The doctor will e-you now

For patients frustrated by problems reaching their doctors, there may be a new treatment: e-mail.

Beginning in August, Blue Cross & Blue Shield of Massachusetts will start paying primary care physicians at Beth Israel Deaconess Medical Center, Caritas Christi Health Care, and Baystate Health System for ''Web visits" with their patients. Harvard Vanguard Medical Associates, the large Eastern Massachusetts doctors' group, and the insurer Harvard Pilgrim Health Care, also are experimenting with doctor-patient e-mail programs.

Blue Cross, following the lead of several large California insurers and employers, is expanding a pilot program that pays doctors to respond to patient e-mails--something many doctors are reluctant to do because they are too busy, worried about privacy, or not getting paid for it. Blue Cross executives suggest that Web visits can save doctors time as well as reduce the frustrating waits for patients with minor ailments.

''We hear over and over from our members how difficult it is to get into their doctors' offices," said Vinny Plourde, Blue Cross vice president of provider services. ''Doctors are stressed about how they can continue to provide a good level of care and focus on patients who really need intense attention. We want them to spend more face time with the people who need that level of care, and not with those who don't."

The insurer will pay $24 for a Web visit -- $19 from the insurer plus a $5 copayment from the patient. Executives at the company working with Blue Cross estimate that a Web visit takes 5 to 7 minutes for patients and 5 minutes for physicians to reply.

In comparison, the insurer pays $25 for a 10-minute in-person office visit for a simple complaint such as flu or allergies--not including the patient's $5 or $10 copayment. Blue Cross will not pay doctors to refill patients' prescriptions online or to respond to very quick e-mails. Emergencies are not to be addressed via e-mail.

Just 8 percent of US doctors use e-mail regularly with their patients, according to a recent survey by the market-information firm Manhattan Research in New York. Nine million Americans say they currently e-mail their doctors, and another 54.5 million want to, the company estimates.

At Beth Israel Deaconess, patients already can enroll in ''PatientSite," an online system that allows them to schedule appointments, look up test results, and e-mail their doctors. Even so, many Beth Israel Deaconess physicians are reluctant to use e-mail, fearing they'll be overwhelmed by frivolous messages, and the hospital is looking for incentives.

''Patients love it, doctors don't," said Dr. David Ives, 46, a Beth Israel Deaconess physician who encourages his patients to e-mail him any time.

Ives' e-mail traffic on Tuesday was typical. When he arrived at work at 9:30 a.m., 15 patients had e-mailed overnight. One patient thanked Ives for sending him a blood test form, and shared his happiness about being able to marry his partner later in the week. Another patient wanted to know whether he could wait to see a specialist for the arthritis in his neck, because his brother had died suddenly. Other patients were worried, including Roseann Tully, who e-mailed at 11:14 p.m. that her throat had been raw for about four weeks.

Ives, who is known by his colleagues as the king of e-mail, tossed a pile of postal mail cluttering his desk into a corner and began pounding out his replies on the computer. He answers his patients' e-mails within 24 hours, but usually faster, he said. By the end of the day, 20 patients had e-mailed him, a busy day. In April, 333 patients sent e-mails, about 10 patients a day.

Tully, a magazine publisher, knew she'd be too busy to call Ives on Tuesday or to come in. ''I don't have time to pick up the phone and wait to talk to someone or play phone tag," said Tully, who had already tested negative for strep throat.

Ives believes he's saving time. PatientSite saves all e-mails into the patient's medical record, but if he talks to a patient on the telephone, he has to summarize the conversation later and put it into the file. And telephone calls--not to mention office visits--seem to involve more small talk.

''In a completely selfish way, I didn't want to spend 12 minutes on the phone with him," he said of one patient. ''One line is enough."

Not all doctors see it this way. Many doctors view e-mail as another hassle at a time when they're stretched thin, trying to increase productivity and coping with rising malpractice costs and stagnant reimbursements from insurers. They worry about patient privacy and malpractice, too.

''I do e-mail a little with my patients, but I do it under protest," said Dr. Michael Thane, a Beth Israel Deaconess physician. ''It's a very inefficient way to communicate."

Rather than taking care of all the patient's questions in one phone call, Thane said, e-mail patients expect a back-and-forth ''dialogue that can get burdensome in a hurry, especially if a dozen patients e-mail you in a day." That's compounded by the fact, Thane said, that ''I'm not the world's fastest typist."

He doesn't like e-mail because he can't tell when a patient is angry or upset. And he worries that a husband could read his wife's private medical e-mail without her permission, or vice versa. Getting paid is not going to change his mind, he said.

Blue Cross is paying only doctors who use a Web visit form developed by RelayHealth, a California company that provides secure online communication for the medical industry. When patients try to e-mail Beth Israel Deaconess doctors, the software will ask them to select their illness or condition from a list, which prompts questions on how long they've been sick, their symptoms, and the treatments they've tried. Patients also can choose to send a quick note to their doctor, but doctors won't get paid for answering those.

Blue Cross executives said they want to pay only for Web visits that closely mirror actual office visits. They don't want to pay for ''a rambling, long-winded e-mail that you've written to your physician and that he has to decipher," Plourde, of Blue Cross, said

As a result, some of the 172 doctors who've participated in the Blue Cross pilot project so far said many e-mails don't qualify as paid Web visits. Dr. Alan Cole, an endocrinologist with Charles River Medical Associates in Natick, said most patients prefer to write a quick note. ''We're rarely reimbursed," he said.

RelayHealth also charges doctors $59 a month to subscribe to the service, which Blue Cross subsidizes for the first nine months. But Cole said that ''instead of charging doctors for this, RelayHealth should charge patients, since they benefit not us."

Plourde said physicians' experiences with reimbursement vary. And most doctors who use e-mail said physicians cannot expect to earn money from the service -- unless insurers start paying for more types of e-mail services.

In the end, it may be a service patients simply demand. Carol Bortman, 61, of Winchester said she briefly switched to a female doctor but went back to Ives, partly because he was more willing to communicate by e-mail. ''Regardless of when you call them, doctors can't talk to you. Therefore, you haven't accomplished anything," Bortman said.