will rage over the next five years." |
Only the most prescient forensic obstetrician/gynecologist can foresee the results if patients are given access to alter the very record upon which medical diagnosis and treatment depend. Who would be the defendant in that medmal case?
Technical experts believe data encryption with 128- or 160-bit algorithms, providing virtually infinite coding possibilities, will make confidential Internet storage and transmittal of medical information a reality. But it is still sobering to consider a hacker selling medical information to plaintiffs’ attorneys, overzealous journalists or insurance companies bent on underwriting only the healthiest, genetically pure lives. In spite of the above no one realistically believes the electronic medical record is avoidable. As J. Arthur Gleiner, MD, Primetime Software Vice President notes in the January 2000 issue of The Physician Executive,
"One thing seems certain. The first organization to successfully realize a significant amount of the potential benefit from electronic medical records will have a huge competitive advantage in its marketplace."
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Electronic medical records will occur because there’s money to be made.
I enjoy considering the boundless possibilities of Internet medicine but at the same time keep a critical eye toward its excesses. I’m no longer surprised when today’s curious news blurb becomes tomorrow’s headline. For example, Alternative Technology Resources and Healtheon have developed a joint venture for referring uninsured patients to doctors who will accept discounted cash payments equal to large health insurers’ usual and customary fee schedules. Medicineonline.com is planning a surgery reverse-auction, allowing a patient to advertise her desired surgical procedure on the Net for competitive bidding by surgeons. Caveat emptor.
