If you're old enough, you probably remember visiting the doctor's office in the 1950s. It was like walking into a church. The waiting room was quiet, and when you met with the doctor, it was: "Yes, doctor. No, doctor. Whatever you say, doctor." Mostly it was: Speak when you're spoken to.

That kind of reverential tone has disappeared from medical practice, mostly for the better. Patients have much higher expectations of their caregivers and shop around to find clinicians who are willing to communicate, not just face to face but electronically as well.

A growing number of tech-savvy clinicians appreciate the change. Paula Hillard, MD, a gynecologist at Stanford University Medical Center, for instance, recognizes that despite all the challenges involved in communicating with patients via email, it's still a good idea.

Stanford Medical Center uses a Web tool called My Health in conjunction with its Epic electronic health record system to let patients "securely and confidentially email questions and get updates on labs," Hillard says. "These communications then become a part of the medical records." Patients also provide updates via email, telling Hillard, for instance, whether they're doing well on a new birth control pill or describing a menstrual period and asking whether to come in for an office visit. These email exchanges sometimes save the patient time and worry.

As more patients come to expect this kind of service, the key questions IT executives and forward-thinking doctors and nurses need answers to include:

>> What sort of electronic communications do patients want from their caregivers?

>> What are clinicians willing to provide?

>> Which e-tools can facilitate two-way communications, and are they right for your hospital or practice?

The Patient's E-Wish List

The empowered patient insists on being an active participant in his or her healthcare, Kevin Pho, MD, an advocate for the use of social media in medical practice, recently told Inspire, a patient-oriented healthcare website. "Some doctors … fear empowered patients and think that it's infringing on the traditional doctor-patient relationship," says Pho, a primary care practitioner in Nashua, N.H. "But I think the trend is toward more shared decision-making and having patients being partners in their healthcare."

Recent surveys shed light on just what patients are looking for. Sixty percent of the 843 adults surveyed by Public Policy Polling say they would take advantage of doctor email if it were offered. Similarly, more than half would welcome online appointment scheduling.

But there were also a few surprises: 84% of survey respondents say they aren't interested in talking to their doctors on social media like Facebook and Twitter, and three out of four nix chat and instant messaging. One of the most popular communication tools, according to this survey, is decidedly old school: 72% want a nurse telephone help line.

Nearly three-quarters of Americans would use a secure online tool to get lab results, request appointments, pay bills, and communicate with their doctor's office, according to a survey of 1,000 adults conducted by Intuit Health, a patient portal. Even more significant is the fact that almost half of the respondents say they'd consider switching doctors to obtain such e-services.

Clearly, patients want fast, easy access to essential information about their care. Healthcare providers run the risk of losing business if they wait on the sidelines.

What Docs Are Willing To Provide

Ninety-five percent of doctors say they want patients to fill out medical and registration forms online before coming in for appointments, according to an Intuit Health survey.

InformationWeek Analytics' 2011 Healthcare IT Priorities Survey found that only 24% of healthcare providers report widespread use of email to communicate with patients. Similarly, the same survey found that only 6% use videoconferencing on a widespread basis to talk with patients..

Reasons for such reluctance include concerns about privacy, security, legal liability, lack of compensation for time spent on e-communications, and the simple fact that opening up one's practice to email traffic can overwhelm a physician and the physician's staff.

Privacy concerns shouldn't get in the way of email communications with patients as long as the email is secured, Hilliard says. "When we're communicating directly with the patient by email, not with a third party, HIPAA doesn't really apply," she says.

Liability also shouldn't be an obstacle. "I don't see that it's any different from the usual telephone advice a doctor would give a patient over the phone," says John Selle, DO, an internist practicing in San Francisco. Selle says he makes sure the patients he emails come in for exams or further discussion if needed.

Doctors would like to be compensated for extensive online interaction with patients, such as telemedicine visits and virtual office visits offered by some patient portals. In those interactions, patients fill out a short informational survey about their symptoms and then communicate with the doctor via email. Aetna and Cigna are among the private insurers that now cover such online consultations between doctors and patients. And Medicare offers limited coverage for telemedicine services.

Even the American Medical Association, despite its cautious approach to e-communication, has established two specific Current Procedural Terminology (CPT) reimbursement codes for online consultations: 99444, physician online evaluation and management; and 98969, nonphysician online assessment and management.

And to help manage the volume and flow of messages, some EHR systems and patient portals include email management capabilities, routing messages to the appropriate clinician. In the Intuit Health survey, 67% of medical providers say they plan to offer a patient portal, e-communication, or EHR system in the next 12 months to provide patients with access to health records and clinical information, appointment scheduling, and prescription refills.

