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Patients now able to connect with their doctors without leaving home Issues remain with treatments offered online

BlueCross BlueShield of Western New York leaped big time into the digital era last year.

The giant health insurer launched an online service that allows patients to connect with a physician using webcams for video links, secure text messages or telephone conversations.

Now, any New York resident willing to pay $25 for a 10-minute conversation can talk to a doctor from their home, workplace or anywhere else with a computer connection.

It is the first such service here and one of only a handful in the nation -- so far.

Questions remain over whether and when online care will firmly take hold among patients and physicians, including what is most appropriate to diagnose without examining a patient in person.

BlueCross BlueShield and others -- including Blue Cross & Blue Shield of Minnesota and the Hawaii Medical Services Association, which is also licensed by the Blues Association -- are betting that online consultations will grow.

Officials see their major customers as the "worried well" or "gently ill" -- individuals who need more reassurance than real major care. Evidence also suggests that patients with chronic diseases, such as diabetes, will use the service if their regular doctor is available for a conversation, officials say.

It's not just a matter of providing advice or care in a new way.

A 2008 study for American Well by the actuarial firm Millman found that the use of online consultations in certain circumstances might provide insurers with significant savings by reducing non-emergent emergency room visits and in-person visits to doctors' offices.

American Well is the Boston-based technology company that insurers are partnering with to adopt online care.

"There is a shortage of primary care doctors. As patients experience issues with access to care, they will want another way to connect with a doctor. We feel there is tremendous opportunity but, like anything new, it will take time to gain acceptance," said Dr. Cynthia Ambres, senior vice president and chief medical officer at BlueCross BlueShield.

In a typical encounter, a patient will visit the online portal and choose from a list of available doctors, whose names will be accompanied by professional information and a patient rating. Patients will fill out a summary of their health status and chat with a physician, who can prescribe only nonnarcotic medications.

Doctors will not have access to a patient's medical records. But they will see more detailed information, including the patient's top medications and past procedures based on insurance claims, if the patient is a BlueCross BlueShield member.

So far, only about 30 physicians from the Blues' network have agreed to see patients online, so it remains difficult for patients to chat with their own doctors. To be robust, the service will need far more practitioners, and the insurer is hoping that happens as doctors see the benefits of online consults and receive some compensation for it.

"It can be effective, but physicians and patients have to be comfortable with it," Ambres said.

To be sure, online care comes with unresolved issues.

Some medical organizations express concern about a virtual visit that lacks a physical examination or a full medical record. They worry about potential physician liability over malpractice. In addition, skeptics wonder about what to do if doctors with a license in one state offer care to patients in states in which they are not licensed.

It's also unlikely doctors will bother with online visits unless insurers reimburse them sufficiently to make participation worth their time.

With the move toward online care and the growth of telemedicine in such fields as psychiatry, dermatology and prison medicine, the Federation of State Medical Boards in March plans to reexamine its 1996 policy on online communications.

"The technology is rapidly evolving, and we want to ensure policies are in line with the changes," said Humayun Chaudhry, federation president.

Nevertheless, Chaudhry said the federation, whose policies are not binding, continues to advocate that doctors should have at least one face-to-face encounter with a patient, with such exceptions as in the field of psychiatry.

"There is a value to an existing physician-patient relationship," he said.

Advocates of online care say the fears over liability are unfounded and see the circumstances as little different than the concerns raised when medical groups and health insurers started using nurses in call centers to respond to patients seeking advice.

As for demands that doctors see patients first, Ambres and others offer several responses.

First, Ambres said, online care can improve communication between doctors and patients, assuming enough doctors participate so that their patients are able to reach them over the Internet. Second, she said such demands ignore how medicine already is practiced, such as the commonplace use of telephone communications to offer medical advice.

The BlueCross BlueShield online service doesn't support out-of-state patients, although the onus is on users to provide accurate address information when they pay for a consultation. Regardless, Ambres doesn't see much merit to the licensure issue anyway.

"It doesn't make sense," she said. "I don't practice differently if a patient is from New York or another state."