Online house calls offered to acne patients
Dermatologists at two Boston hospitals will start treating acne patients this month via Web visits that include patients transmitting photos from their digital cameras, in a major test of whether doctors can care for certain patients as successfully over the Internet as in person.
Patients who agree to participate in the study will see their dermatologist once in the office and then will be assigned randomly to either eight follow-up visits online, or four office visits and four online visits, spaced out over a year. For Web visits, patients will log onto a secure website with a password, fill out a questionnaire about their condition, and e-mail the information and three photographs to their doctor. The process should take 10 to 30 minutes. The physician will have three business days to decide whether the patient's treatment is working and to respond with feedback and instructions.
At first, doctors at Massachusetts General and Brigham and Women's hospitals will focus only on acne patients, because the condition is not life threatening and because the photos, of faces, will guarantee that doctors can confirm their patients' identities. But doctors in Boston and other cities are experimenting with online visits for a wide range of nonemergency conditions, from follow-up for colds and the flu to monitoring the wounds of surgery patients for infection by having them transmit pictures from home. If such care were to become widespread, some doctors believe it could give patients more access to their physicians and make medical care more efficient and convenient.
Dr. Joseph Kvedar, who is overseeing the acne study, said it is possible to provide many types of nonemergency care and follow-up care for chronic conditions online. But there are limitations to its usefulness, affordability, and acceptance -- at least for now. For example, he said, dermatologists probably could tell from digital photos if a patient's mole was potentially cancerous. But, he said, he would not want to communicate results by e-mail or by phone for any condition ''that has a high degree of emotional impact." Companies also are developing monitors, sort of home EKGs, that allow patients to measure cardiac activity and transmit the data to their doctor, but the technology is expensive.
If the acne program is successful, doctors will consider extending online visits to patients with the skin condition psoriasis, and to patients with hypertension, who would be asked to transmit blood pressure readings to doctors using a device registered to each patient for security purposes, said Kvedar, director of telemedicine for Partners HealthCare, the parent organization of Mass. General and Brigham and Women's.
He says he believes online visits will appeal most to patients who travel extensively or work long hours. ''The idea of taking off half a day to check on their acne with their doctor is not high on their priority list," he said. Patients can complete the online visit whenever it is convenient for them at roughly six-week intervals.
Patients wanting to see a dermatologist endure some of the longest waits for doctors' appointments in the city, and the study organizers hope to ease the delay. Last year, the consulting firm Merritt, Hawkins & Associates, based in Texas, studied the wait to see a doctor for four common reasons; it found that the wait to see a dermatologist to check for skin cancer averaged 50 days in Boston, with a range of seven to 120 days. Boston had the longest wait for a skin check of 15 cities surveyed.
Stuart Altman, a professor of national health policy at Brandeis University, said many hospitals reduced or eliminated dermatology training programs as they looked to cut costs during the height of managed care in the 1990s, deciding that internists could take care of most skin problems. More recently some dermatologists have stopped seeing patients with medical problems to focus on more lucrative cosmetic procedures.
''In the context of a seriously shorthanded specialty, I hope they can make this work," Altman said of the Web visits. ''If it becomes a true alternative where you no longer have any direct relationship with the physician, then it would be bad. Ultimately, a good physician talks to people and finds out things about them that they haven't wanted to talk about, things that often lead to problems. It needs to be a supplement."
In the past several years, doctors have expanded the amount of care they provide for patients over the Internet, although only a limited number of physicians have embraced the idea. Last August, Blue Cross & Blue Shield of Massachusetts began paying primary care physicians at Beth Israel Deaconess Medical Center, Caritas Christi Health Care, Baystate Health System, and Tufts-New England Medical Center to respond to their patients' questions and concerns via Web visits. Harvard Vanguard Medical Associates, the Eastern Massachusetts doctors' group, and the insurer Harvard Pilgrim Health Care, also are experimenting with doctor-patient e-mail communications.
The dermatology program goes a step further, because the e-mail exchanges are intended to take the place of office visits, not supplement them, and allow doctors to review a patient's progress and make treatment decisions. Also, the random assignment of patients to two groups will allow researchers to evaluate whether getting follow-up care in-person or online affects patient satisfaction, physician productivity, and the success of acne treatment. Ten dermatologists have volunteered, and initially they will enroll 160 patients. Office staff will instruct patients during their first visit how to take the photos and transmit them, and they can access instructions online. Blue Cross has agreed to pay a $30 ''Web visit" fee to the doctors, which is about half the amount the insurer pays for a regular office visit. As a result, the study is open only to Blue Cross members; they will pay their standard office visit copayment for Web visits, typing in their credit card number online.
Kvedar, vice chairman of dermatology at Harvard Medical School, acknowledges that patients -- and doctors -- who participate in online visits make a sacrifice. One reason he believes doctors will increase productivity with e-visits is that visits won't include small talk about families and jobs. But, he added, ''some patients value access and timeliness more than that." In a survey by Mass. General and Brigham doctors two years ago of 92 adult dermatology patients, 73 percent said they preferred online visits if they could ''see" their doctor sooner than in person; 20 percent preferred remote visits whether or not the wait was shorter.
Alex Reissig, 17 and one of Kvedar's patients, said she will volunteer for the study and hopes to end up in the group of patients that have all their follow-up visits online. Reissig, of Walpole, rides and grooms horses, a job for which she travels the East Coast all week in the summer and works every day after classes during the school year. Reissig just bought a laptop and she owns a digital camera. She said that when Kvedar told her about the study, she ''wasn't sure I'd get the right comments back from the doctor or that he'd see online everything that's going on." But because it's so difficult for her to get to Mass. General for appointments, she wants to try it.
Dr. Alexa Kimball, director of clinical trials for dermatology at Mass. General and Brigham and Women's, said she will participate. She plans to set aside part of her daily clinic time to go through her Web visits all at once. ''Obviously the face-to-face interaction has benefits; you pick up on subtle nuances," she said. ''But a lot of times when you get patients on a stable regimen and it just needs tweaking, this might be perfect."