Still, many in the healthcare community remain cautious, including the AMA. Its 18 guidelines on doctor-patient e-communication and 15 medicolegal and administrative guidelines read like a "proceed at your own risk" advisory. They likely turn off many clinicians who don't have the time or resources to make sure they're crossing all their t's. The American College of Physicians is more proactive in helping docs jump on board, but it too provides a long discussion on legal issues. (For more on these groups' guidelines, see story, p. 20.)

As for social media, clinicians are still leery. Facebook, for instance "isn't a good platform for interacting with patients because of privacy issues," says Selle. "I know some doctors do it, but it's very risky."

Debra Wolf, associate professor of nursing at Slippery Rock University, agrees. Social media "frightens me to death," she said at the InformationWeek Healthcare IT Leadership Forum earlier this month in New York. People are consulting all manner of healthcare websites "to find patients like themselves," she said. "What frightens me is they don't know how to safely evaluate a website." But rather than advise patients to avoid the Web, Wolf called attention to several organizations that are laying out best practices for using social media and other websites, including the Mayo Clinic Center for Social Media and Cleveland Clinic.

Mayo Clinic, an early leader in the use of social media in healthcare, has a YouTube channel and a Facebook page, is active on Twitter, and runs several blogs, including one that encourages patients to tell their Mayo Clinic stories. Mayo Clinic also provides tools and guidance to other healthcare organizations on social media use through its Social Media Health Network.

The Right E-Communication Tools

Clinicians are starting to embrace patient portals, partly because the portals do a lot of the heavy lifting clinicians would normally have to do themselves if they had to communicate directly with their patients 24/7. A properly designed portal offers secure patient messaging, eliminating the need for clinicians to worry about HIPAA violations. Portals often provide automated systems that route messages to the right clinical and administrative staff. Some portals also provide the structured format mentioned earlier for virtual office visits that can save healthcare providers time.

The secure portals from vendors such as Intuit Health and RelayHealth let patients see test results, make appointments, renew prescriptions, and even ask their doctors questions about their care. Caregivers can respond to queries on their own schedule and even bill patients for online visits, when appropriate.

Some patient portals also can help providers meet government "meaningful use" requirements, such as the one that mandates providers be able to give patients electronic copies of their health information within three business days.

Telemedicine, another potent way for patients and doctors to communicate, is also gaining traction. Telehealth provider American Well, for instance, recently unveiled Online Care for Providers, which lets medical practices nationwide offer live, on-demand consultations to patients in their homes and workplaces over the Internet.

Online Care for Providers is aimed at small and midsize physician practices that lack the resources and IT expertise to store and maintain large volumes of patient data. The program includes two-way video, text chat, telephone consultation, and fee-based messaging. Clinicians can convert patient interactions into structured documents that can be incorporated into electronic medical records. Depending on the level of service that clinicians opt for, patients will need phone service, high-speed Internet access, and a webcam to take advantage of the services.

The American Well tool also provides a mechanism for credit card payments. Medical practices that sign up for the service pay a monthly subscription fee based on how many users access the system and which features they choose.

Online Care for Providers incorporates Microsoft's HealthVault personal health record, as well as IBM tools for transmission security, authentication, and session management.

Mobile Mania To The Rescue

On a less grand scale, some practices may want to consider telemedicine options like Bosch's Health Buddy, a small appliance patients set up at home that's linked via Ethernet or phone line to their clinicians, who can remotely monitor their blood pressure, blood glucose, and weight. Patients take their readings and enter the data into the appliance. A Web-based patient management tool lets clinicians analyze the data, detect trends, assess risks, and offer advice to patients who need adjustments in their regimens.

Among mobile applications, WellDoc's DiabetesManager lets patients submit to their clinicians daily information on blood glucose readings, medications, diet, and exercise. The app, which runs on any data-enabled mobile phone, tracks and analyzes the data and lets healthcare providers communicate back adjustments to a patient's therapeutic regimen.

No doubt many physicians, especially older ones, will continue to have doubts about communicating with patients online. Someone once said, "Policy changes from funeral to funeral." But with the right tools and a persuasive style, you may not have to wait for the old guard to die off to get such projects off the ground. The right approach can make allies of both young and old.

EDUCATED PATIENTS

Doctors can refer patients to electronic education materials or attach relevant files, cutting the number of emails and phone calls to answer basic questions. Here are some worth exploring.

Healthwise Patient care instructions for specific conditions, including a module that lets clinicians access them from an EHR. Krames Online and printable education videos, articles, and interactive disease management tools. Micromedex's CareNotes Details on treatment, lab tests, psychosocial issues, and drugs in 15 languages. Wired.MD Easy-to-understand videos on hernia repair, appendectomies, tubal ligation and other procedures in nonthreatening language, with "gore-free" images.