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Friday, October 30, 2009

Our implementation of virtual office visits

The first components of the medical home we implemented were a web site and virtual office visits. We chose MedFusion (http://www.medfusion.net) as our vendor because TransforMed paid for installation and the first two years of maintenance. The template for the website was structured and easy. My office manager fortunately had the skills to build the site. She spent 3 hours in training with the vendor and 12 hours building the site. Each provider spent 2 hours training.

For the virtual office visits portion of the site, we first had to establish the problems and topics for which we would offer virtual visits. MedFusion offered more than 200 types of virtual visit, with the type based on the patient's reason for the visit. The web software is set up to ask the patient to specify the reason for the visit and then ask a series of questions pertinent to that reason. That way it collects answers the treating physician can review later. Among the visit types offered were chest pain, abdominal pain and others we did not think could be dealt with safely without a face-to-face visit and exam, so the other providers and I started by reviewing titles for safety. We came up with a list of approximately 15 visit topics we thought would be safe and finalized the list by surveying the patients.

Here is the survey:

Dear Patient:

The Whitehouse Clinic will soon be offering "E-visits," This is a secure e-mail portal where you may receive care directly from your physician. You will be given a site address and password and will be able to select from a variety of problems, answer specific questions about your problem then receive advice or treatment from your physician. No visit to the office is required. We are interested in knowing some of your thoughts on this service before we proceed. Please take a moment to answer these questions so we can provide you with the best service.

1) For which of the following types of problems do you think you may use an e-visit? (Please circle your choices)

Dental problem
Depression follow-up
High blood pressure
High cholesterol
Medication monitoring
Obesity/weight loss advice
Problems with sex drive
Sleep problems
Would never use an e-visit

2) Almost no insurance companies in our area currently pay physicians for this type of service (though insurance companies in other areas of the country are paying). Knowing this, how much would you be willing to pay for the convenience of an e-visit?


Please provide any additional comment or thoughts regarding this service:

Thank you for your time.

We used the results of this survey to construct our program. We offer a dozen visit types (all of the above except "warts") and charge $20 per visit. The visits are very easy for patients to navigate and complete. They incorporate branching logic, so the questions asked are determined partly by the patient's answers to earlier questions. We found that the histories produced by this process are often more complete than those we would take in a face-to-face office visit. The physician can elect to "no charge" the patient if she simply provides advice or recommends that the patient come in for a face-to-face visit based upon the answers collected.

Utilization for the first 12 months was spotty:

 Number of Visits
 January 2007
 2 $ 30
 February 8 $180
 March 4 $ 80
 April 16 $320
 May 9 $180
 June 6 $120
 July 0 $   0
 August 0 $   0
 September 0 $   0
 October 2 $ 40
 November 7 $140
 December 9 $180
 Totals 63 $1,270


As you can see, utilization started out rather low (our practice of 2.0 FTE family physicians treats 5,000 patients). It has continued to be low, and this service does not generate much revenue. In fact, annual maintenance fees for the website and virtual office visit service are $2280, so it hasn't even come close to breaking even. If TransforMed hadn't paid the set-up fee of $2,000, the financial picture would be worse.

We found that certain types of patients tend to use these visits: shift workers, cash-pay patients, and busy people. Sinus problems account for 90 percent of the visits. Next are depression and anxiety medication follow-ups. Some patients use the hypertension template for monitoring their blood pressure numbers.

Given the low initial response, we decided to promote this service heavily by specifically scheduling virtual visits with appointment cards. We have posted advertisements in all our exam rooms and lobby.  I also wrote an article in the local paper about the service, and we ran some ads. Despite all these efforts, this service is not highly utilized and not profitable. I think the main reason is that our office also provides open access scheduling and our capacity to see patients in the office is well matched with our panel size. Nevertheless, as patients become more comfortable with conducting their medical business on-line, utilization may increase.

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About the Author

Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.

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