Family physicians are always looking for new ways to achieve better outcomes for patients and create a more satisfying and financially sound practice. One strategy that has worked well for my practice is virtual office visits.

What are virtual office visits?

Virtual office visits are simply doctor-patient interactions that occur via e-mail or through a Web-based portal. They offer patients an alternative way to communicate with their doctors regarding health issues that do not require face-to-face contact, such as simple urinary tract infections, upper respiratory infections or routine follow-up of chronic diseases.

Virtual visits satisfy patients' thirst for timely access to care and allow them to communicate with their doctor when it's convenient for them, whether from home or work, regardless of the time of day. With a virtual visit, patients don't have to wait on hold to schedule an appointment, they don't have to miss work and they don't have to waste time in a waiting room. This type of information exchange allows them to describe their problem and formulate their questions without feeling rushed, and because they have their physician's response in writing, they can reread the information as often as they like or need to understand the content.

Virtual visits are generally paid for out-of-pocket by patients, although some insurers are beginning to reimburse for the service because they believe it is cost effective and increases patient satisfaction.¹ Earlier this year, I began participating in a pilot project with Kaiser Permanente of Colorado Springs, which reimburses me $50 per virtual office visit (using CPT code 0074T). This is about 95 percent of the reimbursement for a 99213 for this area. Because physicians can conduct virtual visits in less time than face-to-face visits and with fewer overhead costs, they make good financial sense for a medical practice, in addition to all of the other benefits.

How the process works

I initially started providing online communication in the form of e-mail with my patients when I began my solo ideal medical practice in 2003. (For more information about the ideal medical practice model, see the series overview.) At that time, my patients paid $50 per year for this service, and most were amenable to paying the fee because of the many benefits of virtual visits. They signed a consent form advising that e-mail communication may not be completely secure.

In 2006, I updated my practice Web site to offer a more formal and secure system for conducting virtual office visits. My system is powered by Medfusion (http://www.medfusion.net), and it cost about $2,000 for initial setup, with about $500 in ongoing costs per year. Additional resources for virtual visits are DocIn Touch (https://www.fcnintouch.com), Medem (http://www.medem.com) and Relay Health (https://www.relayhealth.com).

The patient's perspective. For my patients, the process goes something like this. The patient accesses my Web site (http://www.pinnaclefamilymedicine.com) and clicks on the “Virtual office visit” link. After logging in, the patient is taken to a secure Web portal for virtual visits. The patient enters information including medications, allergies and vitals and is presented with a drop-down list of chief complaints to choose from. Then the patient answers a series of questions related to his or her symptoms. If needed, the patient can submit attachments (e.g., a Microsoft Word or Excel file with a blood pressure log, a digital image of a rash or suspicious mole, or even an audio file of a cough). The patient can communicate any additional information in a space designated for free text. The patient selects his or her pharmacy, or adds it to the list, and enters credit card information for payment of the virtual office visit. When all steps are completed, the system informs the patient that it has notified me of the virtual visit via e-mail. Later, when I have completed the virtual office visit, the patient receives e-mail notification to check his or her account. The patient logs in and can view my advice, which may include links to educational Web sites, attachments, information on over-the-counter remedies, advice about what to expect and a description of any prescriptions being sent to the pharmacy.

The physician's perspective. When a patient initiates a virtual office visit, a message shows up in my designated e-mail inbox as an alert. I then log into the secure Web portal and find the patient's virtual office visit request. I open the encounter and review the chief complaint and concise medical history, which has been converted to medical terms (versus layperson's terms on the patient side), with pertinent negative and positive responses shown. I can also open any files the patient has attached. I then determine whether I need to query the patient for more details (I do this infrequently), abort the virtual visit and request an in-office appointment instead (a rare occurrence), or complete the virtual encounter (this happens the majority of the time). My instructions are saved on the site for the patient to access and review, and I can then import the complete visit documentation into my electronic health record (I could also print it for a paper chart, if needed). With a few key strokes, the prescription is electronically sent to the pharmacy, and the patient or insurance company is billed for the visit.

This type of virtual office visit system helps streamline the workflow for physicians. Patients can take as long as they want to complete the questions online regarding their symptoms and history, yet the information is presented to the physician in a concise, complete format that aids rapid diagnosis and treatment.

General guidelines

Following some general guidelines can optimize this type of interaction.

First, physicians should provide virtual office visits only to established patients. Because I have a small patient panel and rich relationships with my patients, I am quite comfortable treating them in this way. As with any family doctor who knows his or her patients, I know their circumstances and can interpret their responses appropriately. If I am not comfortable with a particular situation, I do not hesitate to have the patient come in for an office visit. (I do not charge the patient for the virtual visit in these cases.) When the patient does come in, the history is already nearly complete, so the visit runs smoothly.

Second, patients should be advised up front and in writing that virtual visits are not for urgent matters, such as chest pain, and that they should call 911 if they experience an emergency.

Third, patients should also be advised that the physician's response can take up to 24 hours. That said, it's important for physicians to respond to virtual office visit requests promptly. I run a paper-free office, which means that all messages, whether e-mails from patients or phone messages from my medical assistant, show up in a message center within my integrated electronic health record/practice management system. Because of this, I can check e-mail frequently throughout the day, and my patients experience little delay.

What are you waiting for?

With declining reimbursement, rising overhead and increasing productivity demands, family physicians must seek alternative methods for interacting with patients that offer appropriate payment, lend greater efficiency, support sound clinical judgment and boost the patient-physician relationship. Virtual office visits do all of these things.